DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

42 CFR Parts 410, 414, 415, 421, 423, 425, 486, and 495 

[CMS-1590-FC] 

RIN 0938-AR11 

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME 

Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random 

Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013

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

ACTION: Final rule with comment period. 

SUMMARY: This major final rule with comment period addresses changes to the physician fee 

schedule, payments for Part B drugs, 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 implements provisions of the Affordable Care Act by establishing a face-to-face 

encounter as a condition of payment for certain durable medical equipment (DME) items. In 

addition, it implements statutory changes regarding the termination of non-random prepayment 

review. This final rule with comment period also includes a discussion in the Supplementary 

Information regarding various programs . (See the Table of Contents for a listing of the specific 

issues addressed in this final rule with comment period.) 

DATES: Effective date: The provisions of this final rule with comment period are effective on 

January 1, 2013 with the exception of provisions in §410.38 which are effective on July 1, 2013.

The incorporation by reference of certain publications listed in the rule was approved by the 

Director of the Federal Register on May 16, 2012. 

Comment date: 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 
2 

public inspection at OFR.] (See the SUPPLEMENTARY INFORMATION section of this final 

rule with comment period for a list of the provisions open for comment.) 

ADDRESSES: In commenting, please refer to file code CMS-1590-FC. 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 

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-1590-FC, 

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-1590-FC, 

 Mail Stop C4-26-05, 

 7500 Security Boulevard, 

Baltimore, MD 21244-1850. 
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4. By hand or courier. If you prefer, you may deliver (by hand or courier) your 

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

a. For delivery in Washington, DC-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

Room 445-G, Hubert H. Humphrey Building, 

 200 Independence Avenue, SW., 

 Washington, DC 20201 

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

available to persons without federal government identification, commenters are encouraged to 

leave their comments in the CMS drop slots located in the main lobby of the building. A stampin 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) 786-7195 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: 

Elliott Isaac, (410) 786-4735, for any physician payment issue not identified below. 
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Ryan Howe, (410) 786-3355, for issues related to practice expense methodology and 

direct practice expense inputs, telehealth services, and issues related to primary care and care 

coordination. 

Sara Vitolo, (410) 786-5714, for issues related to potentially misvalued services, 

malpractice RVUs, molecular pathology, and payment for new preventive service HCPCS Gcodes, and the sustainable growth rate. 

Carol Schwartz (410) 786- 0576, for issues related to colonoscopy and preventive 

services. 

Ken Marsalek, (410) 786-4502, for issues related to the multiple procedure payment 

reduction and payment for the technical component of pathology services. 

Craig Dobyski, (410) 786-4584, for issues related to geographic practice cost indices. 

Pam West, (410) 786-2302, for issues related to therapy services. 

Chava Sheffield, (410) 786-2298, for issues related to certified registered nurse 

anesthetists scope of benefit. 

Roberta Epps, (410)786-4503, for issues related to portable x-ray. 

Anne Tayloe-Hauswald, (410) 786-4546, for issues related to ambulance fee schedule 

and Part B drug payment. 

Amanda Burd, (410) 786-2074, for issues related to the DME provisions. 

Debbie Skinner, (410) 786-7480, for issues related to non-random prepayment complex 

medical review. 

Latesha Walker, (410) 786-1101, for issues related to ambulance coverage-physician 

certification statement. 

Alexandra Mugge, (410) 786-4457, for issues related to physician compare. 

Christine Estella, (410) 786-0485, for issues related to the physician quality reporting 

system, incentives for e-prescribing, and Medicare shared savings program. 
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Pauline Lapin, (410) 786-6883, for issues related to the chiropractic services 

demonstration budget neutrality issue. 

Gift Tee, (410) 786-9316, for issues related to the physician feedback reporting program 

and value-based payment modifier. 

Jamie Hermansen, (410) 786-2064, for issues related to Medicare coverage for hepatitis 

B vaccine. 

Andrew Morgan, (410) 786-2543, for issues related to e-prescribing under Medicare 

Part D. 

SUPPLEMENTARY INFORMATION: 

Provisions open for comment: We will consider comments that are submitted as 

indicated above in the “Dates” and “Addresses” sections on the following subject areas discussed 

in this final rule with comment period: 

● Interim final work, practice expense, and malpractice RVUs (including physician time, 

direct practice expense (PE) inputs, and the equipment utilization rate assumption) for new, 

revised, potentially misvalued, and certain other CY 2013 HCPCS codes as indicated in the 

sections that follow and listed in Addendum C to this final rule with comment period; and 

● The appropriate direct PE inputs for establishing nonfacility PE RVUs for CPT code 

63650 (Percutaneous implantation of neurostimulator electrode array, epidural). 

 Inspection of Public Comments: All comments received before the close of the comment 

period are available for viewing by the public, including any personally identifiable or 

confidential business information that is included in a comment. We post all comments received 

before the close of the comment period on the following website as soon as possible after they 

have been received: www.regulations.gov. Follow the search instructions on that website to 

view public comments. 
6 

 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 regulations impact appears throughout the preamble and, therefore, is not discussed 

exclusively in section VIII. of this final rule with comment period. 

I. Executive Summary and Background 

II. Provisions of the Final Rule with Comment Period 

A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs) 

B. Potentially Misvalued Codes Under the Physician Fee Schedule 

C. Malpractice RVUs 

D. Geographic Practice Cost Indices (GPCIs) 

E. Medicare Telehealth Services for the Physician Fee Schedule 

F. Extension of Payment for Technical Component of Certain Physician Pathology 

Services 

G. Therapy Services 

H. Primary Care and Care Coordination 

I. Payment for Molecular Pathology Services 

J. Payment for New Preventive Services HCPCS G Codes 

K. Certified Registered Nurse Anesthetists Scope of Benefit 
7 

L. Ordering of Portable X-Ray Services 

M. Addressing Interim Final Relative Value Units (RVUs) from CY 2012 and Establish 

Interim Final Rule RVU's for CY 2013 

N. Allowed Expenditures for Physicians' Services and the Sustainable Growth Rate 

III. Other Provisions of the Final Rule With Comment Period 

 A. Ambulance Fee Schedule 

 B. Part B Drug Payment: Average Sales Price (ASP) Issues 

C. Durable Medical Equipment (DME) Face-to-Face Encounters and Written Orders 

Prior to Delivery 

 D. Elimination of the Requirement for Termination of Non-random Prepayment 

Complex Medical Review 

 E. Ambulance Coverage-Physician Certification Statement 

F. Physician Compare Website 

G. Physician Payment, Efficiency, and Quality Improvements – Physician Quality 

Reporting System 

H1. Electronic Prescribing (eRx) Incentive Program 

H2. The PQRS-Medicare EHR Incentive Pilot 

I. Medicare Shared Savings Program 

J. Discussion of Budget Neutrality for the Chiropractic Services Demonstration 

K. Physician Value-Based Payment Modifier and the Physician Feedback Reporting 

Program 

L. Medicare Coverage of Hepatitis B Vaccine 

M. Updating Existing Standards for E-prescribing under Medicare Part D and Lifting the 

LTC Exemption 

IV. Additional Provisions 
8 

A. Waiver of Deductible for Surgical Services Furnished on the Same Date as a Planned 

Screening Colorectal Cancer Test and Colorectal Cancer Screening Test Definition—

Technical Correction 

B. Physician Self-Referral Prohibition: Annual Update to the List of CPT/HCPCS 

Codes 

V. Collection of Information Requirements 

VI. Waiver of Proposed Rulemaking 

VII. Response to Comments 

VIII. Regulatory Impact Analysis 

Acronyms 

 Because of the many organizations and terms to which we refer by acronym in this final 

rule with comment period, we are listing these acronyms and their corresponding terms in 

alphabetical order below: 

AHRQ [HHS] Agency for Healthcare Research and Quality 

AMA American Medical Association 

AMA RUC AMA [/Specialty Society] Relative [Value] Update Committee 

ARRA American Recovery and Reinvestment Act (Pub. L. 111-5) 

BBA Balanced Budget Act of 1997 (Pub. L. 105-33) 

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

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

BIPA [Medicare, Medicaid, and SCHIP] Benefits Improvement Protection Act of 2000 

(Pub. L. 106-554) 

BLS Bureau of Labor Statistics 

BN Budget neutrality 

CAH Critical access hospital 
9 

CBSA Core-Based Statistical Area 

CF Conversion factor 

CfC Conditions for Coverage 

CFR Code of Federal Regulations 

CNS Clinical nurse specialist 

CoPs Conditions of Participation 

CORF Comprehensive Outpatient Rehabilitation Facility 

CPI Consumer Price Index 

CPT [Physicians] Current Procedural Terminology (CPT codes, descriptions and other 

data only are copyright 2012 American Medical Association. All rights reserved.)

CRNA Certified registered nurse anesthetist 

CY Calendar year 

DHS Designated health services 

DME Durable medical equipment 

DMEPOS Durable medical equipment, prosthetics, orthotics, and supplies 

DOTPA Development of Outpatient Therapy Payment Alternatives 

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

E/M Evaluation and management 

EHR Electronic health record 

eRx Electronic prescribing 

FFS Fee-for-service 

FR Federal Register 

GAF Geographic adjustment factor 

GAO [U.S.] Government Accountability Office 

GPRO Group Practice Reporting Option 
10 

GPCI Geographic practice cost index 

HAC Hospital-acquired conditions 

HCPCS Healthcare Common Procedure Coding System 

HHA Home health agency 

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) 

HPSA Health Professional Shortage Area 

ICD International Classification of Diseases 

IMRT Intensity Modulated Radiation Therapy 

IOM Internet-only Manual 

IPCI Indirect practice cost index 

IPPS Inpatient prospective payment system 

IWPUT Intra-service work per unit of time 

MAC Medicare Administrative Contractor 

MCTRJCA Middle Class Tax Relief and Job Creation Act of 2012 (Pub. L. 112-96) 

MEDCAC Medicare Evidence Development and Coverage Advisory Committee (formerly 

the Medicare Coverage Advisory Committee ) 

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) 
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MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003 

(Pub. L. 108-173) 

MMEA Medicare and Medicaid Extenders Act of 2010 (Pub. L. 111-309) 

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

MPPR Multiple procedure payment reduction 

MQSA Mammography Quality Standards Act of 1992 (Pub. L. 102-539) 

NP Nurse practitioner 

NPP Nonphysician practitioner 

OACT [CMS] Office of the Actuary 

OBRA Omnibus Budget Reconciliation Act (Pub. L. 101-239) 

OIG [HHS] Office of Inspector General 

PA Physician assistant 

PC Professional component 

PE Practice expense 

PE/HR Practice expense per hour 

PERC Practice Expense Review Committee 

PFS Physician Fee Schedule 

PGP [Medicare] Physician Group Practice 

PLI Professional liability insurance 

PPS Prospective payment system 

PQRS Physician Quality Reporting System 

PRA Paperwork Reduction Act 

PPTRA Physician Payment and Therapy Relief Act of 2010 (Pub. L. 111-286) 

PVBP Physician and Other Health Professional Value-Based Purchasing Workgroup 

RAC [Medicare] Recovery Audit Contractor 
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RFA Regulatory Flexibility Act 

RIA Regulatory impact analysis 

RVU Relative value unit 

SBRT Stereotactic body radiation therapy 

SGR Sustainable growth rate 

TC Technical component 

TIN Tax identification number 

TPTCCA Temporary Payroll Tax Cut Continuation Act of 2011(Pub. L.112-78) 

TRHCA Tax Relief and Health Care Act of 2006 (Pub. L. 109-432) 

VBP Value-based purchasing 

Addenda Available Only Through the Internet on the CMS Website 

 In the past, the Addenda referred to throughout the preamble of our annual PFS proposed 

and final rules with comment period were included in the printed Federal Register. However, 

effective with the CY 2012 PFS final rule with comment period, the PFS Addenda no longer 

appear in the Federal Register. Instead these Addenda to the annual proposed and final rules 

with comment period will be available only through the Internet. The PFS Addenda along with 

other supporting documents and tables referenced in this final rule with comment period are 

available through the Internet on the CMS website at www.cms.gov/PhysicianFeeSched/. Click 

on the link on the left side of the screen titled, ‘‘PFS Federal Regulations Notices’’ for a 

chronological list of PFS Federal Register and other related documents. For the CY 2013 PFS 

final rule with comment period, refer to item CMS–1590–FC. Readers who experience any 

problems accessing any of the Addenda or other documents referenced in this final rule with 

comment period and posted on the CMS Website identified above should contact Elliott Isaac at 

(410) 786–4735. 
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CPT (Current Procedural Terminology) Copyright Notice 

 Throughout this final rule with comment period, we use CPT codes and descriptions to 

refer to a variety of services. We note that CPT codes and descriptions are copyright 2012 

American Medical Association. All Rights Reserved. CPT is a registered trademark of the 

American Medical Association (AMA). Applicable Federal Acquisition Regulations (FAR) and 

Defense Federal Acquisition Regulations (DFAR) apply. 

I. Executive Summary and Background 

A. Executive Summary

1. Purpose 

 This major final rule with comment period revises payment policies under the Medicare 

Physician Fee Schedule (PFS) and makes other policy changes related to Medicare Part B 

payment. These changes are applicable to services furnished in CY 2013. It also implements 

provisions of the Affordable Care Act by establishing a face-to-face encounter as a condition of 

payment for certain durable medical equipment (DME) items. In addition, it implements 

statutory changes regarding the termination of non-random prepayment review. 

2. Summary of the Major Provisions 

The Social Security Act (Act) requires us to establish payments under the PFS based on 

national uniform relative value units (RVUs) and the relative resources used in furnishing a 

service. The Act requires that national RVUs be established for physician work, practice 

expense (PE), and malpractice expense. In this major final rule with comment period, we 

establish payment rates for CY 2013 for the PFS, payments for Part B drugs, and other Medicare 

Part B payment policies to ensure that our payment systems are updated to reflect changes in 

medical practice and in the relative value of services. It also implements provisions of the 

Affordable Care Act by establishing a face-to-face encounter as a condition of payment for 

certain durable medical equipment (DME) items, and by removing certain regulations regarding 
14 

the termination of non-random prepayment review. It also establishes new claims-based data 

reporting requirements for therapy services to implement a provision in the Middle Class Tax 

Relief and Jobs Creation Act (MCTRCA). In addition, this rule: 

● Identifies Potentially Misvalued Codes to be Evaluated. 

● Establishes Additional Multiple Procedure Payment Reductions (MPPR). 

● Expands Medicare Telehealth Services. 

● Implements Regulatory Changes Regarding Payment for Technical Component of 

Certain Physician Pathology Services to Conform to Statute. 

● Requires the inclusion of specific information on claims for therapy services. 

● Establishes New Transitional Care Management Services. 

● Clarifies Services Included in the Certified Registered Nurse Anesthetists Scope of 

Benefit 

● Modifies Ordering Requirements for Portable X-ray Services. 

● Updates the Ambulance Fee Schedule. 

● Sets Part B Drug Payment Rates for 2013. 

● Addresses Ambulance Coverage--Physician Certification Statement. 

● Updates policies regarding the-- 

++ Physician Compare Website. 

++ Physician Quality Reporting System. 

++ Electronic Prescribing (eRx) Incentive Program. 

++ Electronic Health Record (EHR) Incentive Program. 

++ Medicare Shared Savings Program. 

● Discusses Budget Neutrality for the Chiropractic Demonstration. 

● Addresses Implementation of the Physician Value-Based Payment Modifier and the 

Physician Feedback Reporting Program. 
15 

● Establishes Medicare Coverage of Hepatitis B Vaccine. 

● Updates Existing Standards for e-prescribing under Medicare Part D and Lifting the 

LTC Exemption. 

3. Summary of Costs and Benefits 

The statute requires that we establish by regulation each year payment amounts for all 

physicians’ service. These payment amounts are required to be adjusted to reflect the variations 

in the costs of providing services in different geographic areas. The statute also requires that 

annual adjustments to the RVUs not cause annual estimated expenditures to differ by more than 

$20 million from what they would have been had the adjustments not been made. If adjustments 

to RVUs would cause expenditures to change by more than $20 million, we must make 

adjustments to preserve budget neutrality. 

Several changes affect the specialty distribution of Medicare expenditures. This final 

rule with comment period reflects the Administration’s priority to improve payment for primary 

care services. As described in Section II.N, in the absence of Congressional action, an overall 

reduction of 26.5 percent will be imposed in the conversion factor used to calculate payment for 

physicians’ services on or after January 1, 2013 due to the Sustainable Growth Rate (SGR). To 

isolate the impact of changes that we are proposing in this final rule with comment period, we 

analyze and discuss the policies’ impact with a constant conversion factor. In the absence of a 

change in the conversion factor, payments to primary care specialties will increase and payments 

to select other specialties will decrease due to several changes in how we calculate payments for 

CY 2013. 

The largest payment increase for primary care specialties overall will result from a new 

payment for managing a beneficiary’s care when the beneficiary is discharged from an inpatient 

hospital, a SNF, an outpatient hospital observation, partial hospitalization services, or a 
16 

community mental health center. Payments to primary care specialties also will increase due to 

redistributions from changes in payments for services furnished by other specialties. Because of 

the budget-neutral nature of this system, decreases in payments for one service result in increases 

in payments in others. 

Payments to primary care specialties are also impacted by the completion of the 4-year 

transition to new PE RVUs using the new Physician Practice Information Survey (PPIS) data that 

was adopted in the CY 2010 PFS final rule with comment period. The projected impacts of 

using the new PPIS data are generally consistent with the impacts discussed in the CY 2012 final 

rule with comment period (76 FR 72452). 

Several types of providers are projected to see decreases in Medicare PFS payments, 

mainly as a result of the potentially misvalued codes initiative. We have received numerous new 

codes with new values and revised codes with new values for CY 2013 as a result of our ongoing 

misvalued codes initiative, an effort to improve payment accuracy. Many of the new and revised 

codes that we valued on an interim basis for CY 2013 originated with the potentially misvalued 

codes initiative. Reductions for pathology, neurology, and independent laboratories are a result 

of the misvalued code initiative. In the case of independent laboratories, we note that 

independent laboratories receive the majority of the Medicare revenue from the Clinical Lab Fee 

Schedule, which is unaffected by the misvalued code initiative. Radiation therapy centers will 

see an overall decrease of 9 percent primarily as a result of the PPIS transition discussed above 

and a change in the interest rate assumption used to calculate PE. Radiation oncology sees a 7 

percent decrease for the same reasons as radiation therapy centers. 

B. Background

 We note that throughout this final rule with comment period, unless otherwise noted, the 

term “practitioner” is used to describe both physicians and nonphysician practitioners (such as 
17 

physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, 

psychologists, or clinical social workers) who are permitted to bill Medicare under the PFS for 

their services. Since January 1, 1992, Medicare has paid for physicians’ services under section 

1848 of the Act, “Payment for Physicians' Services.” The Act requires that CMS make payments 

under the PFS using 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, PE, and malpractice expense. Before the establishment of the 

resource-based relative value system, Medicare payment for physicians’ services was based on 

reasonable charges. 

1. Development of the Relative Value System 

a. 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. 

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 work RVUs for 

most codes in a cooperative agreement with the Department of Health and Human Services 

(HHS). 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 
18 

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, in part, on our 

review of recommendations received from the American Medical Association/Specialty Society 

Relative Value Update Committee (AMA RUC). 

b. Practice Expense Relative Value Units (PE RVUs) 

Initially, only the physician work RVUs were resource-based, and the PE and malpractice RVUs 

were based on average allowable charges. Section 121 of the Social Security Act Amendments 

of 1994 (Pub. L. 103-432), and 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 and required us to develop 

resource-based PE RVUs for each physicians’ service. We were to consider general categories 

of expenses (such as office rent and wages of personnel, but excluding malpractice expenses) 

comprising PEs. 

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. Separate 

PE RVUs are established for procedures that can be furnished in both a nonfacility setting, such 

as a physician's office, and a facility setting, such as a hospital outpatient department (HOPD). 

The difference between the facility and nonfacility RVUs reflects the fact that a facility typically 

receives separate payment from Medicare for its costs of furnishing the service, apart from 

payment under the PFS. The nonfacility RVUs reflect all of the direct and indirect PEs of 

furnishing a particular service. Based on the BBA 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. 
19 

This resource-based system was based on two significant sources of actual PE data. 

Panels of physicians, practice administrators, and nonphysician health professionals (for 

example, registered nurses (RNs)), who were nominated by physician specialty societies and 

other groups identified the direct inputs required for each physicians’ service. (We have since 

refined and revised these inputs based on recommendations from the AMA RUC.) Aggregate 

specialty-specific information on hours worked and PEs was obtained from the AMA’s 

Socioeconomic Monitoring System (SMS). 

Section 212 of the Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113) 

directed us 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 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 CY 2007 PFS final rule with comment period (71 FR 69624), we revised the 

methodology for calculating direct PE RVUs from the top-down to the bottom-up methodology 

beginning in CY 2007. We adopted a 4-year transition to the new PE RVUs. This transition was 

completed in CY 2010. Direct PE RVUs were calculated for CY 2013 using this methodology, 

unless otherwise noted. 

In the CY 2010 PFS final rule with comment period, we updated the practice expense per 

hour (PE/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) 
20 

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 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). Beginning in 

CY 2010, we provided for a 4-year transition for the new PE RVUs using the updated PE/HR 

data. In CY 2013, the final year of the transition, PE RVUs are calculated based on the new 

data. 

c. Resource-Based Malpractice RVUs 

Section 4505(f) of the BBA amended section 1848(c) of the Act to require that we 

implement resource-based malpractice RVUs for services furnished on or after CY 2000. The 

resource-based malpractice RVUs were implemented in the PFS final rule with comment period 

published November 2, 1999 (64 FR 59380). The malpractice RVUs were based on malpractice 

insurance premium data collected from commercial and physician-owned insurers. 

d. 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. Prior to CY 2013, we conducted separate periodic reviews of work RVUs and PE 

RVUs. The First Five-Year Review of Work RVUs was published on November 22, 1996 

(61 FR 59489) and was effective in 1997. The Second Five-Year Review of Work RVUs 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 Work RVUs was published in the CY 2007 PFS final 

rule with comment period (71 FR 69624) and was effective on January 1, 2007. The Fourth 

Five-Year Review of Work RVUs was published in the CY 2012 PFS final rule with comment 

period (76 FR 73026). 
21 

Initially refinements to the direct PE inputs relied on input from the AMA RUCestablished the Practice Expense Advisory Committee (PEAC). Through March 2004, the PEAC 

provided recommendations to CMS for more than 7,600 codes (all but a few hundred of the 

codes included in the AMAs 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 PE/HR data used to develop PE RVUs, adopting a 4-year 

transition to PE RVUs developed using the PPIS data. 

In the CY 2012 PFS final rule with comment period (76 FR 73057), we finalized a 

proposal to consolidate reviews of work and PE RVUs under section 1848(c)(2)(B) of the Act 

and reviews of potentially misvalued codes under section 1848(c)(2)(K) of the Act into one 

annual process. 

In the CY 2005 PFS final rule with comment period (69 FR 66236), we implemented the 

first Five-Year Review of the malpractice 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 resource-based malpractice RVUs 

was published in the CY 2010 PFS final rule with comment period (74 FR 61758) and was 

effective in CY 2010. 

In addition to the Five-Year Reviews, beginning for CY 2009, CMS and the AMA RUC 

have identified and reviewed a number of potentially misvalued codes on an annual basis based 

on various identification screens. This annual review of work and PE RVUs for potentially 

misvalued codes was supplemented by the amendments to Section 1848 of the Act, as enacted 
22 

by section 3134 of the Affordable Care Act, which requires the agency to periodically identify, 

review and adjust values for potentially misvalued codes with an emphasis on the following 

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 PEs; (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 fee schedule (the so-called ‘Harvard valued 

codes’); and (7) other codes determined to be appropriate by the Secretary. 

e. Application of Budget Neutrality to Adjustments of RVUs 

 Budget neutrality (BN) typically requires that expenditures not increase or decrease as a 

result of changes or revisions to policy. However, section 1848(c)(2)(B)(ii)(II) of the Act 

requires adjustment only if the change in expenditures resulting from the annual revisions to the 

PFS exceeds a threshold amount. Specifically, 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 would 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. 

2. Components of the Fee Schedule Payment Amounts 

To calculate the payment for each physicians’ service, the components of the fee 

schedule (work, PE, and malpractice RVUs) are adjusted by geographic practice cost indices 

(GPCIs). The GPCIs reflect the relative costs of physician work, PE, and malpractice 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). 
23 

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. 

3. Most Recent Changes to the Fee Schedule 

The CY 2012 PFS final rule with comment period (76 FR 73026) implemented changes 

to the PFS and other Medicare Part B payment policies. It also finalized many of the CY 2011 

interim RVUs and implemented interim RVUs for new and revised codes for CY 2012 to ensure 

that our payment systems are updated to reflect changes in medical practice and the relative 

values of services. In the CY 2012 PFS final rule with comment period, we announced the 

following for CY 2012: the total PFS update of -27.4 percent; the initial estimate for the 

sustainable growth rate (SGR) of -16.9 percent; and the conversion factor (CF) of $24.6712. 

These figures were calculated based on the statutory provisions in effect on November 1, 2011, 

when the CY 2012 PFS final rule with comment period was issued. 

A correction notice was issued (77 FR 227) to correct several technical and typographical 

errors that occurred in the CY 2012 PFS final rule with comment period. 

On December 23, 2011, the Temporary Payroll Tax Cut Continuation Act of 2011 

(TPTCCA) (Pub. L. 112-78) was signed into law. Section 301 of the TPTCCA specified a zero 

percent update to the PFS from January 1, 2012 through February 29, 2012. As a result, the 

CY 2012 PFS conversion factor was revised to $34.0376 for claims with dates of service on or 

after January 1, 2012 through February 29, 2012. In addition, the TPTCCA extended several 

provisions affecting Medicare services furnished on or after January 1, 2012 through February 

29, 2012, including: 

● Section 303 - the 1.0 floor on the physician work geographic practice cost index; 

● Section 304 - the exceptions process for outpatient therapy caps; 
24 

● Section 305 - the payment to independent laboratories for the technical component 

(TC) of physician pathology services furnished to certain hospital patients, and 

● Section 307 - the 5 percent increase in payments for mental health services. 

On February 22, 2012, the Middle Class Tax Relief and Job Creation Act of 2012 (Pub. 

L. 112-96) (MCTRJCA) was signed into law. Section 3003 of the MCTRJCA extended the zero 

percent PFS update to the remainder of CY 2012. As a result of the MCTRJCA, the CY 2012 

PFS CF was maintained as $34.0376 for claims with dates of service on or after March 1, 2012 

through December 31, 2012. In addition: 

● Section 3004 of MCTRJCA extended the 1.0 floor on the physician work geographic 

practice cost index through December 31, 2012; 

● Section 3006 continued payment to independent laboratories for the TC of physician 

pathology services furnished to certain hospital patients through June 30, 2012; and 

● Section 3005 extended the exceptions process for outpatient therapy caps through CY 

2012 and made several other changes related to therapy claims and caps. 

II. Provisions of the Final 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, amended section 1848(c)(2)(C)(ii) of 

the Act to require us 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. 
25 

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 year may not cause total PFS payments to 

differ by more than $20 million from what they would have otherwise 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 

explanation 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 involved with furnishing 

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

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

recommendations received from the AMA 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 
26 

 We use survey data on indirect PEs incurred per hour worked in developing the indirect 

portion of the PE RVUs. Prior to CY 2010, we primarily used the practice expense per hour 

(PE/HR) by specialty that was obtained from the AMA’s Socioeconomic Monitoring Surveys 

(SMS). The AMA administered a new survey in CY 2007 and CY 2008, the Physician Practice 

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

nonphysician practitioners (NPPs) paid under the PFS. 

 The PPIS is a multispecialty, nationally representative, PE survey of both physicians and 

NPPs using a consistent survey instrument and methods highly consistent with those used for the 

SMS and the supplemental surveys. The PPIS gathered information from 3,656 respondents 

across 51 physician specialty and healthcare professional groups. We believe the PPIS is the 

most comprehensive source of PE survey information available to date. Therefore, we used the 

PPIS data to update the PE/HR data for the CY 2010 PFS for almost all of the 

Medicare-recognized specialties that participated in the survey. 

 When we began using the PPIS data beginning in CY 2010, we did not change the PE 

RVU methodology itself or the manner in which the PE/HR data are used in that methodology. 

We only updated the PE/HR data based on the new survey. Furthermore, as we explained in the 

CY 2010 PFS final rule with comment period (74 FR 61751), because of the magnitude of 

payment reductions for some specialties resulting from the use of the PPIS data, we finalized a 

4-year transition (75 percent old/25 percent new for CY 2010, 50 percent old /50 percent new for 

CY 2011, 25 percent old /75 percent new for CY 2012, and 100 percent new for CY 2013) from 

the previous PE RVUs to the PE RVUs developed using the new PPIS data. 

 Section 1848(c)(2)(H)(i) of the Act 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. 
27 

 We do not use the PPIS data for reproductive endocrinology and spine surgery since 

these specialties currently are not separately recognized by Medicare, nor do we have a method 

to blend these data with Medicare-recognized specialty data. Similarly, we do not use the PPIS 

data for sleep medicine since there is not a full year of Medicare utilization data for that specialty 

given when the specialty code was created. 

 Supplemental survey data on independent labs, from the College of American 

Pathologists, were implemented for payments in CY 2005. Supplemental survey data from the 

National Coalition of Quality Diagnostic Imaging Services (NCQDIS), representing independent 

diagnostic testing facilities (IDTFs), were blended with supplementary survey data from the 

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

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

that was developed from their supplemental survey data. 

 Consistent with our past practice, the previous indirect PE/HR values from the 

supplemental surveys for medical oncology, independent laboratories, and IDTFs were updated 

to CY 2006 using the MEI to put them on a comparable basis with the PPIS data. 

 Previously, we have established PE/HR values for 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 for physician time. 

 For registered dietician services, the resource-based PE RVUs have been calculated in 

accordance with the final policy that crosswalks the specialty to the “All Physicians” PE/HR 
28 

data, as adopted in the CY 2010 PFS final rule with comment period (74 FR 61752) and 

discussed in more detail in the CY 2011 PFS final rule with comment period (75 FR 73183). 

 There were five specialties whose utilization data were newly incorporated into 

ratesetting for CY 2012. In accordance with the final policies adopted in the CY 2012 final rule 

with comment period (76 FR 73036), we use proxy PE/HR values for these specialties by 

crosswalking values from other, similar specialties as follows: Speech Language Pathology from 

Physical Therapy; Hospice and Palliative Care from All Physicians; Geriatric Psychiatry from 

Psychiatry; Intensive Cardiac Rehabilitation from Cardiology, and Certified Nurse Midwife from 

Obstetrics/gynecology. 

 For CY 2013, there are two specialties whose utilization data will be newly incorporated 

into ratesetting. We proposed to use proxy PE/HR values for these specialties by crosswalking 

values from other specialties that furnish similar services as follows: Cardiac Electrophysiology 

from Cardiology; and Sports Medicine from Family Practice. These proposed changes are 

reflected in the “PE HR” file available on the CMS website under the supporting data files for 

the CY 2013 PFS final rule with comment period at www.cms.gov/PhysicianFeeSched/. 

We did not receive any comments regarding our proposal to use these proxy PE/HR 

values for these specialties, and we continue to believe that the values crosswalked from other 

specialties that furnish similar services are appropriate. Therefore, we are finalizing our 

CY 2013 proposals to update the PE/HR data as reflected in the "PE HR" file available on the 

CMS website under the supporting data files for the CY 2013 PFS final rule with comment 

period at http://www.cms.gov/PhysicianFeeSched/. 

 As provided in the CY 2010 PFS final rule with comment period (74 FR 61751), 

CY 2013 is the final year of the 4-year transition to the PE RVUs calculated using the PPIS data. 

Therefore, the CY 2013 PE RVUs are developed based entirely on the PPIS data, except as noted 

in this section. 
29 

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. 

(1) Direct Costs 

 The relative relationship between the direct cost portions of the PE RVUs for any 

two services is determined by the relative relationship between the sum of the direct cost 

resources (that is, the clinical staff, equipment, and supplies) typically involved with 

furnishing 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 of the first service would be twice as much as the direct portion 

of the PE RVUs for the second service. 

(2) Indirect Costs 

 Section II.A.2.b. of this final rule with comment period describes the current data 

sources for specialty-specific indirect costs used in our PE calculations. We allocated 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 incorporated the survey data described earlier in the PE/HR discussion. The general 

approach to developing the indirect portion of the PE RVUs is described as follows: 

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

previously described and the average percentage that direct costs represent of total costs 

(based on survey data) across the specialties that furnish the service to determine an 

initial indirect allocator. For example, if the direct portion of the PE RVUs for a given 

service was 2.00 and direct costs, on average, represented 25 percent of total costs for the 
30 

specialties that furnished the service, the initial indirect allocator would be 6.00 since 

2.00 is 25 percent of 8.00 and 6.00 is 75 percent of 8.00. 

• Next, we add the greater of the work RVUs or clinical labor portion of the 

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

service had work RVUs of 4.00 and the clinical labor portion of the direct PE RVUs was 

1.50, we would add 6.00 plus 4.00 (since the 4.00 work RVUs are greater than the 1.50 

clinical labor portion) to get an indirect allocator of 10.00. In the absence of any further 

use of the survey data, the relative relationship between the indirect cost portions of the 

PE RVUs for any two services would be determined by the relative relationship between 

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

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

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

RVUs for the second service. 

• Next, 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 

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

specialties furnishing the first service with an allocator of 10.00 was half of the average 

indirect cost of the specialties furnishing 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 
31 

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 furnished 

independently or by different providers, or they may be furnished together as a “global” 

service. When services have PC and TC components that can be billed separately, the 

payment for the global component equals the sum of the payment for the TC and PC. 

This is a result of using a weighted average of the ratio of indirect to direct costs across 

all the specialties that furnish the global components, TCs, and PCs; that is, we apply the 

same weighted average indirect percentage factor to allocate indirect expenses to the 

global components, PCs, and TCs for a service. (The direct PE RVUs for the TC and PC 

sum to the global under the bottom-up methodology.) 

f. 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). 

(1) Setup File 

First, we create a setup file for the PE methodology. The setup file contains the 

direct cost inputs, the utilization for each procedure code at the specialty and 

facility/nonfacility place of service level, and the specialty-specific PE/HR data from the 

surveys. 

(2) Calculate the Direct Cost PE RVUs 

Sum the costs of each direct input. 

Step 1: Sum the direct costs of the inputs for each service. 

Apply a scaling adjustment to the direct inputs. 
32 

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. 

(3) 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. 

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. 
33 

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.) 

For presentation purposes in the examples in Table 1, 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. 
34 

Step 9: Calculate the current aggregate pool of indirect PE RVUs by multiplying 

the current aggregate pool of PE RVUs by the average indirect PE percentage from the 

survey data. 

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

adding the product of the indirect PE allocators for a service from Step 8 and the 

utilization data for that service. 

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

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

aggregate indirect PE RVUs and apply it to indirect allocators calculated in Step 8. 

Calculate the indirect practice cost index. 

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

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

adding the product of the adjusted indirect PE allocator for each service and the 

utilization data for that service. 

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

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

adding the product of the indirect PE/HR for the specialty, the physician time for the 

service, and the specialty's utilization for the service across all services furnished 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. 
35 

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. 

(4) Calculate the Final PE RVUs 

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

Step 17 and apply the final PE budget neutrality (BN) adjustment. 

The final PE BN adjustment is calculated by comparing the results of Step 18 to 

the current pool of PE RVUs. This final BN adjustment is required in order to 

redistribute RVUs from step 18 to all PE RVUs in the PFS and because certain specialties 

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

included for purposes of calculating the final BN adjustment. (See “Specialties excluded 

from ratesetting calculation” later in this section.) 
36 

(5) Setup File Information 

• Specialties excluded from ratesetting calculation: For the purposes of 

calculating the PE RVUs, we exclude certain specialties, such as certain nonphysician 

practitioners paid at a percentage of the PFS and low-volume specialties, from the 

calculation. These specialties are included for the purposes of calculating the BN 

adjustment. They are displayed in Table 1. 

TABLE 1: Specialties Excluded From Ratesetting Calculation 

Specialty Code Specialty Description

49 Ambulatory surgical center 

50 Nurse practitioner

51 Medical supply company with certified orthotist 

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 

97 Physician assistant

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 

In the CY 2013 PFS proposed rule, we proposed to calculate the specialty mix for 

low volume services (fewer than 100 billed services in the previous year) using the same 
37 

methodology we used for non-low volume services. We currently use the survey data 

from the dominant specialty for these low volume services. We proposed to calculate a 

specialty mix for these services rather than use the dominant specialty in order to smooth 

year-to-year fluctuations in PE RVUs due to changes in the dominant specialty. 

However, the PE RVUs for the affected HCPCS codes were inadvertently displayed in 

Addendum B for the CY 2013 PFS proposed rule using our previously established 

methodology of using the dominant specialty for these services. While we received 

comments on our proposal, including some suggesting alternative methods for handling 

low volume services, we do not believe that it would be appropriate to make changes to 

the current methodology since the correct impact of the proposed calculation was not 

reflected in the displayed PE RVUs. We appreciate the commenters’ perspective on the 

proposal, and will take those comments into account as we consider the best methodology 

for calculating the specialty mix for low volume services in future rulemaking. 

● Crosswalk certain low volume physician specialties: Crosswalk the utilization 

of certain specialties with relatively low PFS utilization to the associated specialties. 

• Physical therapy utilization: Crosswalk the utilization associated with all 

physical therapy services to the specialty of physical therapy. 

• Identify professional and technical services not identified under the usual TC 

and 26 modifiers: Flag the services that are PC and TC services, but do not use TC and 

26 modifiers (for example, electrocardiograms). This flag associates the PC and TC with 

the associated global code for use in creating the indirect PE RVUs. For example, the 

professional service, CPT code 93010 (Electrocardiogram, routine ECG with at least 12 

leads; interpretation and report only), is associated with the global service, CPT code 

93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and 

report). 
38 

• Payment modifiers: Payment modifiers are accounted for in the creation of the file 

consistent with current payment policy as implemented in claims processing. 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. Similarly, for those services to which 

volume adjustments are made to account for the payment modifiers, time adjustments are applied 

as well. For time adjustments to surgical services, the intraoperative portion in the physician 

time file is used; where it is not present, the intraoperative percentage from the payment files 

used by Medicare contractors to process Medicare claims is used instead. Where neither is 

available, we use the payment adjustment ratio to adjust the time accordingly. Table 2 details the 

manner in which the modifiers are applied. 

TABLE 2: Application of Payment Modifiers to Utilization Files 

Modifier Description Volume Adjustment Time Adjustment 

80,81,82 Assistant at Surgery 16% Intraoperative 

portion 

AS Assistant at Surgery – 

Physician Assistant 

14% (85% * 16%) Intraoperative 

portion 

50 or 

LT and RT 

Bilateral Surgery 150% 150% of physician 

time 

51 Multiple Procedure 50% Intraoperative 

portion 

52 Reduced Services 50% 50% 

53 Discontinued Procedure 50% 50% 

54 Intraoperative Care only Preoperative + 

Intraoperative 

Percentages on the 

payment files used by 

Medicare contractors 

to process Medicare 

claims 

Preoperative + 

Intraoperative 

portion 

55 Postoperative Care only Postoperative 

Percentage on the 

payment files used by 

Medicare contractors 

to process Medicare 

claims 

Postoperative 

portion 
39 

62 Co-surgeons 62.5% 50% 

66 Team Surgeons 33% 33% 

We also make adjustments to volume and time that correspond to other payment rules, 

including special multiple procedure endoscopy rules and multiple procedure payment reductions 

(MPPR) including the final ophthalmology and cardiovascular diagnostic services MPPR 

discussed in section II.B.4. of this final rule with comment period. We note that section 

1848(c)(2)(B)(v) of the Act exempts certain reduced payments for multiple imaging procedures 

and multiple therapy services from the budget-neutrality calculation under section 

1848(c)(2)(B)(ii)(II) of the Act. These MPPRs are not included in the development of the 

RVUs. 

For anesthesia services, we do not apply adjustments to volume since the average 

allowed charge is used when simulating RVUs and therefore includes all discounts. A 

time adjustment of 33 percent is made only for medical direction of two to four cases 

since that it is the only occasion where time units are duplicative. 

Comment: One commenter expressed concern regarding the accuracy of the 33 percent 

time adjustment made for these services. 

Response: We note that we did not make any proposals regarding the 33 percent time 

adjustment for medical direction in the CY 2013 PFS proposed rule. As such, we do not believe 

it would be appropriate to modify that figure in this final rule. However, we would welcome any 

independently verifiable data that could inform the accuracy of our assumption regarding 

duplicative time units. The 33 percent time adjustment effectively assumes medical direction of 

three cases. We would consider any such data for future rulemaking. 

● Work RVUs: The setup file contains the work RVUs from this final rule with 

comment period. 

(6) Equipment Cost Per Minute 
40 

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 = 0.5 is the standard equipment utilization assumption; 0.75 for certain 

expensive diagnostic imaging equipment (see 74 FR 61753 through 61755 and section 

II.A.3. of the CY 2011 PFS final rule with comment period). 

price = price of the particular piece of equipment. 

interest rate = sliding scale (see proposal below) 

life of equipment = useful life of the particular piece of equipment. 

maintenance = factor for maintenance; 0.05. 

The interest rate we have previously used was proposed and finalized during rulemaking 

for CY 1998 PFS (62 FR 33164). In the CY 2012 proposed rule (76 FR 42783), we 

solicited comment regarding reliable data on current prevailing loan rates for small 

businesses. In response to that request, the AMA RUC recommended that rather than 

applying the same interest rate across all equipment, CMS should consider a “sliding 

scale” approach which varies the interest rate based on the equipment cost, useful life, 

and SBA (Small Business Administration) maximum interest rates for different 

categories of loan size and maturity. The maximum interest rates for SBA loans are as 

follows: 

● Fixed rate loans of $50,000 or more must not exceed Prime plus 2.25 percent if 

the maturity is less than 7 years, and Prime plus 2.75 percent if the maturity is 7 years or 

more. 
41 

● For loans between $25,000 and $50,000, maximum rates must not exceed 

Prime plus 3.25 percent if the maturity is less than 7 years, and Prime plus 3.75 percent if 

the maturity is 7 years or more. 

● For loans of $25,000 or less, the maximum interest rate must not exceed Prime 

plus 4.25 percent if the maturity is less than 7 years, and Prime plus 4.75 percent, if the 

maturity is 7 years or more. 

The current Prime rate is 3.25 percent. 

 Based on that recommendation, for CY 2013, we proposed to use a “sliding scale” 

approach based on the current SBA maximum interest rates for different categories of 

loan size (price of the equipment) and maturity (useful life of the equipment). 

Additionally, we proposed to update this assumption through annual PFS rulemaking to 

account for fluctuations in the Prime rate and/or changes to the SBA’s formula to 

determine maximum allowed interest rates. 

Comment: Both MedPAC and the AMA RUC supported the proposal. MedPAC 

stated: 

We support CMS’s proposal to use more accurate interest rate information 

because this will improve the accuracy of practice expense payment rates and 

redistribute dollars from overvalued codes to undervalued codes. 

The AMA RUC commented: 

The RUC appreciates that CMS intends to adopt the RUC recommendation of 

implementing a “sliding scale” for the interest rate utilized in computing 

equipment costs. 

Other commenters, also supported the proposal. However, while physician 

organizations that represent specialties that provide medical equipment intensive services 

and medical equipment manufacturers generally acknowledged that the interest rate used 
42 

in the calculation had not been updated in over 12 years, they did not support the specific 

proposed update approach. These commenters assertions included: the proposal is 

“overly complicated” to administer since the interest rates vary by loan size and maturity, 

and interest rates can fluctuate; the SBA loan program is designed to encourage loans to 

small businesses so the SBA rates are below market rates unrelated to the cost of capital 

for physician practices; the proposed methodology may be inconsistent with the statute 

since it does not reflect relative resources; CMS should factor in the opportunity cost for 

practices that pay cash for the equipment (a weighted average cost of capital (WACC) 

approach) using WACC measures available in the private sector; CMS should transition 

this policy given the investments in equipment that have already been made; CMS should 

use a multiyear average of the Prime rate rather than the most recent Prime rate in the 

calculation; and, CMS should only update the interest rate every few years to help ensure 

more stable practice expenses. 

Response: We agree with MedPAC, the AMA RUC, and the commenters who 

supported our proposed approach for the interest rate calculation. Our proposed approach 

recognizes that the goal of the practice expense methodology is to calculate, as accurately 

as possible given the available data sources, the relative resources required to furnish 

services that are paid under the physician fee schedule. To continue to use an 11 percent 

interest rate assumption in the calculation of the equipment portion of the practice 

expense RVUs when this rate does not reflect a market rate would unnecessarily distort 

this relativity. We are unaware of, nor did commenters suggest, a readily available and 

transparent data source that specifically provides nationally representative data on the 

typical interest rates charged to physicians when obtaining financing for medical 

equipment. We believe that the use of the SBA maximum loan rates leads to a more 

reasonable estimate of relative resource used across the fee schedule and, consistent with 
43 

the MedPAC comment, that the continued use of an 11 percent interest rate would 

inappropriately skew physician fee schedule relativity towards equipment intensive 

services. 

Additionally, we disagree that the maximum SBA loan rates are not sufficient as 

an assumption for the rate at which a typical physician practice would obtain financing, 

nor did the commenters offer nationally representative data indicating that this is the case. 

We agree with commenters that, in an ideal world, the interest rate assumption 

used in the equipment calculation would explicitly factor in the opportunity costs for 

practices that pay cash for the equipment (a WACC approach) and not just the cost of 

financing. However, as with the interest rates typically charged to physicians for medical 

equipment financing, we are unaware of any nationally representative data source that 

would provide the opportunity cost for physician practices deciding on purchasing 

medical equipment. Some commenters suggested we use proprietary WACC measures 

designed for industry and company stock valuations. We do not believe it would be 

appropriate to use proprietary measures in this calculation, nor do we believe that 

measures developed to value the stock prices of individual medical equipment companies 

or the medical device industry are necessarily applicable to the opportunity costs of 

typical medical practices. Also, we do not agree that the opportunity cost of a physician 

practice purchase of medical equipment, if known or estimable, would exceed the SBA 

maximum loan rates. 

We also do not believe that our proposal is overly complicated to administer. The 

Prime rate is readily available, as are the SBA loan maximums. As such, we believe our 

proposal is a very transparent approach. We stated that we would update the rate through 

our annual PFS rulemaking process. In response to comments on this aspect of our 

proposal, we are clarifying that we generally intend to update the interest rate calculation 
44 

through future rulemaking when we broadly update one or more of the other direct 

practice expense inputs, such as pricing or labor wage rates, to maintain relatively 

between the practice expense components. Given that we do not anticipate updating the 

interest rate assumption every year, we do not believe it is necessary to use a rolling 

average in the calculation. Periodic updates using the most recent Prime rate will balance 

commenters’ desire for stability in the PE RVUs with the need to maintain appropriate 

relativity under the PFS. We also do not believe a transition is appropriate in this 

situation. We believe it is important to update the interest rate assumptions to 

appropriately adjust the relativity of equipment in relation to other PE inputs and the 

relation of equipment intensive services to other services on the PFS. 

In summary, we are finalizing without modification our proposal to use a “sliding 

scale” approach based on the current SBA maximum interest rates for different categories 

of loan size (price of the equipment) and maturity (useful life of the equipment). We will 

update the interest rate assumption through PFS rulemaking to account for fluctuations in 

the Prime rate and/or changes to the SBA’s formula to determine maximum allowed 

interest rates. We are clarifying that we generally intend to update the interest rate 

calculation through future rulemaking only in years when we broadly update one or more 

of the other direct practice expense inputs. Accordingly, we anticipate updating the 

interest rate calculation less frequently than annually. 

The effects of this policy on direct equipment inputs are reflected in the CY 2013 

direct PE input database, available on the CMS website under the downloads for the CY 

2013 PFS final rule with comment period at http://www.cms.gov/PhysicianFeeSched/. 

Additionally, we note that the PE RVUs included in Addendum B reflect this policy. 
TABLE 3: CALCULATION OF PE RVUS UNDER METHODOLOGY FOR SELECTED CODES 

Step Source Formula 

99213 Office visit, est Nonfacility 

33533 CABG, arterial, single Facility 

71020 Chest xray Nonfacility 71020-TC Chest x-ray Nonfacility 71020-26 Chest x-ray Nonfacility 93000 ECG, complete Nonfacility 93

EN

(1) Labor cost (Lab) Step 1 AMA 

13.32 77.52 5.74 5.74 0.00 6.12 6

(2) Supply cost (Sup) Step 1 AMA 

2.98 0.00 3.39 3.39 0.00 1.19 1

(3) Equipment cost (Eqp) 

Step 1 AMA 

0.17 0.58 7.24 7.24 0.00 0.11 0

(4) Direct cost (Dir) Step 1 '=(1)+(2)+(3) 

16.48 78.1 16.38 16.38 0.00 7.42 7

(5) Direct adjustment (Dir. Adj.) 

Steps 2-4 See footnote* 

0.5989 0.5989 0.5989 0.5989 0.5989 0.5989 0

(6) Adjusted Labor 

Steps 2-4 =Labor * Dir Adj =(1)*(5) 7.98 46.43 3.44 3.44 0.00 3.67 3

(7) Adjusted Supplies 

Steps 2-4 =Eqp * Dir Adj =(2)*(5) 1.79 0.00 2.03 2.03 0.00 0.72 0

(8) Adjusted Equipment 

Steps 2-4 =Sup * Dir Adj =(3)*(5) 0.1 0.35 4.34 4.34 0.00 0.06 0

(9) Adjusted Direct 

Steps 2-4 =(6)+(7)+(8) 

9.87 46.78 9.81 9.81 0.00 4.44 4

(10) Conversion Factor (CF) 

Step 5 PFS 

34.0376 34.0376 34.0376 34.0376 34.0376 34.0376 3

(11) Adj. labor cost converted 

Step 5 =(Lab * Dir Adj)/CF =(6)/(10) 

0.23 1.36 0.1 0.1 0.00 0.11 0

(12) Adj. supply cost converted 

Step 5 =(Sup * Dir Adj)/CF =(7)/(10) 

0.05 0 0.06 0.06 0.00 0.02 0
Step Source Formula 

99213 Office visit, est Nonfacility 

33533 CABG, arterial, single Facility 

71020 Chest xray Nonfacility 71020-TC Chest x-ray Nonfacility 71020-26 Chest x-ray Nonfacility 93000 ECG, complete Nonfacility 93

EN

(13) Adj. equipment cost converted 

Step 5 =(Eqp * Dir Adj)/CF =(8)/(10) 

0.00 0.01 0.13 0.13 0.00 0.00 0

(14) Adj. direct cost converted 

Step 5 =(11)+(12)+(1 3) 

0.29 1.37 0.29 0.29 0.00 0.13 0

(15) Work RVU Setup File PFS 

0.97 33.75 0.22 0.00 0.22 0.17 0

(16) Dir_pct Steps 6,7 Surveys 

0.31 0.18 0.31 0.31 0.31 0.31 0

(17) Ind_pct Steps 6,7 Surveys 

0.69 0.82 0.69 0.69 0.69 0.69 0

(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)*(17)

((7

(19) Ind. Alloc.(1st part) 

Step 8 See 18 

0.87 6.43 0.71 0.71 0.00 0.32 0

(20) Ind. Alloc. Formula (2nd part) 

Step 8 See Step 8 

(15) (15) (15+11) (11) (15) (15+11) (1

(21) Ind. Alloc.(2nd part) 

Step 8 See 20 

0.97 33.75 0.32 0.10 0.22 0.28 0

(22) Indirect Allocator (1st + 2nd) 

Step 8 =(19)+(21) 

1.84 40.18 1.03 0.81 0.22 0.60 0
Step Source Formula 

99213 Office visit, est Nonfacility 

33533 CABG, arterial, single Facility 

71020 Chest xray Nonfacility 71020-TC Chest x-ray Nonfacility 71020-26 Chest x-ray Nonfacility 93000 ECG, complete Nonfacility 93

EN

(23) Indirect Adjustment (Ind. Adj.) 

Steps 9-11 See Footnote** 

0.4037 0.4037 0.4037 0.4037 0.4037 0.4037 0

(24) Adjusted Indirect Allocator 

Steps 9-11 =Ind Alloc * Ind Adj 

0.74 16.22 0.42 0.33 0.09 0.24 0

(25) Ind. Practice Cost Index (IPCI) 

Steps 12-16 

1.08 0.79 0.93 0.93 0.93 0.92 0

(26) Adjusted Indirect 

Step 17 = Adj.Ind Alloc * PCI =(24)*(25) 

0.81 12.76 0.39 0.3 0.08 0.22 0

(27) PE RVU Step 18 

=(Adj Dir + Adj Ind) * budn 

 =((14)+(26)) * budn 

1.09 14.12 0.67 0.59 0.08 0.35 0

Note: PE RVUs in table 2, row 28, may not match Addendum B due to rounding. * The direct adj = [current pe rvus * CF * avg dir pct]/[sum d[Step 2]/[Step 3]** The indirect adj = [current pe rvus * avg ind pct]/[sum of ind allocators] = [Step 9]/[Step 10] Note: The use of any particular conversion factor (CF) in Table 3 to illustrate the PE calculation has no effect on the resulting RVUs. 
3. Changes to Direct PE Inputs for Specific Services 

In this section, we discuss other specific CY 2013 proposals and changes related to direct 

PE inputs for specific services. The changes we proposed and are finalizing are included in the 

final rule CY 2012 direct PE database, which is available on the CMS Web site under the 

supporting data files for the CY 2012 PFS final rule with comment period at 

www.cms.gov/PhysicianFeeSched/. We note that we address comments on the interim direct PE 

inputs established in the CY 2012 PFS final rule with comment period in section II.M. of this 

final rule with comment period. 

a. Equipment Minutes for Interrogation Device Evaluation Services 

It has come to our attention that the pacemaker follow-up system (EQ138) associated 

with two interrogation device management service codes does not have minutes allocated in the 

direct PE input database. Based on our analysis of these services, we believed that 10 minutes 

should be allocated to the equipment for each of the following CPT codes: 93294 (Interrogation 

device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system 

with interim physician analysis, review(s) and report(s)), and 93295 (Interrogation device 

evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable cardioverterdefibrillator system with interim physician analysis, review(s) and report(s)). Therefore, the 

direct PE input database was modified to allocate 10 minutes to the pacemaker follow-up system 

for CPT codes 93294 and 93295. 

Comment: One commenter expressed support for this modification. 

Response: We appreciate the support for the modification and will maintain the allocated 

equipment minutes in the final direct PE input database. 

b. Clinical Labor for Pulmonary Rehabilitation Services (HCPCS Code G0424) 

It has come to our attention that the direct PE input database includes 15 minutes of 
49 

clinical labor time in the nonfacility setting allocated for a CORF social worker/psychologist 

(L045C) associated with HCPCS code G0424 (Pulmonary rehabilitation, including exercise 

(includes monitoring), one hour, per session, up to two sessions per day). Based on our analysis 

of this service, we believed that these 15 minutes should be added to the 15 minutes currently 

allocated to the Respiratory Therapist (L042B) associated with this service. Therefore, we 

proposed to modify the direct PE input database to allocate 15 additional minutes to the 

Respiratory Therapist (L042B) (for a total of 30 minutes) and to delete the CORF social 

worker/psychologist (L045C) associated with HCPCS code G0424. 

Comment: One commenter supported the modification as accurate and fair. Another 

commenter suggested that the appropriate clinical staff time for the code should be 60 minutes 

since the code describes an hour long session. Furthermore, the same commenter expressed 

opposition to reassigning the 15 minutes to the Respiratory Therapist because the rate per minute 

of the Respiratory Therapist is lower than the rate per minute of the CORF social 

worker/psychologist and the change, however modest, may potentially reduce the PE RVUs for 

the service. 

Response: We appreciate the support for the modification and understand the 

commenter’s concerns. We recognize that for many services with code descriptors that include 

procedure time assumptions, the number of clinical labor minutes allocated during the service 

period corresponds to the time as described by the code. However, as we explained in the CY 

2011 PFS final rule with comment period (75 FR 73299), because pulmonary rehabilitation 

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 pulmonary rehabilitation service. We also recognize that reclassifying the direct PE 

input labor category from CORF social worker/psychologist to Respiratory Therapist for 15 

minutes will reduce the direct labor costs used in calculating PE RVUs for the service. However, 
50 

we continue to believe that the Respiratory Therapist is the most appropriate labor category to 

include as a direct PE input for this service. 

After consideration of the comments we received, we are finalizing the modification of 

the direct PE labor inputs for this service to allocate 15 additional minutes to the Respiratory 

Therapist (L042B) (for a total of 30 minutes) and to delete the CORF social worker/psychologist 

(L045C) associated with HCPCS code G0424. 

c. Transcranial Magnetic Stimulation Services 

For CY 2011, the CPT Editorial Panel converted Category III CPT codes 0160T and 

0161T to Category I status (CPT codes 90867 (Therapeutic repetitive transcranial magnetic 

stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, 

delivery and management), and 90868 (Therapeutic repetitive transcranial magnetic stimulation 

(TMS) treatment; subsequent delivery and management, per session)), which were contractor 

priced on the PFS. For CY 2012, the CPT Editorial Panel modified CPT codes 90867 and 

90868, and created CPT code 90869 ((Therapeutic repetitive transcranial magnetic stimulation 

(TMS) treatment; subsequent motor threshold re-determination with delivery and management.) 

In the CY 2012 PFS final rule with comment period, we established interim final values based on 

refinement of RUC-recommended work RVUs, direct PE inputs, and malpractice risk factor 

crosswalks for these services (76 FR 73201). 

Subsequent to the development of interim final PE RVUs, it came to our attention that the 

application of our usual PE methodology resulted in anomalous PE values for these services. As 

we explain in section II.A.2.c.2 of this final rule with comment period, for a given service, we 

use the direct costs associated with a service (clinical staff, equipment, and supplies) and the 

average percentage that direct costs represent of total costs (based on survey data) across the 

specialties that furnish the service to determine an initial indirect allocator. 

For services almost exclusively furnished by one specialty, the average percentage of 
51 

indirect costs relative to direct costs would ordinarily be used to determine the initial indirect 

allocator. For specialties that typically incur significant direct costs relative to indirect costs, the 

initial indirect allocator for their services is generally lower than for the specialties that typically 

incur lower direct costs relative to indirect costs. Relative to direct costs, the methodology 

generally allocates a greater proportion of indirect PE to services furnished by psychiatrists, for 

example, than to services furnished by specialties that typically incur significant direct costs, 

such as radiation oncologists. In the case of TMS, however, the direct costs incurred by 

psychiatrists reporting the codes far exceed the direct costs typical to any other service 

predominantly furnished by psychiatrists. This drastic difference in the direct costs of TMS 

relative to most other services furnished by psychiatrists, results in anomalous PE values since 

code-level indirect PE allocation relies on typical resource costs for the specialties that furnish 

the service. In other words, the amount of indirect PE allocated to TMS services is based on the 

proportion of indirect expense to direct expense that is typical of other psychiatric services, and 

is not on par with other services that require similar investments in capital equipment and highcost, disposable supplies. 

Historically, we have contractor-priced (meaning our claims processing contractors 

develop payment rates) for services with resource costs that cannot be appropriately valued 

within the generally applicable PE methodology used to price services across the PFS. Because 

there is no mechanism to develop appropriate payment rates for these services within our current 

methodology, we proposed to contractor price these codes for CY 2013. 

Comment: One commenter objected to the proposal to contractor price these codes for 

CY 2013 and suggested that CMS should establish PE RVUs using the generally applicable PE 

methodology and must endeavor in ensuing rulemaking to revise the methodology to refine any 

values the agency views as “anomalous.” The commenter also questioned CMS’s assumption 

that the direct costs for psychiatrists who furnish these services “far exceed” the direct costs for 
52 

psychiatrists who do not furnish these services. The commenter stated that CMS made this 

assessment without any empirical support and that CMS needs to conduct a survey or obtain 

other data from psychiatrists before drawing any conclusions regarding the appropriateness of 

Medicare payment rates on this basis. 

Response: We understand the commenter’s objections, but as we explained in the 

proposal, we do not believe that there is a mechanism within the current methodology that allows 

us to develop appropriate payment rates for these services. We agree with the commenter that it 

may be appropriate to consider potential changes to the practice expense methodology to 

accommodate changing circumstances of medical practice. We do not agree with the 

commenter, however, that we have no means to pay appropriately for services when we 

recognize areas where the practice expense methodology is inadequate and that we must 

establish national RVUs based on that methodology, even when it does not accommodate the 

unique circumstances of particular services. Instead, we believe that in outlier cases, contractor 

pricing allows Medicare to pay more appropriately for particular services furnished to 

beneficiaries. 

 In our proposal, we pointed out that the direct costs incurred by psychiatrists reporting 

the codes far exceed the direct costs typical to any other service predominantly furnished by 

psychiatrists. The commenter objected to this assertion and claimed it was made without any 

empirical support. We made that assertion based on comparing the direct practice expense input 

costs for transcranial magnetic stimulation services and the current direct practice expense input 

costs in the direct PE database for services predominantly furnished by the specialty based on 

Medicare claims data. In our examination of 20 frequently billed psychiatry services (where 

greater than half of the Medicare allowed services were reported by psychiatrists), the total direct 

costs (clinical labor, disposable medical supplies, or medical equipment) in the direct PE input 

database summed to under $ 10 for all but 3 of these 20 services. Examples of these services 
53 

include CPT codes 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), 90862 (Pharmacologic 

management, including prescription, use, and review of medication with no more than minimal 

medical psychotherapy), and 90845 (Psychoanalysis). For the three where the direct PE input 

costs summed to greater than $10, HCPCS code M0064 (Brief office visit for the sole purpose of 

monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and 

personality disorders), and CPT codes 90865 (Narcosynthesis for psychiatric diagnostic and 

therapeutic purposes (eg, sodium amobarbital (Amytal) interview)), and 90870 

(Electroconvulsive therapy (includes necessary monitoring)) , the service with the highest direct 

cost sum was $32.24. In contrast, the transcranial magnetic stimulation services treatment 

delivery (CPT code 90867) included direct PE inputs that summed to direct costs of $145.19. 

The disparity between the TMS direct costs and the direct costs in other frequent psychiatry 

codes was the basis for our assertion that the direct costs for this service far exceeded the direct 

costs typical to any other service predominantly furnished by psychiatrists. Thus, we continue to 

believe our decision to contractor price these codes is the proper one. 

Comment: Another commenter requested that CMS use the existing methodology to 

price the codes or contractor price the codes. This commenter also urged CMS to consider 

alternate sources of data for resource costs as they become available, or to make appropriate 

future refinements to the practice expense methodology. 

Response: We appreciate the commenter’s support for our proposal as a suitable means 

of pricing the services. We will consider appropriate means to develop national prices for these 

services in the context of potential changes to the practice expense methodology and the 

availability of new data sources. 

After consideration of these public comments, we are finalizing our proposal to 
54 

contractor price CPT codes 90867, 90868, and 90869 for CY 2013. 

d. Spinal Cord Stimulation Trial Procedures in the Nonfacility Setting 

Stakeholders have recently brought to our attention that CPT code 63650 (Percutaneous 

implantation of neurostimulator electrode array, epidural) is frequently furnished in the physician 

office setting but is not priced in that setting. We note that the valuation of a service under the 

PFS in particular settings does not address whether those services are medically reasonable and 

necessary in the case of individual patients, including being furnished in a setting appropriate to 

the patient’s medical needs and condition. However, because these services are being furnished 

in the nonfacility setting, we believed that CPT code 63650 should be reviewed to establish 

appropriate nonfacility inputs. We proposed to review CPT code 63650 and requested 

recommendations from the AMA RUC and other public commenters on the appropriate 

physician work RVUs (as measured by time and intensity), and facility and nonfacility direct PE 

inputs for this service. We understand that disposable leads comprise a significant resource cost 

for this service and are currently separately reportable to Medicare for payment purposes when 

the service is furnished in the physician office setting. Disposable medical supplies are not 

considered prosthetic devices paid under the Durable Medical Equipment, Prosthetic/Orthotic, 

and Supplies (DMEPOS) fee schedule and generally are incorporated as nonfacility direct PE 

inputs to PE RVUs. We sought comment on establishing nonfacililty PE RVUs for CPT code 

63650. 

 Comment: Several commenters expressed concerns regarding the possibility of 

establishing nonfacility PE RVUs for this service based on the assumption that the nonfacility 

PFS payment rate would be lower than the rate paid by the Medicare hospital outpatient 

prospective payment system (OPPS). These commenters stated that the supply, personnel, and 

administration costs are higher in the non-facility setting than in the facility setting and that 

current Medicare payment for L8680 under the DMEPOS fee schedule offsets the difference in 
55 

costs between the facility and nonfacility setting. Many of these commenters also stated that it is 

more cost effective for the Medicare program for these services to be furnished in the nonfacility 

setting. These commenters also stated that it is more convenient for patients to receive this 

service in the nonfacility setting, so that Medicare should not implement nonfacility payment 

rates because doing so might discourage practitioners from furnishing the service in the 

nonfacility setting. 

Response: We understand the commenters’ interest in ensuring that Medicare 

beneficiaries retain access to the service in the nonfacility setting. We do not agree with the 

commenters’ underlying assumption that developing accurate payment rates for the service in the 

nonfacility setting will necessarily deter practitioners from furnishing the service to Medicare 

beneficiaries outside the facility setting. Additionally, we do not know how to reconcile the 

contradictory contentions of many individual commenters that the costs of furnishing the 

services in the nonfacility setting are greater so that payment rates should be higher, but 

furnishing services there would still be more cost effective for Medicare. 

Comment: One commenter supported the proposal to create nonfacility RVUs for this 

service since it would reduce overutilization of the service and lower the likelihood of fraud. 

Response: We appreciate the support for the proposal, and we generally agree that 

developing accurate payment rates encourages appropriate utilization. 

Comment: One commenter stated that CMS should continue to provide payment for 

HCPCS code L8680 until non-facility PE inputs for CPT code 63650 including the leads have 

been developed. 

Response: We appreciate the commenter’s concerns. We would continue a mechanism 

to provide payment for the disposable leads used in furnishing the service while we develop nonfacility PE inputs. We also agree that once a practice expense payment reflects these disposable 

leads, that a separate payment mechanism would no longer be necessary. 
56 

Comment: The AMA RUC agreed that the direct practice expense inputs for the service 

should be reviewed to establish appropriate inputs in both the facility and nonfacility setting. 

After consideration of the comments we received regarding our proposal to establish 

nonfacility PE RVUs for CPT code 63650 (Percutaneous implantation of neurostimulator 

electrode array, epidural), we continue to believe that it would be appropriate to do so since these 

services are being furnished in the nonfacility setting. The AMA RUC expects to review the 

direct PE inputs for this service during CY 2013. We anticipate receiving recommendations 

from the AMA RUC for the CY 2014 PFS, and we request comments from other stakeholders 

regarding the appropriate direct PE inputs for this service 

B. Potentially Misvalued Codes Under the Physician Fee Schedule

1. Valuing Services Under the PFS 

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: work; practice 

expense (PE); and malpractice. 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.” 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 II.B.1.b. and II.B.1.c. of this final rule with comment 

period, 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.” Section 1848(c)(1)(C) of the 
57 

Act defines the malpractice component as “the portion of the resources used in furnishing the 

service that reflects malpractice expenses in furnishing the service.” Clause (ii) and clause (iii) 

of section 1848 (c)(2)(C) of the Act specify that PE and malpractice expense RVUs shall be 

determined based on the relative PE/malpractice expense resources involved in furnishing the 

service. 

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. On March 23, 2010, the 

Affordable Care Act was enacted, further requiring the Secretary to periodically identify and 

review potentially misvalued codes and make appropriate adjustments to the relative values of 

those services identified as being potentially misvalued. Section 1848(c)(2)(K) to the Act 

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 

1848(c)(2)(L) of the Act requires the Secretary to develop a process to validate the RVUs of 

certain potentially misvalued codes under the PFS, identified using the same criteria used to 

identify potentially misvalued codes, and to make appropriate adjustments. 

As discussed in section I.B.1.a. of this final rule with comment period, each year we 

develop and propose appropriate adjustments to the RVUs, taking into account the 

recommendations provided by the American Medical Association Specialty Society Relative 

Value Scale Update Committee (AMA RUC), the Medicare Payment Advisory Commission 

(MedPAC), and others. For many years, the AMA RUC has provided us with recommendations 

on the appropriate relative values for new, revised, and potentially misvalued PFS services. We 

review these recommendations on a code-by-code basis and consider these recommendations in 

conjunction with the recommendations of other public commenters, and with analyses of data 

sources, such as claims data, to inform the decision-making process as authorized by the law. 

We may also consider analyses of physician time, work RVUs, or direct PE inputs using other 
58 

data sources, such as Department of Veteran Affairs (VA) National Surgical Quality 

Improvement Program (NSQIP), the Society for Thoracic Surgeons (STS), and the Physician 

Quality Reporting Initiative (PQRI) databases. In addition to considering the most recently 

available data, we also assess the results of physician surveys and specialty recommendations 

submitted to us by the AMA RUC. We conduct a clinical review to assess the appropriate RVUs 

in the context of contemporary medical practice. 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. In accordance with 

section 1848(c) of the Act, we determine appropriate adjustments to the RVUs, explain the basis 

of these adjustments, and respond to public comments in the PFS proposed and final rules. 

2. Identifying, Reviewing, and Validating the RVUs of Potentially Misvalued Services on the 

PFS 

a. Background 

In its March 2006 Report to the 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, MedPAC stated, “when a new service is added to the PFS, it may be assigned a 

relatively high value because of the time, technical skill, and psychological stress that are often 

required to furnish that service. Over time, the work required for certain services would be 

expected to decline as physicians become more familiar with the service and more efficient in 

furnishing it.” That is, the amount of physician work needed to furnish an existing service may 

decrease as physicians build experience furnishing that service. Services can also become 

overvalued when PEs decline. This can happen when the costs of equipment and supplies fall, or 
59 

when equipment is used more frequently than is estimated in the PE methodology, reducing its 

cost per use. Likewise, services can become undervalued when physician work increases or PEs 

rise. In the ensuing years since MedPAC’s 2006 report, additional groups of potentially 

misvalued services have been identified by the 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 directed the Secretary to specifically examine, as determined 

appropriate, potentially misvalued services in seven categories as follows: 

● Codes and families of codes for which there has been the fastest growth; 

● Codes and families of codes that have experienced substantial changes in PEs; 

● Codes that are recently established for new technologies or services; 

● Multiple codes that are frequently billed in conjunction with furnishing a single 

service; 

● Codes with low relative values, particularly those that are often billed multiple times 

for a single treatment; 

● Codes which have not been subject to review since the implementation of the PFS (the 

so-called ‘Harvard-valued codes’); and 

● Other codes determined to be appropriate by the Secretary. 

Section 1848(c)(2)(K)(iii) of the Act 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, as the Secretary determines to be appropriate, to facilitate 
60 

the review and appropriate adjustment of potentially misvalued services. This section also 

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. Additionally, this section provides that the 

Secretary may coordinate the review and adjustment of any RVU with the periodic review 

described in section 1848(c)(2)(B) of the Act. Finally, section 1848(c)(2)(K)(iii)(V) of the Act 

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 PFS. 

In addition to these requirements, section 3003(b)(1) of the Middle Class Tax Relief and 

Job Creation Act of 2012 (MCTRJCA) (Pub. L. 112-96), requires that the Secretary conduct a 

study that examines options for bundled or episode-based payment to cover physicians’ services 

currently paid under the PFS under section 1848 of the Act for one or more prevalent chronic 

conditions or episodes of care for one or more major procedures. In conducting the study, the 

Secretary shall consult with medical professional societies and other relevant stakeholders. 

Additionally, the study shall include an examination of related private payer payment initiatives. 

This section also requires that not later than January 1, 2013, the Secretary submit to certain 

committees of the Congress a report on the study. The report shall include recommendations on 

suitable alternative payment options for services paid under the PFS and on associated 

implementation requirements. 

Bundling is one method for aligning incentives for hospitals, post-acute care providers, 

physicians, and other practitioners to partner closely across all specialties and settings that a 

patient may encounter to improve the patient’s experience of care. The typical goals of 

developing an effective bundled payment system are to improve quality, reduce costs, and 

promote efficiency. Current work on bundling services paid under the PFS to date has been 
61 

limited to targeting specific codes and sets of codes and repackaging those codes into “bundles.” 

As detailed above, through the potentially misvalued codes initiative we are currently identifying 

for review codes that are frequently billed together and codes with low relative values billed in 

multiples. Many of the codes identified through these screens have been referred to the CPT 

Editorial Panel for the development of a comprehensive or bundled code, and several bundled 

codes have already been created and valued. However, we believe that we now need to move 

beyond this “repackaging” of codes and examine the potential of a larger bundled payment 

within the PFS. In response to section 3003(b)(1) of the MCTRJCA, we have consulted with 

medical professional societies, private payers, healthcare system administrators, and other 

stakeholders; met with other CMS staff involved in other bundling initiatives; and performed an 

extensive literature review. Additionally, we have had representatives of specialty groups such 

as radiation oncologists volunteer to work with us to create a bundled payment for their services. 

If we were to engage in a bundling project for radiation therapy, we would want to do more than 

provide a single episode payment for the normal course of radiation therapy that aggregates the 

sum of the individual treatments. Radiation therapy has many common side effects that can vary 

based on the type of cancer the patient has and how it is being treated. Common side effects 

associated with radiation therapy include fatigue, skin problems, eating problems, blood count 

changes, emotional issues such as depression, etc... If we were to engage in a bundling project 

that includes radiation therapy, we would be interested in exploring whether it could also include 

treating and managing the side effects that result from radiation therapy in addition to the 

radiation therapy itself. Such an episode-based payment would allow Medicare to pay for the 

full course of the typical radiation therapy as well as the many medical services the patient may 

be receiving to treat side effects. 

We will continue to examine options for bundled or episode-based payments and will 

include our recommendations and implementation options in our report to the Congress. 
62 

Following completion of this report, we will look forward with interest to the view of 

stakeholders that are interested in testing some of these concepts within the PFS. 

b. Progress in Identifying and Reviewing Potentially Misvalued Codes 

In accordance with our statutory mandate, we have identified and reviewed numerous 

potentially misvalued codes in all seven of the categories specified in section 1848(c)(2)(K)(ii) 

of the Act, and we plan to continue our work examining potentially misvalued codes in these 

areas over the upcoming years. In the current process, we identify potentially misvalued codes 

for review, and request recommendations from the AMA RUC and other public commenters on 

revised work RVUs and direct PE inputs for those codes. The AMA RUC, through its own 

processes, identifies potentially misvalued codes for review, and through our public nomination 

process for potentially misvalued codes established in the CY 2012 PFS final rule, other 

individuals and stakeholder groups submit nominations for review of potentially misvalued 

codes as well. 

Since CY 2009, as a part of the annual potentially misvalued code review and Five-Year 

Review processes, we have reviewed over 1,000 potentially misvalued codes to refine work 

RVUs and direct PE inputs. We have adopted appropriate work RVUs and direct PE inputs for 

these services as a result of these reviews. 

Our prior reviews of codes under the potentially misvalued codes initiative have included 

codes in all seven categories specified in section 1848(c)(2)(K)(ii) of the Act, listed above. 

A more detailed discussion of the extensive prior reviews of potentially misvalued codes is 

included in the CY 2012 PFS final rule with comment period (76 FR 73052 through 73055). 

In the CY 2012 final rule with comment period, under the potentially misvalued codes 

category of “Other codes determined to be appropriate by the Secretary,” we finalized our 

proposal to review a list of the highest PFS expenditure services, by specialty, that had not been 

recently reviewed (76 FR 73059 through73068). In the CY 2012 final rule with comment period 
63 

we also finalized policy to consolidate the periodic reviews of physician work and PE at the 

same time (76 FR 73055 through 73958), and established a process for the annual public 

nomination of potentially misvalued services to replace the Five-Year review process (76 FR 

73058 through 73059). Below we discuss the CY 2013 PFS proposals that support our 

continuing efforts to appropriately identify, review, and adjust values for potentially misvalued 

codes. 

c. Validating RVUs of Potentially Misvalued Codes 

In addition to identifying and reviewing potentially misvalued codes, section 

1848(c)(2)(L) of the Act specifies that the Secretary shall establish a formal process to validate 

RVUs under the PFS. The validation process may include validation of work elements (such as 

time, mental effort and professional judgment, technical skill and physical effort, and stress due 

to risk) involved with furnishing a service and may also include validation of the pre-, post-, and 

intra-service time components of work. The Secretary is directed, as part of the validation, to 

validate a sampling of the work RVUs of codes identified through any of the seven categories of 

potentially misvalued codes specified by section 1848(c)(2)(K)(ii) of the Act. 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. 

In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS proposed rule (76 

FR 42790), we solicited public comments on possible approaches, methodologies, and data 

sources that we should consider for a validation process. A summary of the comments along 

with our responses are included in the CY 2011 PFS final rule with comment period (75 FR 

73217) and the CY 2012 PFS final rule with comment period (77 FR 73054 through 73055). In 

September 2012 we entered into two contracts to assist us in validating RVUs of potentially 
64 

misvalued codes; the implementation details for these contracts are currently under development. 

Contractors will explore models for the validation of physician work under the PFS, both for new 

and existing services. We plan to discuss these models further in future rulemaking. 

d. Improving the Valuation of the Global Surgical Package 

(1) Background 

We applied the concept of payment for a global surgical package under the PFS at its 

inception on January 1, 1992 (56 FR 59502). For each global surgical procedure, we establish a 

single payment, which includes payment for a package of all related services typically furnished 

by the surgeon furnishing the procedure during the global period. Each global surgery is paid on 

the PFS as a single global surgical package. Each global surgical package payment rate is based 

on the work necessary for the typical surgery and related pre- and post-operative work. The 

global period may include 0, 10, or 90 days of post-operative care, depending on the procedure. 

For major procedures, those with a 90-day global period, the global surgical package payment 

also includes services typically furnished the day prior to the day of surgery. 

Some global surgical packages have been valued by adding the RVU of the surgical 

procedure and all pre- and post-operative evaluation and management (E/M) services included in 

the global period. Others have been valued using magnitude estimation, in which case the 

overall RVU for the surgical package was determined without factoring in the specific RVUs 

associated with the E/M services in the global period. The number and level of E/M services 

identified with a global surgery payment are based on the typical case. Even though a surgical 

package may have been developed with several E/M services included, a physician is not 

required to furnish each pre- or post-operative visit to bill for the global surgical package. 

Similar to other bundled services on the PFS, when a global surgery code is billed, the 

bundled pre- and post-operative care is not separately payable; surgeons or other physicians 
65 

billing a surgical procedure, cannot separately bill for the E/M services that are included in the 

global surgical package. 

(2) Measuring Post-Operative Work 

The use of different methodologies for valuing global surgical packages since 1992 has 

created payment rates that reflect a wide range of E/M services within the post-operative period. 

This is especially true among those with 90-day global periods. More recently reviewed codes 

tend to have fewer E/M services in the global period, and the work RVUs of those E/M services 

are often accounted for in the value for the global surgical package. The values of global 

surgical packages reviewed less recently frequently do not appear to include the full work RVUs 

of each E/M service in the global surgical package, and the numbers of E/M services included in 

the post-operative period can be inconsistent within a family of procedures. 

In 2005, the HHS Office of Inspector General (OIG) examined whether global surgical 

packages are appropriately valued. In its report on eye and ocular surgeries, “National Review 

of Evaluation and Management Services Included in Eye and Ocular Adnexa Global Surgery 

Fees for Calendar Year 2005” (A-05-07-00077), the OIG reviewed a sample of 300 eye and 

ocular surgeries, and counted the actual number of face-to-face services in the surgeons’ medical 

records to establish whether the surgeon furnished post-operative E/M services. The OIG 

findings show that surgeons typically furnished fewer E/M services in the post-operative period 

than were identified with the global surgical package payment for each procedure. A smaller 

percentage of surgeons furnished more E/M services than were identified with the global surgical 

package payment. The OIG could only review the number of face-to-face services and was not 

able to review the level of the E/M services that the surgeons furnished due to a lack of 

documentation in surgeons’ medical records. The OIG concluded that the RVUs for the global 

surgical package are too high because they include the work of E/M services that are not 

typically furnished within the global period for the reviewed procedures. 
66 

Following the 2005 report, the OIG continued to investigate E/M services furnished 

during the global surgical period. In May 2012, the OIG published a report titled 

“Musculoskeletal Global Surgery Fees Often Did Not Reflect the Number of Evaluation and 

Management Services Provided” (A-05-09-00053). For this investigation, the OIG sampled 300 

musculoskeletal global surgeries and again found that, for the majority of sampled surgeries, 

physicians furnished fewer E/M services than were identified as part of the global period for that 

service. Once again, a smaller percentage of surgeons furnished more E/M services than were 

identified with the global surgical package payment. The OIG concluded that the RVUs for the 

global surgical package are too high because they include the work of E/M services that are not 

typically furnished within the global period for the reviewed procedures. 

In both reports, the OIG recommended that we adjust the number of E/M services 

identified with the global surgical payments to reflect the number of E/M services that are 

actually being furnished. Under the PFS, we do not ask surgeons to detail the component 

bundled services on their claim when billing for the global surgical package as we do providers 

furnishing bundled services under other Medicare payment systems. Since it is not necessary for 

a surgeon to identify the level or CPT code of the E/M services actually furnished during the 

global period, there is very limited documentation on the frequency or level of post-operative 

services. Without sufficient documentation, a review of the medical record cannot accurately 

determine the number or level of E/M services furnished in the post-operative period. This is an 

area of concern, and is discussed in more detail later in this section. 

As noted above, section 1848(c)(2)(K) of the Act, which codified and expanded the 

potentially misvalued codes initiative that CMS had begun, requires that the Secretary identify 

and review potentially misvalued services with an emphasis on several categories, and 

recognizes the Secretary’s discretion to identify additional potentially misvalued codes. Several 

of the categories of potentially misvalued codes support better valuation of global surgical 
67 

package codes. We have made efforts to prioritize the review of RVUs for services on the PFS 

that have not been reviewed recently or for services where there is a potential for misuse. One of 

the priority categories for review of potentially misvalued codes is services that have not been 

subject to review since the implementation of the PFS (the so-called “Harvard-valued codes”). 

In the CY 2009 PFS proposed rule, we requested that the AMA RUC engage in an ongoing effort 

to review the remaining Harvard-valued codes, focusing first on the high-volume codes (73 FR 

38589). For the Fourth Five-Year Review (76 FR 32410), we requested that the AMA RUC 

review services that have not been reviewed since the original implementation of the PFS with 

utilization greater than 30,000 (Harvard-valued—Utilization > 30,000). In the CY 2013 PFS 

proposed rule, we proposed to review Harvard-valued services with annual allowed charges that 

totaled at least $10,000,000 (Harvard-valued—Allowed charges ≥$10,000,000), and requested 

recommendations from the AMA RUC and other public commenters on appropriate values for 

these services (77 FR 44741). 

Of the more than 1,000 identified potentially misvalued codes, just over 650 are surgical 

services with a global period of 0, 10, or 90 days. We have completed our review of 450 of these 

potentially misvalued surgical codes. As we stated in the CY 2013 PFS proposed rule, these 

efforts are important, but we believe the usual review process does not go far enough to assess 

whether the valuation of global surgical packages reflects the number and level of post-operative 

services that are typically furnished. To support our statutory obligation to identify and review 

potentially misvalued services and to respond to the OIG’s concern that global surgical package 

payments are misvalued, we believe that we should gather more information on the E/M services 

that are typically furnished with surgical procedures. Information regarding the typical work 

involved in surgical procedures with a global period is necessary to evaluate whether certain 

surgical procedures are appropriately valued. While the AMA RUC reviews and recommends 

RVUs for services on the PFS, we complete our own assessment of those recommendations, and 
68 

may adopt different RVUs. However, for procedures with a global period, the lack of detail in 

claims data and documentation restrict our ability to review and assess the appropriateness of 

their RVUs. 

In the CY 2013 proposed rule, we requested comments on methods of obtaining accurate 

and current data on E/M services furnished as part of a global surgical package. We stated that 

we were especially interested in and invited comments on a claims-based data collection 

approach that would include reporting E/M services furnished as part of a global surgical 

package, as well as other valid, reliable, generalizable, and robust data to help us identify the 

number and level of E/M services typically furnished in the global surgical period for specific 

procedures. 

The following is summary of the comments we received regarding the methods of 

obtaining accurate and current data on E/M services furnished as part of a global surgical 

package proposal. 

 Comment: Several commenters stated that the global payment methodology has 

restricted CMS’ ability to audit the accuracy of the current value of services as well as the 

accuracy of the AMA RUC recommendations for services with a global period. Many 

commenters offered recommendations on how CMS could validate the current global surgical 

packages or obtain accurate and current data on E/M services furnished as a part of the global 

surgical package. Some commenters recommended that CMS establish auditable documentation 

requirements for inpatient and outpatient post-operative visits, and many believed that these 

auditable post-operative visit notes should follow E/M documentation guidelines. Other 

commenters suggested that CMS adjust all surgical services to a 0-day global period, require 

surgeons to bill post-operative E/M services separately for payment purposes, and subject those 

billings to the same coding and documentation standards and audits to which other practitioners 

are already subject. Several commenters noted that CMS could validate the global surgical 
69 

packages with the hospital Diagnosis-Related Group (DRG) length of stay data, and that CMS 

could explore the use of surgical specialties’ registries to collect data on services furnished 

within the global period. Commenters also suggested that CMS could draw upon the OIG’s 

approach and review the medical record for a statistically valid sample of claims and then 

extrapolate those results to clinically similar families of codes. One commenter suggested that 

CMS could establish G-codes through which a large sample of surgeons might report the number 

and intensity of post-operative visits. 

 In response to our request for comments on methods of obtaining accurate and current 

data on E/M services furnished as part of a global surgical package, some commenters stated that 

they believe post-operative work is appropriately surveyed, vetted and valued by the AMA RUC 

during its ongoing reviews of surgical procedures, and therefore, claims-based reporting is 

unnecessary in order to verify that the number of visits assigned to global surgical procedures is 

accurate. Some commenters stated that if CMS has concerns with a specific code, or group of 

codes, regarding the number of E/M visits valued within the physician work RVU, CMS should 

work with the AMA RUC to review these services. One commenter noted that there are 4,258 

CPT codes on the PFS with a global period, but that only 271 of these CPT codes are billed 

more than 10,000 times annually, and most of the 271 CPT codes have been reviewed by CMS 

and the AMA RUC since 2005. 

 Response: We thank the commenters for their recommendations on this important 

issue. We will carefully weigh all comments received as we consider how best to measure the 

number and level of visits that occur during the global period. 

 In addition to the broader comments on measuring post-operative work, we also 

received a comment from the AMA RUC noting that the hospital and discharge management 

services included in the global period for many surgical procedures may have been inadvertently 

removed from the time file in 2007. With its comment letter, the AMA RUC sent us a revised 
70 

time file with updated post-operative visits for the services that may be incorrectly displayed 

with zero visits. We are reviewing this file, and if appropriate, we intend to propose 

modifications to the physician time file in the CY 2014 PFS proposed rule. We note that should 

time have been removed from the physician time file inadvertently, it would not have affected 

the physician work RVUs or direct practice expense inputs for these services. It would have a 

small impact on the indirect allocation of practice expense at the specialty level, which we will 

review when we explore this potential time file change. 

3. CY 2013 Identification and Review of Potentially Misvalued Services 

a. Public Nomination of Potentially Misvalued Codes 

In the CY 2012 PFS final rule, we finalized a public nomination process for potentially 

misvalued codes (76 FR 73058). Under the previous Five-Year Reviews for PE and work, we 

invited the public to nominate potentially misvalued codes for review. To allow for public input 

and to preserve the public’s ability to identify and nominate potentially misvalued codes for 

review under our annual potentially misvalued codes initiative, we established a process by 

which the public can submit codes, along with documentation supporting the need for review, on 

an annual basis. Stakeholders may nominate potentially misvalued codes for review by 

submitting the code with supporting documentation during the 60-day public comment period 

following the release of the annual PFS final rule with comment period. Supporting 

documentation for codes nominated for the annual review of potentially misvalued codes may 

include the following: 

● Documentation in the peer reviewed medical literature or other reliable data that there 

have been changes in physician work due to one or more of the following: technique; knowledge 

and technology; patient population; site-of-service; length of hospital stay; and physician time. 

● Evidence of an anomalous relationship between the code being proposed for review 

and other codes. 
71 

● Evidence that technology has changed physician work, that is, diffusion of technology. 

● Analysis of other data on time and effort measures, such as operating room logs or 

national and other representative databases. 

● Evidence that incorrect assumptions were made in the previous valuation of the 

service, such as a misleading vignette, survey, or flawed crosswalk assumptions in a previous 

evaluation. 

● Prices for certain high cost supplies or other direct PE inputs that are used to determine 

PE RVUs are inaccurate and do not reflect current information. 

● Analyses of physician time, work RVU, or direct PE inputs using other data sources 

(for example, Department of Veteran Affairs (VA) National Surgical Quality Improvement 

Program (NSQIP), the Society for Thoracic Surgeons (STS), and the Physician Quality 

Reporting System (PQRS) databases). 

● National surveys of physician time and intensity from professional and management 

societies and organizations, such as hospital associations. 

Under this newly established process, after we receive the nominated codes during the 

60-day comment period following the release of the annual PFS final rule with comment period, 

we evaluate the supporting documentation and assess whether the submitted codes appear to be 

potentially misvalued codes appropriate for review under the annual process. In the following 

year’s PFS proposed rule, we publish the list of nominated codes, and propose -which nominated 

codes will be reviewed as potentially misvalued. We encourage the public to submit 

nominations for potentially misvalued codes in the 60-day comment period following the 

publication of this CY 2013 PFS final rule with comment period. 

TABLE 4: CPT Codes Nominated as Potentially Misvalued for CY 2013 Rulemaking 

CPT 

Code Short Descriptor CMS Action 
72 

CPT 

Code Short Descriptor CMS Action 

33282 Implant pat-active ht record 

Establish nonfacility inputs, and review the work, facility and 

nonfacility inputs together. Not considered a potentially misvalued 

code. 

33284 Remove pat-active ht record 

Establish nonfacility inputs, and review the work, facility and 

nonfacility inputs together. Not considered a potentially misvalued 

code. 

36819 Av fuse uppr arm basilic Review as a potentially misvalued code. 

36825 Artery-vein autograft Review as a potentially misvalued code. 

53445 Insert uro/ves nck sphincter Interim Final in CY 2012, Final for CY 2013. Comments addressed in 

section II.M.2.a.of this CY 2013 PFS final rule with comment period. 

77336 Radiation physics consult Review as a potentially misvalued code. 

94762 Measure blood oxygen level Adopt direct PE revisions discussed below on an interim final basis for 

CY 2013. 

28820 Amputation of toe Last reviewed for CY 2012. No further review required at this time. 

28825 Partial amputation of toe Last reviewed for CY 2012. No further review required at this time. 

35188 Repair blood vessel lesion Last reviewed for CY 2012. No further review required at this time. 

35612 Artery bypass graft Last reviewed for CY 2012. No further review required at this time. 

35800 Explore neck vessels Last reviewed for CY 2012. No further review required at this time. 

35840 Explore abdominal vessels Last reviewed for CY 2012. No further review required at this time. 

35860 Explore limb vessels Last reviewed for CY 2012. No further review required at this time. 

43283 Lap esoph lengthening Last reviewed for CY 2012. No further review required at this time. 

43327 Esoph fundoplasty lap Last reviewed for CY 2012. No further review required at this time. 

43328 Esoph fundoplasty thor Last reviewed for CY 2012. No further review required at this time. 

43332 Transab esoph hiat hern rpr Last reviewed for CY 2012. No further review required at this time. 

43333 Transab esoph hiat hern rpr Last reviewed for CY 2012. No further review required at this time. 

43334 Transthor diaphrag hern rpr Last reviewed for CY 2012. No further review required at this time. 

43335 Transthor diaphrag hern rpr Last reviewed for CY 2012. No further review required at this time. 

43336 Thorabd diaphr hern repair Last reviewed for CY 2012. No further review required at this time. 

43337 Thorabd diaphr hern repair Last reviewed for CY 2012. No further review required at this time. 

43338 Esoph lengthening Last reviewed for CY 2012. No further review required at this time. 

47563 Laparo cholecystectomy/graph Last reviewed for CY 2012. No further review required at this time. 

49507 Prp i/hern init block >5 yr Last reviewed for CY 2012. No further review required at this time. 

49521 Rerepair ing hernia blocked Last reviewed for CY 2012. No further review required at this time. 

49587 Rpr umbil hern block > 5 yr Last reviewed for CY 2012. No further review required at this time. 

49652 Lap vent/abd hernia repair Last reviewed for CY 2012. No further review required at this time. 

49653 Lap vent/abd hern proc comp Last reviewed for CY 2012. No further review required at this time. 

49654 Lap inc hernia repair Last reviewed for CY 2012. No further review required at this time. 

49655 Lap inc hern repair comp Last reviewed for CY 2012. No further review required at this time. 

60220 Partial removal of thyroid Last reviewed for CY 2012. No further review required at this time. 

60240 Removal of thyroid Last reviewed for CY 2012. No further review required at this time. 

60500 Explore parathyroid glands Last reviewed for CY 2012. No further review required at this time. 

95800 Slp stdy unattended Last reviewed for CY 2012. No further review required at this time. 

 

In the 60 days following the release of the CY 2012 PFS final rule with comment period, 

we received nominations and supporting documentation for review of the codes listed above in 

Table 4. A total of 36 CPT codes were nominated. The majority of the nominated codes were 
73 

codes for which we finalized RVUs in the CY 2012 PFS final rule. That is, the RVUs were 

interim in CY 2011 and finalized for CY 2012, or proposed in either the Fourth Five-Year 

Review of Work or the CY 2012 PFS proposed rule and finalized for CY 2012. In the CY 2013 

proposed rule, we noted that under this annual public nomination process it would be highly 

unlikely that we would determine that a nominated code is appropriate for review under the 

potentially misvalued codes initiative if it had been reviewed in the years immediately preceding 

its nomination since we believe that the best information on the level of physician work and PE 

inputs already would have been available through that recent review. We stated that, 

nonetheless, we would evaluate the supporting documentation for each nominated code to 

ascertain whether the submitted information demonstrated that the code is potentially misvalued. 

CPT codes 33282 (Implantation of patient-activated cardiac event recorder) and 33284 

(Removal of an implantable, patient-activated cardiac event recorder) were nominated for review 

as potentially misvalued codes. The requestor stated that CPT codes 33282 and 33284 are 

misvalued in the nonfacility setting because these CPT codes currently are only priced in the 

facility setting even though physicians furnish these services in the office setting. The requestor 

asked that we establish appropriate payment for the services when furnished in a physician’s 

office. Specifically, the requestor asked that CMS establish nonfacility PE RVUs for these 

services. In the CY 2013 proposed rule, we stated that we do not consider the lack of pricing in a 

particular setting as an indicator of a potentially misvalued code. However, given that these 

services are now furnished in the nonfacility setting, we believe that CPT codes 33282 and 

33284 should be reviewed to establish appropriate nonfacility inputs. We noted, as did the 

requestor, that the valuation of a service under the PFS in a particular setting does not address 

whether those services and the setting in which they are furnished are medically reasonable and 

necessary for a patient’s medical needs and condition. We proposed to review CPT codes 33282 

and 33284 and requested recommendations from the AMA RUC and other public commenters 
74 

on the appropriate physician work RVUs (as measured by time and intensity), and facility and 

nonfacility direct PE inputs for these services. 

Like CPT codes 33282 and 33284, stakeholders requested that we establish appropriate 

payment for CPT code 63650 (Percutaneous implantation of neurostimulator electrode array, 

epidural) when furnished in an office setting. In the CY 2013 proposed rule, we noted that this 

request was not submitted as a potentially misvalued code nomination. However, given that 

these services are now furnished in the nonfacility setting, we stated that we believed CPT code 

63650 should be reviewed to establish appropriate nonfacility inputs. Please see section III.A.3 

(Changes to Direct Inputs for Specific Services) for a discussion of spinal code stimulation trial 

procedures in the nonfacility setting. 

The following is a summary of the comments we received in response to our proposal to 

review the physician work, facility, and nonfacility direct PE inputs for CPT codes 33282 and 

33284. 

Comment: Several commenters did not support our proposal to review CPT codes 33282 

and 33284. Commenters stated that the very low utilization in the nonfacility setting does not 

justify a review of the codes for nonfacility PE inputs. One commenter noted that physicians are 

not interested in furnishing these services in the nonfacility setting due to concerns for patient 

safety. Commenters recommended that we not consider establishing nonfacility PE RVUs for 

these CPT codes until additional studies indicate a clinical need to furnish these services in the 

nonfacility setting. Additionally, commenters stated that they do not believe it is necessary to 

review physician work and PE in the facility setting, as that was not the concern that the 

stakeholder brought forward. The AMA RUC stated that it continues to support the current work 

RVUs and facility PE inputs for these services. 

Another commenter recommended that CMS finalize the proposal to revalue CPT codes 

33282 and 33284 in order to establish nonfacility PE RVUs. The commenter stated that the lack 
75 

of nonfacility PE RVUs prevents physicians from furnishing these services in the office for 

select patients for whom this setting of care is safe and appropriate. This commenter 

recommended that CMS maintain the existing work RVUs, and focus the revaluation on the 

nonfacility PE inputs. The commenter requested that CMS remain flexible in its approach to 

nominated codes and allow for more expeditious review of codes by not requiring full provider 

surveys. 

Response: After reviewing the comments received, we are finalizing our proposal to 

review the physician work, and facility and nonfacility direct PE inputs for CPT codes 33282 and 

33284. We acknowledge that we received very few Medicare claims for these services in the 

nonfacility setting in CY 2011; nonetheless, we believe it is appropriate to consider the relative 

resources involved in furnishing this service in the nonfacility setting. We reiterate that the 

valuation of a service under the PFS in a particular setting does not address whether those 

services and the setting in which they are furnished are medically reasonable and necessary for a 

patient’s medical needs and condition. 

We acknowledge that commenters support the current work and facility RVUs, however, 

it is our policy generally to review the physician work, facility, and nonfacility direct PE inputs 

for each service together to ensure consistency in the inputs used to value the service. Based on 

information provided by the requestor and the 2011 nonfacility utilization for this code, we 

believe it is appropriate to review this service for nonfacility PE inputs. As explained above, we 

intend to review the work and facility inputs as well. Additionally, we note that the physician 

work and facility PE inputs for these two services have not been reviewed in over a decade, so 

we believe it is reasonable to assess whether the inputs on which the current payment rates are 

based accurately reflect the resources involved in furnishing these services today. Accordingly, 

we are finalizing our proposal to review the physician work, and facility and nonfacility direct 

practice expense inputs for CPT codes 33282 and 33284, and request comments on the 
76 

appropriate physician work, and facility and nonfacility direct practice expense inputs for these 

services. 

Traditionally, we have received recommendations from the AMA RUC on the 

appropriate physician work, PE, and malpractice inputs for services CMS plans to review and 

revalue. However, we understand that the AMA RUC may not issue recommendations for all 

codes under review by CMS. In addition to requesting recommendations from the AMA RUC 

on services we intend to review, we request and encourage recommendations on these services 

from other public commenters as well. We acknowledge the requestor’s comment that CMS 

remain flexible in its approach to nominated codes and not require full practitioner surveys for 

CPT codes 33282 and 33284. We understand that practitioner surveys regarding work, 

malpractice, and PE are not always available, practical, or reliable. We encourage commenters 

to submit the best data available on the appropriate valuation and inputs for the services under 

review, including the information listed above under supporting documentation for the 

nomination of potentially misvalued codes. 

In the CY 2013 proposed rule, we stated that we did not consider CPT codes 36819 

(Arteriovenous anastomosis, open; by upper arm basilic vein transposition) and 36825 (Creation 

of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); 

autogenous graft) to be potentially misvalued because these codes were last reviewed and valued 

for CY 2012 and the supporting documentation did not provide sufficient evidence to 

demonstrate that the codes should be reviewed as potentially misvalued for CY 2013 or 

CY 2014. The following is a summary of the comments we received in response to our proposal 

not to review CPT codes 36819 and 36825 as potentially misvalued codes. 

Comment: One commenter reiterated its belief that CPT codes 36819 and 36825 are 

potentially misvalued because the work RVUs finalized by CMS in CY 2012 place these services 

out of rank order with services that involve similar resources. To support this position, the 
77 

commenter provided a list showing these services relative to all services with a similar global 

period, intra-service time, and work RVU. The commenter also restated the rationale previously 

submitted to CMS when it nominated these services as potentially misvalued. The commenter 

requested that CMS reconsider the work RVUs of these two services. 

Response: After reviewing the comments received and conducting a clinical review of 

CPT codes 36819 and 36825 alongside similar services, we agree with the commenter that these 

services may be out of rank order and are potentially misvalued. Therefore, we are modifying 

our proposal to not review CPT codes 36819 and 36825 as potentially misvalued codes. We will 

review CPT codes 36819 and 36825 along with their code families, which include CPT codes 

36818 through 36821 and CPT codes 36825 through 36830, as potentially misvalued. We thank 

commenters for the additional supporting documentation provided, and request additional 

comments on the appropriate physician work and direct PE inputs for these services. 

CPT code 53445 (Insertion of inflatable urethral/bladder neck sphincter, including 

placement of pump, reservoir, and cuff) was nominated for review as a potentially misvalued 

code. CPT code 53445 was identified through the site-of-service anomaly potentially misvalued 

code screen for CY 2008. We completed our review and established RVUs for this code on an 

interim basis for CY 2012 subject to public comment. In the CY 2013 proposed rule, we stated 

that we would consider the supporting documentation submitted under the potentially misvalued 

code nomination process for CPT code 53445 as comments on the CY 2012 interim final value, 

and would address the comments in the CY 2013 PFS final rule with comment period when we 

address the final value of the CPT code. A summary of the comments received on CPT code 

53445 and our response to those comments is included in section II.M.2 of this final rule with 

comment period. 

CPT code 77336 (Continuing medical physics consultation, including assessment of 

treatment parameters, quality assurance of dose delivery, and review of patient treatment 
78 

documentation in support of the radiation oncologist, reported per week of therapy) was 

nominated for review as a potentially misvalued code. The requestor stated that CPT code 77336 

is misvalued because changes in the technique for furnishing continuing medical physics 

consultations have resulted in changes to the knowledge required, time, and effort expended, and 

complexity of technology associated with the tasks performed by the physicist and other staff. 

Additionally the requestor stated that the direct PE inputs no longer accurately reflect the 

resources used to deliver this service and may be undervalued. CPT code 77336 was last 

reviewed for CY 2003. In the CY 2013 proposed rule, we stated that after evaluating the 

detailed supporting information that the commenter provided, we believed there may have been 

changes in technology and other PE inputs since we last reviewed the service, and that further 

review is warranted. As such, we proposed to review CPT code 77336 as potentially misvalued 

and requested recommendations from the AMA RUC and other public commenters on the direct 

PE inputs for this service and for the other services within this family of CPT codes. 

The following is a summary of the comments we received in response to our proposal to 

review CPT code 77336 as potentially misvalued. 

Comment: Commenters supported the CMS proposal to review CPT code 77336 and 

urged CMS to finalize it. The AMA RUC stated that it would review this service and provide 

recommendations to CMS on its valuation. Several commenters reiterated their rationale for why 

they believe CPT code 77336 is potentially misvalued and provided supporting documentation. 

Additionally, commenters indicated that the American Society for Physicists in Medicine 

(AAPM) would submit information on practice expense inputs and other data to support the 

revaluation of this CPT code, and expressed appreciation that CMS is willing to consider data 

and input from professional medical societies that do not participate in the AMA RUC process. 

Response: After reviewing the comments received, we continue to believe that changes in 

technology may have altered the direct practice expense inputs associated with CPT code 77336 
79 

and are finalizing our proposal to review this service as potentially misvalued. We thank 

commenters for the supporting documentation provided, and request additional comments on the 

appropriate direct PE inputs for this service, as well as any other services that may be within this 

family of CPT codes. 

CPT code 94762 (Noninvasive ear or pulse oximetry for oxygen saturation; by 

continuous overnight monitoring (separate procedure)) was nominated for review as a potentially 

misvalued code. Requestors stated that CPT code 94762 is misvalued because the time currently 

allocated to the various direct PE inputs does not accurately reflect current practice. Requestors 

also stated that independent diagnostic testing facilities are not appropriately accounted for in the 

current indirect PE methodology. In the CY 2013 proposed rule, we stated that, in response to 

these stakeholder concerns, we reviewed the PE inputs for CPT code 94762, which was last 

reviewed for CY 2010. We believed that CPT code 94762 is misvalued, and we proposed 

changes to the PE inputs for CY 2013. We stated that, following clinical review, we believed 

that the current time allocated to clinical labor and supplies appropriately reflects current 

practice. However, we believed that 480 minutes (8 hours) of equipment time for the pulse 

oximetry recording slot and pulse oximeter with printer are more appropriate for this overnight 

monitoring procedure code. As such, we proposed this refinement to the direct PE inputs for 

CPT code 94762 for CY 2013. These proposed adjustments were reflected in the CY 2013 

proposed direct PE input database, available on the CMS website under the downloads for the 

CY 2013 PFS final rule with comment period at http://www.cms.gov/PhysicianFeeSched/. 

The following is a summary of the comments received regarding the proposed direct PE 

adjustments to CPT code 94762. 

Comment: Many commenters agreed with CMS’ proposal to refine the equipment 

minutes for this service to 480 minutes. One commenter suggested that CMS should increase the 

proposed allocation of minutes to account for the time that the equipment is unavailable for use 
80 

because the patient has yet to return it to the office. 

Response: We appreciate the support for the proposal. We believe that the appropriate 

allocation of minutes for the equipment is the sum of the times within the intra-service period 

when a clinician is using the piece of equipment, plus any additional time the piece of equipment 

is not available for use for another patient due to its use during the designated procedure. 

However, we also note that the equipment cost per minute calculation incorporates a utilization 

rate assumption that appropriately accounts for the time the equipment cannot be used because it 

is being transported to and from the office or between patients. Therefore, we are not revising 

our proposed adjustment to the equipment time. 

Comment: Several commenters supported the proposed allocation of minutes to the 

equipment and also submitted invoices and other evidence for updating the direct PE inputs for 

the service. The AMA RUC and others submitted information to update the pulse oximeter and 

the recording software used in the service. The information submitted by the AMA RUC 

reflects a pulse oximeter priced at $1418 and recording software priced at $990. Other 

commenters submitted various disposable supplies that might be used to furnish the service, 

including varying types of batteries, oximeter cables, and wristbands that might be used when 

furnishing this service. 

Response: We appreciate the updated information furnished to us by stakeholders and 

other commenters. While we generally urge stakeholders to submit such price update requests 

through the process for updating supply and equipment prices we established for CY 2011, 

because we made a proposal specifically related to the equipment minutes allocated for this 

procedure, we believe it would be appropriate to consider the supplies and equipment price 

inputs associated with the service in conjunction with the proposal to change the equipment 

minutes. Based on the invoice information we received from commenters, we will update the 

price of the ‘pulse oximetry recording software (prolonged monitoring)’ (EQ212) and include a 
81 

new equipment item “Pulse Oximeter 920 M Plus” priced at $1,418 as equipment inputs for the 

code. In reviewing the requested supply items to include, we believe that it would be appropriate 

to include 6 AA batteries (SK095) as a disposable supply for the service as well as incorporate a 

new item, a disposable oximeter cable, priced at $11.08. 

Based on these comments and our clinical review, we are adopting these direct PE inputs, 

including our adjusted allocation of equipment minutes, on an interim basis for CY 2013. These 

values are reflected in the CY 2013 PFS direct PE input database available under downloads for 

the CY 2013 PFS final rule with comment period on the CMS Web site at: 

http://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage. We also note that the PE 

RVUs included in Addenda B and C reflect these interim direct PE inputs. 

In the CY 2013 proposed rule, we stated that we did not consider the nominated codes that were 

last reviewed and valued for CY 2012 to be potentially misvalued because the supporting 

documentation did not provide sufficient evidence to demonstrate that the codes should be 

reviewed as potentially misvalued for CY 2013 or CY 2014. The supporting documentation for 

these services generally mirrored the public comments previously submitted, to which CMS has 

already responded. Below is a summary of the comments we received in response to our 

proposal to not review the CPT codes listed above in Table 4 not discussed above. 

Comment: We received a few limited comments on the nominated codes not previously 

discussed above, however, like the code nominations, the comments and supporting 

documentation for these services mirrored the public comments previously submitted, to which 

CMS has already responded. 

Response: Having received no new information on the CPT codes listed in Table 4 not 

previously discussed, we are finalizing our proposal not to review those services as potentially 

misvalued. 

b. Potentially Misvalued Code Lists 
82 

As mentioned above, in the last several annual PFS proposed rules we have identified 

lists of potentially misvalued codes for review. We believe it is imperative that we continue to 

identify new lists of potentially misvalued codes for review to appropriately identify, review, and 

adjust values for potentially misvalued codes for CY 2013. 

(1) Review of Harvard-Valued Services with Medicare Allowed Charges of $10,000,000 or 

More 

For many years, we have been reviewing ‘Harvard-valued’ CPT codes through the 

potentially misvalued code initiative. The RVUs for Harvard-valued CPT codes have not been 

reviewed since they were originally valued in the early 1990s at the beginning of the PFS. While 

the principles underlying the relative value scale have not changed, over time the methodologies 

we use for valuing services on the PFS have changed, potentially disrupting the relativity 

between the remaining Harvard-valued codes and other codes on the PFS. At this time, nearly 

all CPT codes that were Harvard-valued and had Medicare utilization of over 30,000 allowed 

services per year have been reviewed. In the CY 2013 PFS proposed rule, we proposed to 

review Harvard-valued services with annual Medicare allowed charges of $10 million or greater. 

The CPT codes meeting these criteria have relatively low Medicare utilization (as we have 

reviewed the services with utilization over 30,000), but account for significant Medicare 

spending annually and have never been reviewed. In the CY 2013 proposed rule, we noted that 

several of the CPT codes meeting these criteria have already been identified as potentially 

misvalued through other screens and were scheduled for review for CY 2013. We also 

recognized that other codes meeting these criteria had been referred by the AMA RUC to the 

CPT Editorial Panel. We stated that, in these cases, we were not proposing re-review of these 

already identified services, but for the sake of completeness, we included those codes as a part of 

this category of potentially misvalued services. In our proposal, we recognized that the relatively 

low Medicare utilization for these services may make gathering information on the appropriate 
83 

physician work and direct PE inputs difficult. We requested recommendations from the AMA 

RUC and other public commenters, and stated that we appreciate efforts expended to provide 

RVU and input recommendations to CMS for these lower volume services. Because survey 

sample sizes could be small for these lower volume services, we encouraged the use of valid and 

reliable alternative data sources and methodologies when developing recommended values. In 

sum, we proposed to review Harvard-valued CPT codes with annual allowed charges of $10 

million or more as a part of the potentially misvalued codes initiative. In the CY 2013 proposed 

rule, we stated that the following codes met the criteria for this screen and proposed to review 

these CPT codes as potentially misvalued services. 

TABLE 5: Proposed Harvard-valued CPT Codes with Annual Allowed Charges 

≥$10,000,000 

CPT Code Short Descriptor 

13152* Repair of wound or lesion 

27446 Revision of knee joint 

29823 Shoulder arthroscopy/surgery 

36215** Place catheter in artery 

36245** Ins cath abd/l-ext art 1st 

43264** Endo cholangiopancreatograph 

50360 Transplantation of kidney 

52353* Cystouretero w/lithotripsy 

64450* N block other peripheral 

64590 Insrt/redo pn/gastr stimul 

66180 Implant eye shunt 

67036 Removal of inner eye fluid 

67917 Repair eyelid defect 

92286** Internal eye photography 

92982* Coronary artery dilation 

95860* Muscle test one limb 

*Scheduled for CY 2012 AMA RUC Review 

**Referred by the AMA RUC to the CPT Editorial Panel 

 

The following is summary of the comments we received in response to our proposal to 

review Harvard-valued CPT codes with annual allowed charges of $10 million or more as a part 

of the potentially misvalued codes initiative. 
84 

Comment: Comments on this proposal were specific to the CPT codes we proposed to 

review under this potentially misvalued code screen. A few commenters noted that CPT code 

64590 (Insertion or replacement of peripheral or gastric neurostimulator pulse generator or 

receiver, direct or inductive coupling) does not have annual allowed charges that meet the 

threshold of $10 million and stated that the code should be removed from the list. These 

commenters requested that CMS reexamine this list to ensure all codes meet the specified 

criteria. Other commenters pointed out that certain codes on the list are already scheduled for 

review by the medical specialty societies and the AMA RUC, and that some codes are scheduled 

for deletion by the CPT Editorial Panel. The AMA RUC stated that it would discuss the list of 

codes that meet the criteria for this screen and would determine the next steps in the AMA 

RUC’s review of these services. 

Response: After reviewing the comments received, and reexamining the Medicare claims 

data, we agree with commenters that CPT code 64590 does not have annual Medicare allowed 

charges of $10 million or greater, nor do CPT codes 29823 (Arthroscopy, shoulder, surgical; 

debridement, extensive) and 95860 (Needle electromyography; 1 extremity with or without 

related paraspinal areas). In compiling the list, we inadvertently included allowed charges 

incurred in the ambulatory surgical center setting. We thank commenters for bringing this to our 

attention. Therefore, we have removed these three services from the proposed list of CPT codes 

that are Harvard-value with annual allowed charges of $10 million or greater. 

 In the CY 2013 proposed rule, we noted that several codes that met the criteria for this 

potentially misvalued code screen were currently under review for CY 2013 and others were 

scheduled for review by the CPT Editorial Panel. CPT codes 13152 (Repair, complex, eyelids, 

nose, ears and/or lips; 2.6 cm to 7.5 cm), 52353 (Cystourethroscopy, with ureteroscopy and/or 

pyeloscopy; with lithotripsy (ureteral catheterization is included)), 64450 (Injection, anesthetic 

agent; other peripheral nerve or branch), 92286 (Special anterior segment photography with 
85 

interpretation and report; with specular endothelial microscopy and cell count), and 95860 

(Needle electromyography; 1 extremity with or without related paraspinal areas) were reviewed 

for CY 2013. A discussion of the interim final values for those services is in section III.M.3. of 

this final rule with comment period. CPT code 92982 (Percutaneous transluminal coronary 

balloon angioplasty; single vessel) has been deleted by the CPT Editorial Panel for CY 2013. 

We have updated the list of CPT codes meeting this potentially misvalued code screen to show 

the review status of the codes, and to remove the three CPT codes mentioned above that do not 

meet the parameters of the screen. We are finalizing the list of Harvard-valued CPT codes with 

annual allowed charges of $10 million or more in Table 6, and for CY 2014, we will review the 

services not already reviewed. We request public comments on the appropriate work RVUs and 

direct practice expense inputs for these services. 

TABLE 6: Harvard-valued CPT Codes with Annual Allowed Charges ≥$10,000,000

CPT Code Short Descriptor Review Status 

13152 Repair of wound or lesion Interim Final for CY 2013 

27446 Revision of knee joint Review for CY 2014 

36215 Place catheter in artery Review for CY 2014 

36245 Ins cath abd/l-ext art 1st Review for CY 2014 

43264 Endo cholangiopancreatograph Review for CY 2014 

50360 Transplantation of kidney Review for CY 2014 

52353 Cystouretero w/lithotripsy Interim Final for CY 2013 

64450 N block other peripheral Interim Final for CY 2013 

66180 Implant eye shunt Review for CY 2014 

67036 Removal of inner eye fluid Review for CY 2014 

67917 Repair eyelid defect Review for CY 2014 

92286 Internal eye photography Interim Final for CY 2013 

92982 Coronary artery dilation Deleted for CY 2013 

(2) Review of Services with Stand Alone PE Procedure Time 

Improving the accuracy of procedure time assumptions used in PFS ratesetting continues 

to be a high priority of the potentially misvalued codes initiative. Procedure time is a critical 

measure of the resources typically used in furnishing particular services to Medicare 
86 

beneficiaries, and procedure time assumptions are an important component in the development 

of work and PE RVUs. Discussions in the academic community have indicated that certain 

procedure times used for PFS ratesetting are overstated (McCall, N., J. Cromwell, et al. (2006). 

“Validation of physician survey estimates of surgical time using operating room logs.” Med Care 

Res Rev 63(6): 764-777. Cromwell, J., S. Hoover, et al. (2006). “Validating CPT typical times 

for Medicare office evaluation and management (E/M) services.” Med Care Res Rev 63(2): 236-

255. Cromwell, J., N. McCall, et al. (2010). “Missing productivity gains in the Medicare 

physician fee schedule: where are they?” Med Care Res Rev 67(6): 236-255.) MedPAC and 

others have emphasized the importance of using the best available procedure time information in 

establishing accurate PFS payment rates. (MedPAC, Report to the Congress: Aligning 

Incentives in Medicare, June 2010, p. 230) 

In recent years, CMS and the AMA RUC have taken steps to consider the accuracy of 

available data regarding procedure times used in the valuation of the physician work component 

of PFS payment. Generally, the AMA RUC derives estimates of physician work time from 

survey responses, and the AMA RUC reviews and analyzes those responses as part of its process 

for developing a recommendation for physician work. These procedure time assumptions are 

also used in determining the appropriate direct PE input values used in developing nonfacility PE 

RVUs. Specifically, physician intra-service time serves as the basis for allocating the 

appropriate number of minutes within the service period to account for the time used in 

furnishing the service to the patient. The number of intra-service minutes, or occasionally a 

particular proportion thereof, is allocated to both the clinical staff that assists the physician in 

furnishing the service and to the equipment used by either the physician or the staff in furnishing 

the service. This allocation reflects only the time the beneficiary receives treatment and does not 

include resources used immediately prior to or following the service. Additional minutes are 

often allocated to both clinical labor and equipment resources in order to account for the time 
87 

used for necessary preparatory tasks immediately preceding the procedure or tasks typically 

performed immediately following it. For codes without physician work, the procedure times 

assigned to the direct PE inputs for such codes assume that the clinical labor performs the 

procedure. For these codes, the number of intra-service minutes assigned to clinical staff is 

independent and not based on any physician intra-service time assumptions. Consequently, the 

procedure time assumptions for these kinds of services have not been subject to all of the same 

mechanisms recently used by the AMA RUC and physician community in providing 

recommendations to CMS, and by CMS in the valuation of the physician work component of 

PFS payment. These independent clinical labor time assumptions largely determine the RVUs 

for the procedure. To ensure that procedure time assumptions are as accurate as possible across 

the Medicare PFS, we believe that codes without physician work should be examined with the 

same degree of scrutiny as services with physician work. 

For CY 2012, a series of radiation treatment services were reviewed as part of the 

potentially misvalued code initiative. Among these were intensity modulated radiation therapy 

(IMRT) delivery services and stereotactic body radiation therapy (SBRT) delivery services 

reported with CPT codes 77418 (Intensity modulated treatment delivery, single or multiple 

fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per 

treatment session) and 77373 (Stereotactic body radiation therapy, treatment delivery, per 

fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions), 

respectively. CPT code 77418 (IMRT treatment delivery) had been identified as potentially 

misvalued based on Medicare utilization data that indicated both fast growth in utilization and 

frequent billing with other codes. We identified this code as potentially misvalued in the CY 

2009 PFS proposed rule (73 FR 38586). CPT code 77373 (SBRT treatment delivery) had been 

identified as potentially misvalued by the RUC as a recently established code describing services 

that use new technologies. There is no physician work associated with either of these codes 
88 

since other codes are used to bill for planning, dosimetry, and radiation guidance. Both codes 

are billed per treatment session. Because the physician work associated with these treatments is 

reported using codes distinct from the treatment delivery, the primary determinant of PE RVUs 

for these codes is the number of minutes allocated for the procedure time to both the clinical 

labor (radiation therapist) and the resource-intensive capital equipment included as direct PE 

inputs. 

In the CY 2012 PFS final rule with comment period, we received and accepted without 

refinement PE recommendations from the AMA RUC for these two codes. (We received the 

recommendation for CPT code 77418 (IMRT treatment delivery) too late in 2010 to be evaluated 

for CY 2011 and it was therefore included in the CY 2012 rulemaking cycle.) The AMA RUC 

recommended minor revisions to the direct PE inputs for the code to eliminate duplicative 

clinical labor, supplies, and equipment to account for the frequency with which the code was 

billed with other codes. For CPT code 77373 (SBRT treatment delivery), the RUC 

recommended no significant changes to the direct PE inputs. 

Subsequent to the publication of the final rule, the AMA RUC and other 

stakeholders informed CMS that the direct PE input recommendation forwarded to CMS 

for IMRT treatment delivery (CPT code 77418) inadvertently omitted seven equipment 

items typically used in furnishing the service. These items had been used as direct PE 

inputs for the code prior to CY 2012. There is broad agreement among stakeholders that 

these seven equipment items are typically used in furnishing the services described by 

CPT code 77418. We were unable to reincorporate the items for CY 2012. These 

omitted items are listed in Table 7. In consideration of the comments from the AMA 

RUC and other stakeholders, we proposed to include the seven equipment items omitted 

from the RUC recommendation for CPT code 77418. These proposed adjustments were 

reflected in the CY 2013 proposed direct PE input database, available on the CMS 
89 

website under the downloads for the CY 2013 PFS proposed rule with comment period at 

http://www.cms.gov/PhysicianFeeSched/. We note that the proposed PE RVUs included 

in Addendum B reflected the proposed updates. 

TABLE 7: Equipment Inputs Omitted From RUC Recommendation for CPT Code 77418 

(IMRT Treatment Delivery) 

Equipment 

Code Equipment Description 

ED011 computer system, record and verify 

ED035 video camera 

ED036 video printer, color (Sony medical grade) 

EQ139 intercom (incl. master, pt substation, power, wiring) 

ER006 IMRT physics tools 

ER038 isocentric beam alignment device 

ER040 laser, diode, for patient positioning (Probe) 

It has come to our attention that there are discrepancies between the procedure time 

assumptions used in establishing nonfacility PE RVUs for these services and the procedure times 

made widely available to Medicare beneficiaries and the general public. Specifically, the direct 

PE inputs for IMRT treatment delivery (CPT code 77418) reflect a procedure time assumption of 

60 minutes. These procedure minutes were first assigned to the code for CY 2002 based on a 

recommendation from the AMA RUC indicating that the typical treatment time for the IMRT 

patient was 40 to 70 minutes. The most recent RUC recommendation that CMS received for CY 

2012 rulemaking supported the procedure time assumption of 60 minutes. 

Information available to Medicare beneficiaries and the general public indicates that 

IMRT sessions typically last between 10 and 30 minutes. For example, the American Society for 

Radiation Oncology (ASTRO) publishes a patient fact sheet that explains that for all external 

beam radiation therapy, including IMRT, “treatment is delivered in a series of daily sessions, 

each about 15 minutes long.” [“Radiation Therapy for Prostate Cancer: Facts to Help Patients 

Make an Informed Decision” available for purchase at 

www.astro.org/MyASTRO/Products/Product.aspx?AstroID=6901.] This fact sheet is intended 
90 

for patients with prostate cancer, the typical diagnosis for Medicare beneficiaries receiving 

IMRT. Similarly, the American College of Radiology (ACR) and the Radiological Society of 

North America (RSNA) co-sponsor a website for patients called http://radiologyinfo.org that 

states that IMRT “treatment sessions usually take between 10 and 30 minutes.” 

The direct PE inputs for SBRT treatment delivery (CPT code 77373) reflect a procedure 

time assumption of 90 minutes. These procedure minutes were first assigned to the code for 

CY 2007 based on a recommendation from the AMA RUC. The most recent RUC 

recommendation that CMS received for CY 2012 rulemaking supported continuing that 

procedure time assumption. 

In 2012, information available to Medicare beneficiaries and the general public states that 

SBRT treatment typically lasts no longer than 60 minutes. For example, the American College 

of Radiology (ACR) and the Radiological Society of North America (RSNA) website, 

http://radiologyinfo.org, states that SBRT “treatment can take up to one hour.” 

Given the importance of the procedure time assumption in the development of RVUs for 

these services, using the best available information is critical to ensuring that these services are 

valued appropriately. We believe medical societies and practitioners strive to offer their cancer 

patients accurate information regarding the IMRT or SBRT treatment experience. Therefore, we 

believe that the typical procedure time for IMRT delivery is between 10 and 30 minutes and that 

the typical procedure time for SBRT delivery is under 60 minutes. The services are currently 

valued using procedure time assumptions of 60 and 90 minutes, respectively. We believe these 

procedure time assumptions, distinct from necessary preparatory or follow-up tasks by the 

clinical labor, are outdated and need to be updated using the best information available. 

While we generally have not used publicly available resources to establish procedure 

time assumptions, we believe that the procedure time assumptions used in setting payment rates 

for the Medicare PFS should be derived from the most accurate information available. In the 
91 

case of these services, we believe that the need to reconcile the discrepancies between our 

existing assumptions and more accurate information outweighs the potential value in maintaining 

relativity offered by only considering data from one source. We proposed to adjust the 

procedure time assumption for IMRT delivery (CPT code 77418) to 30 minutes. We proposed to 

adjust the procedure time assumption for SBRT delivery (CPT code 77373) to 60 minutes. 

These procedure time assumptions reflect the maximum number of minutes reported as typical in 

publicly available information. We note that in the case of CPT code 77418, the ‘accelerator, 

6-18 MV’ (ER010) and the ‘collimator, multileaf system w-autocrane’ (ER017) are used 

throughout the procedure and currently have no minutes allocated for preparing the equipment, 

positioning the patient, or cleaning the room. Since these clinical labor tasks are associated with 

related codes typically reported at the same time, we also proposed to allocate minutes to these 

equipment items to account for their use immediately before and following the procedure. All of 

these proposed adjustments are reflected in the CY 2013 proposed direct PE input database, 

available on the CMS website under the downloads for the CY 2013 PFS final rule with 

comment period at http://www.cms.gov/PhysicianFeeSched/. We also note that the proposed PE 

RVUs included in Addendum B reflect the proposed updates. We requested recommendations 

from the AMA RUC and other public commenters on the direct PE inputs for these services. 

While we recognize that using these procedure time assumptions will result in payment 

reductions for these particular services, we believe such changes are necessary to appropriately 

value these services. Recent attention from popular media sources like the Wall Street Journal 

(online.wsj.com/article/SB10001424052748703904804575631222900534954.html December 

7,2010 ) and the Washington Post (www.washingtonpost.com/wpdyn/content/article/2011/02/28/AR2011022805378.html) February 28, 2011 has encouraged us 

to consider the possibility that potential overuse of IMRT services may be partially attributable 

to financial incentives resulting from inappropriate payment rates. In its 2010 Report to 
92 

Congress, MedPAC referenced concerns that financial incentives may influence how cancer 

patients are treated. In the context of the growth of ancillary services in physicians’ offices, 

MedPAC recommended that improving payment accuracy for discrete services should be a 

primary tool used by CMS to mitigate incentives to increase volume (Report to Congress: 

Aligning Incentives in Medicare, June 2010, p. 225). We note that in recent years, PFS 

nonfacility payment rates for IMRT treatment delivery have exceeded the Medicare payment rate 

for the same service paid through the hospital Outpatient Prospective Payment System (OPPS), 

which includes packaged payment for image guidance also used in treatment delivery. We 

believe that such high-volume services that are furnished in both nonfacility and facility settings 

are unlikely to be more resource-intensive in freestanding radiation therapy centers or 

physicians’ offices than when furnished in facilities like hospitals that generally incur higher 

overhead costs, maintain a 24 hour, 7 day per week capacity, are generally paid in larger bundles, 

and generally furnish services to higher acuity patients than the patients who receive services in 

physicians’ offices or freestanding clinics. Given that the OPPS payment rates are based on 

auditable data on hospital costs, we believe the relationship between the OPPS and nonfacility 

PFS payment rates reflects inappropriate assumptions within the current direct PE inputs for CPT 

code 77418. The AMA RUC’s most recent direct PE input recommendations reflect the same 

procedure time assumptions used in developing the recommendations for CY 2002. However, 

we believe that using procedure time assumptions that reflect the maximum times reported as 

typical to Medicare beneficiaries will improve the accuracy of those inputs and the resulting 

nonfacility payment rates. 

We received many comments regarding our proposal to change the direct PE inputs for 

CPT codes 77418 and 77373 based on amended procedure time assumptions and consideration 

of the comments from the AMA RUC and other stakeholders to include the seven equipment 

items omitted from the previous AMA RUC recommendation for CPT code 77418. The 
93 

following is summary of the comments we received and our responses to those comments. 

Comment: Several commenters agreed with CMS’ proposal to add the equipment items 

omitted from the AMA RUC recommendation for CPT code 77418 to the code. 

Response: We appreciate the support for that aspect of the proposal. 

Comment: Many commenters disagreed with CMS’ proposal to adjust the procedure 

time assumptions for these services. Some of these commenters stated that 35 minutes was a 

more appropriate estimate, but none presented alternative sources of objective information for 

determining accurate procedure time assumptions. Many commenters objected to CMS’ 

proposal on the basis that the agency used publicly available information to adjust procedure 

times assumptions instead of basing its proposal on information developed through the AMA 

RUC process. These commenters stated that CMS should not finalize its proposed procedure 

time assumptions for one of four reasons: publicly available procedure time information does not 

consider the time resources required prior to or following the procedure, that educational 

information for patients is an inappropriate data source because such material is not subject to 

the same degree of scrutiny by the medical community as the information presented to the AMA 

RUC, that CMS only has the authority to review or revalue PFS services through the AMA RUC 

process, or that time has been universally inflated by the AMA RUC so that using more accurate 

time assumptions in setting the RVUs for these services would distort their value relative to other 

PFS services. 

Response: We appreciate the commenters’ interest in CMS using the best available data 

to identify the time resources required to furnish services to Medicare beneficiaries. We address 

commenters’ objections to using these patient education materials in the comment summaries 

and response paragraphs that follow. 

Comment: Many commenters stated that patient education materials are not an 

appropriate source of data because the procedure times conveyed through such materials may not 
94 

fully account for the time spent positioning the patient for treatment, performing safety checks or 

the work that occurs before and after treatment. Several commenters explicitly stated that it is 

highly likely that the patient education materials describe only the time the patient is on the 

treatment table. . 

 Response: We understand that the procedure times cited in the patient education 

materials may not include the full time for preparing the equipment, positioning the patient or 

other necessary work required prior to or following the procedure. The procedure time 

assumptions used in developing direct PE inputs only account for a portion of the service period 

minutes allocated to the clinical labor or the equipment direct PE inputs. For example, in our 

proposal to reduce procedure time assumptions for CPT code 77418, we allocated an additional 

seven minutes to the equipment beyond the procedure time assumption for additional tasks. 

These minutes reflect the standard minutes usually recommended by the RUC for these tasks. 

For example, for CY 2013 the AMA RUC recommended these minutes for direct PE inputs for 

CPT code 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure), CPT 

code 52287 (Cystourethroscopy with injection(s) for chemodenervation of the bladder), CPT 

code 65800 (Paracentesis of anterior chamber of eye (separate procedure); with diagnostic 

aspiration of aqueous), and CPT code 11311 (Shaving of epidermal or dermal lesion, single 

lesion, face ears, eyelid, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm). 

We also note that the direct PE inputs for codes describing imaging guidance services 

that are typically reported at the same time include minutes for the radiation therapist to prepare 

the room, position the patient, and clean the room. Similarly, the proposed direct PE inputs for 

CPT code 77373 incorporate clinical labor and equipment minutes that exceed the minutes 

assumed for the procedure itself: 24 minutes of additional nurse time, 24 minutes of additional 

time for the radiation therapist, and 15 additional minutes for the medical physicist for preservice and post-service tasks. On the basis of these tasks, the equipment associated with the 
95 

code has also been allocated 24 minutes beyond the procedure time assumption for pre-service 

and post-service work. Therefore, we do not agree with commenters who suggested that our 

proposed revisions are inappropriate because the procedure time reported in the patient education 

materials may underestimate the procedure time assumptions used in developing direct PE 

inputs. Instead, we believe that the typical procedure time described in the patient education 

material is generally equivalent to the minutes incorporated in the service period for performing 

the procedure. We already have incorporated additional minutes of clinical labor time into the 

direct PE inputs for both CPT codes 77418 and 77373 to account for tasks like preparing the 

equipment and cleaning the room in addition to the minutes allocated for the procedure time 

assumptions. This reflects the direct PE inputs used for most services, where we allocate 

minutes to clinical labor and medical equipment for preparatory or follow-up tasks in addition to 

the equipment time allocated based on the procedure time assumption. While many commenters 

stated that the procedure times reported in the publicly available information do not include 

necessary preparatory or follow-up tasks, we received no comments with specific objections to 

the number of minutes allocated for such tasks in conjunction with our proposal. 

 Comment: The AMA RUC and some medical specialty societies expressed opposition to 

CMS using patient education materials in the process of setting Medicare payment rates. These 

commenters claimed that such information is not evaluated by the same standards applied to the 

extant data used as part of the AMA RUC process, so that CMS’ use of these materials is illconceived. 

 Response: As we stated previously, we believe medical societies and practitioners strive 

to offer their cancer patients accurate information regarding the IMRT or SBRT treatment 

experience. We believe that such information, especially for high-volume services, is more 

likely to reflect typical treatment times than information proffered solely for the purpose of 

developing payment rates. While many commenters objected in principle to the validity of the 
96 

patient education materials, we do not believe that medical specialty societies and providers of 

care would broadly inform their patients that IMRT treatment would last between 10 and 30 

minutes per session if the typical treatment session actually lasted for one hour or that SBRT 

treatment would last for no more than one hour if it typically takes 90 minutes. 

Comment: Many commenters claimed that CMS has the responsibility to conduct a 

comprehensive, empirical review of those procedure time assumptions utilizing the AMA RUC 

if CMS has concerns with those assumptions. 

Response: We agree that AMA RUC review and recommendations are one important 

component in constructing payment rates under the physician fee schedule. While we do not 

agree with the commenters’ statement that CMS has a responsibility to conduct all reviews of 

potentially misvalued codes through the AMA RUC process exclusively, we note the AMA RUC 

reviewed both CPT codes 77418 and 77373 as recently as 2010. Both of these services had been 

identified under our potentially misvalued code initiative. As noted above, the AMA RUC 

recommended minor revisions to the direct PE inputs for the code to eliminate duplicative 

clinical labor, supplies, and equipment to account for the frequency with which the code was 

billed with other codes. For CPT code 77373 (SBRT treatment delivery), the AMA RUC 

recommended no significant changes to the direct PE inputs. We note that in response to this 

proposal, the AMA RUC has recently informed us that since there is no physician work 

associated with these codes, it has asked the relevant specialty society to conduct a survey for 

clinical staff time, in order to ensure accurate procedure times. 

Comment: Some commenters stated that CMS should only consider the accuracy of 

these procedure time assumptions relative to the procedure time estimates for other services. 

Some of these commenters claimed that procedure time assumptions for services across the PFS 

are inflated so that CMS should not use procedure time assumptions for these services that are 

also exaggerated. 
97 

Response: We appreciate the commenters’ concerns with maintaining the relativity of 

time used in developing relative value units. We understand that procedure times may be 

overestimated for some other PFS services. While we agree that maintaining the resource 

relativity of services within the payment system is very important, we also believe that there is 

no practical means for CMS or stakeholders to engage in a complete simultaneous review of time 

assumptions across all payable codes. As such, we must evaluate times (and other factors) and 

make adjustments in smaller increments when we find that adjustments are warranted. We strive 

to maintain relativity by reviewing all RVU components for a code or reviewing all codes within 

families where appropriate. Furthermore, we believe that our proposal to use more accurate 

procedure time assumptions for these services should be considered in the context of broader 

efforts to improve the accuracy of PFS relative values, where time is a significant component of 

developing relative values. 

Since MedPAC’s March 2006 Report to the Congress, CMS has implemented a 

potentially misvalued codes initiative and has taken significant steps to identify and address 

potentially misvalued codes, including establishing physician times that accurately reflect the 

resources involved in furnishing the service. For example, CMS has reduced the physician times 

for services that were originally valued in the inpatient setting but now are frequently performed 

in the outpatient setting, services that are frequently performed together or in multiple units, and 

services billed on the same day as an E/M service. Furthermore, in addition to our proposal to 

review services with stand-alone procedure time, in this CY 2013 PFS final rule with comment 

period, we also discuss recommendations on how best to accurately measure post-operative work 

in the global surgical period, and finalize several proposals to adjust times for services with 

anomalous times in the physician time file. Moreover, in September 2012, we entered into two 

contracts to assist us in validating RVUs of potentially misvalued codes, which may include the 

validation of physician time elements. 
98 

Additionally, we do not agree with the commenters’ assertion that if time is distorted 

across the PFS, it is likely to be distorted with consistent proportionality. While the distortions 

may be relatively consistent for surveys taken at similar times or data gathered through similar 

methods, the procedure time assumptions used in developing practice expense inputs have not 

originated from consistent sources. The 60 minute procedure time assumption for IMRT 

treatment delivery, for example, was originally developed based on a specialty society survey for 

CY 2002. 

Through our misvalued codes initiative and other efforts, we strive to prioritize and 

review values for codes each year and work toward achieving greater calibration of values across 

the PFS over time. 

Comment: MedPAC commented that CMS should implement its proposal to reduce the 

time estimates for these codes based on the credible evidence presented in the proposed rule. 

The commission stated further that if stakeholders object to these changes, they should provide 

objective, valid evidence to CMS that the agency’s proposed time estimates are too low. 

Furthermore, the commission expressed concerns about using physician surveys to develop time 

estimates since physician medical societies have a financial stake in the process. Therefore, 

MedPAC recommended that the AMA RUC should seek evidence other than the surveys 

conducted by specialty societies and that CMS may need to regularly collect data on service time 

and other variables to establish more accurate RVUs for practice expense and physician work. 

 Response: We appreciate MedPAC’s support for the proposal. We agree that there are 

many means to measure time other than through survey methodology, and we are open to 

considering robust data on procedure time from many sources. 

 Comment: Many commenters objected to CMS’ proposal to update the procedure time 

assumptions used in determining the direct PE inputs for these services since CMS did not 

propose corresponding updates to other direct PE inputs for the services. 
99 

 Response: We appreciate the commenters’ interest in CMS’ use of the most accurate and 

up-to-date information in establishing practice expense RVUs for these services. We note that 

we recently received direct PE input recommendations from the AMA RUC for these services 

and used them to establish interim final direct PE inputs for CY 2012 . We also note that in the 

CY 2011 PFS final rule (75 FR 73205 through 73207) we established a public process for 

updating prices for supplies and equipment used as direct PE inputs. Prior to making our CY 

2013 proposal regarding procedure times for the IMRT and SBRT codes, we had received no 

requests to update prices for the inputs associated with these codes. 

Comment: Several commenters submitted specific information regarding appropriate 

input revisions for CPT codes 77418 and 77373. Several commenters (including the AMA 

RUC) suggested that IMRT treatment requires two radiation therapists, working simultaneously, 

to furnish the service safely. Others suggested that the linear accelerator (ER010) and collimator 

(ER017) used as direct PE inputs for CPT code 77418 IMRT treatment are no longer typical. 

These commenters submitted evidence, consisting of a collection of paid invoices, that 

demonstrated that the typical accelerator used in IMRT includes the functionality of the 

collimator and should be priced at $ 2,641,783 and that the price of the “laser, diode, for patient 

positioning (Probe)” (ER040) should be $18,160. Several commenters also noted that two 

equipment items included in many other radiation treatment codes, the radiation treatment vault 

(ER056) and water chiller (ER065) ought to be included in the equipment inputs for IMRT and 

SBRT treatment delivery. Finally, several commenters suggested that the equipment items used 

in these treatment delivery services require practitioners to purchase maintenance and service 

contracts in addition to the price of the equipment itself. 

Response: We appreciate all the submitted information to assist us in conducting a 

comprehensive update of the appropriate direct PE inputs for these services. We agree with the 

commenters that we should use the best information available in developing direct PE inputs for 
100 

PFS services. Based on this information, we believe it would be appropriate to include two 

radiation therapists as direct PE inputs for CPT code 77418. We also believe it would be 

appropriate to update the current accelerator and collimator equipment inputs used in CPT code 

77418 based on the invoices provided to us by commenters. While we generally urge 

stakeholders to submit such requests through the process we established for CY 2011, because 

we made a proposal specifically related to the equipment minutes allocated for these procedures, 

we believe it would be appropriate to consider the associated equipment and prices. We have 

observed that some other radiation treatment codes incorporate the water chiller and radiation 

treatment vault as direct PE inputs. We believe it would be appropriate to incorporate the water 

chiller as an equipment item into the IMRT and SBRT treatment delivery codes for the sake of 

consistency with the other radiation treatment codes. However, we question whether it is fully 

consistent with the principles underlying the PFS PE methodology to continue to classify the 

radiation treatment vault as medical equipment (a direct cost) since it is difficult to distinguish 

the cost of the construction of the vault from the cost of the construction of the building. The 

submitted architectural invoices for vault construction illustrate the difficulty in making that 

distinction. Furthermore, the typical circumstances of the vault’s use are unclear, especially 

regarding whether or not the vault may be servicing multiple patients at the same time. 

However, we do not believe that it would be appropriate to remove the radiation treatment vault 

as a direct input for all PFS services for CY 2013. We expect to address the status of the 

radiation treatment vault as a direct PE input during CY 2014 rulemaking. For CY 2013, we 

believe that it would be appropriate to include the radiation treatment vault for CPT codes 77373 

and 77418 to align the code with the similar radiation treatment delivery codes. In terms of the 

maintenance and service contract costs submitted to us by commenters, we remind stakeholders 

that we have generally not considered such costs as direct costs attributable to furnishing services 

to individual Medicare beneficiaries and that our standard equipment cost per minute calculation 
101 

includes a maintenance factor that adequately incorporates such costs in amortizing the cost of 

the equipment itself 

Comment: A few commenters suggested that CMS should re-price the capital equipment 

associated with CPT code 77373. However, none of these commenters submitted invoices. 

Response: We urge commenters to submit invoices and other evidence appropriate for 

pricing the capital equipment used in SBRT delivery as part of our public process for updating 

supply and equipment prices. We direct interested stakeholders to the CY 2011 PFS final rule 

(75 FR 73205-73207) for information regarding that process. We also note that as we explained 

in the CY 2012 PFS final rule with comment period (76 FR 73214), we could not accept the 

invoices accompanying the AMA RUC’s recommendation for CPT Code 77373 to update the 

price of the ‘‘SRS system, SBRT, six systems, average’’ equipment (ER083). Each of these 

invoices included line items that we would not accept as part of the cost of the equipment, such 

as costs for training technologists to use the equipment, and the prices for these items were not 

separately identifiable. Therefore, we did not update the equipment price for ER083 in 

establishing interim final direct PE inputs for CY 2012. Were we to receive updated invoices 

through the process established during CY 2012 that did not include embedded costs that we 

would not accept as part of the cost of the equipment, we would consider those invoices in 

rulemaking for CY 2014. 

Comment: Many commenters suggested that reductions in Medicare payment rates for 

these services would put serious financial strain on community radiation oncology practices, and 

result in significant negative impact on patient access to life-saving cancer treatment, particularly 

in rural communities. One commenter provided the results of an informal study that suggested 

that if the proposed RVUs become effective for CY 2013, many providers will stop providing 

charity care, lay off staff, limit hours of operation, refrain from purchasing new equipment, limit 

or stop accepting Medicare patients, or consolidate or close practice locations. 
102 

Response: We appreciate and share commenters’ concerns regarding Medicare 

beneficiaries’ access to care for radiation treatment services. While we share these concerns in 

general, we believe that accurately valuing services promotes Medicare beneficiaries’ access to 

many different kinds of important services paid under the PFS, including radiation treatment. 

We continue to be interested in information related to beneficiaries’ access to these kinds of 

services, and we will monitor for evidence of such problems. We would welcome being alerted 

to access problems, should they arise. At present, we do not have reason to believe that the 

proposed changes in procedure time assumptions, in conjunction with other corresponding 

updates in the direct PE inputs for these services, will jeopardize access to care for Medicare 

beneficiaries. We note that the final PE RVUs for these services, based on direct PE inputs 

updated with information provided by commenters, are significantly greater than those reflected 

in the proposed rule. We also note that the specialty-level impact of this final rule with comment 

period is significantly reduced relative to the policy as proposed. We direct interested readers to 

the section VIII.C. of this final rule with comment period regarding the specialty-level impacts of 

this and other finalized policies. 

Comment: Many commenters objected to CMS’ assumptions that the services would be 

more costly for facilities such as hospital outpatient departments that generally have Emergency 

Medical Treatment and Labor Act (EMTALA) obligations and standby capacity than for freestanding centers or offices. These commenters stated that the cost structure and the services 

furnished in freestanding and hospital outpatient settings are the same. These commenters stated 

that, while outpatient hospital departments may have to maintain standby capacity, they do not 

typically furnish IMRT 24 hours per day, seven days a week nor do the radiation oncology 

departments of hospitals generally furnish radiation treatment to higher acuity patients than the 

patients who receive services in physicians’ offices or freestanding clinics. 
103 

Several other commenters suggested that the payment decrease expected to result from 

this proposal will force patients into the more expensive hospital setting and patients will be 

steered toward treatment options that result in greater financial returns. These commenters 

stated that this migration will increase costs both to the Medicare program and to patients 

through higher co-insurance payments. Others suggested that significant differences between 

nonfacility PFS and OPPS payment are likely to result in consolidation of free-standing cancer 

centers and hospitals that will reduce competition, inhibit access to care, and undermine focused 

care for cancer patients. 

Response: As we stated in the proposal, we continue to believe that high-volume 

services, such as IMRT, that are widely furnished in both nonfacility and facility settings are 

highly unlikely to be more resource-intensive in freestanding radiation therapy centers or 

physicians’ offices than when furnished in facilities like hospitals. We agree with commenters 

that the direct costs of furnishing the service may be similar, but we continue to believe that 

hospitals are likely to incur additional indirect costs. For example, hospitals incur greater costs 

for maintaining the capacity to furnish services 7 days per week, 24 hours per day, even if IMRT 

delivery is not typically furnished during all of those hours. As we have already noted, the 

disparity between OPPS and PFS payment is even greater than a direct comparison of the 

payment rates would suggest. OPPS payment for CPT code 77148 includes packaged payment 

for image guidance, which is almost always furnished and billed with CPT code 77418. The PFS 

continues to make separate payment for several forms of image guidance. 

We understand commenters’ concerns regarding the inadvertent impact that financial 

incentives may make on the usual site of service for particular services. We believe that utilizing 

the most accurate cost inputs possible is a reasonable approach to mitigating the impact of such 

potential incentives. 
104 

As a result of the comments we received regarding our proposal to change the procedure 

time assumptions used in determining direct PE inputs for CPT codes 77418 and 77373, we are 

finalizing our proposals to adjust the procedure time assumption for IMRT delivery (CPT code 

77418) to 30 minutes and to adjust the procedure time assumption for SBRT delivery (CPT code 

77373) to 60 minutes. These codes continue to include clinical labor time for preparatory and 

follow-up tasks in addition to revisions to the procedure times. Based on comments received 

regarding additional updates to the direct PE inputs for these services, we are also adjusting other 

direct PE inputs for these services on an interim final basis for CY 2013. Based on comments 

received on our proposal, we are incorporating a second radiation therapist for CPT code 77418. 

The second therapist will be allocated 30 minutes of service period time, consistent with the first. 

Furthermore, we are incorporating a new equipment item called “IMRT accelerator” to replace 

the linear accelerator (ER010) and collimator (ER017) used as current direct PE inputs for CPT 

code 77418. Based on the evidence submitted by commenters, the new equipment item will be 

priced at $2,641,783 in the direct PE input database. Additionally, we are incorporating the 

radiation treatment vault (ER056) and water chiller (ER065) as direct PE inputs for both CPT 

codes 77418 and 77373. We are also updating the price of the “laser, diode, for patient 

positioning (Probe)” (ER040) from $7,678 to $18,160. We are adopting these direct PE inputs 

on an interim basis for CY 2013 and these values are reflected in the CY 2013 PFS direct PE 

input database. That database is available under downloads for the CY 2013 PFS final rule with 

comment period on the CMS Web site at: 

http://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage. We also note that the PE 

RVUs included in Addenda B and C reflect these interim direct PE inputs. 

These two IMRT and SBRT treatment delivery codes are PE only codes and are fairly 

unique in that the resulting RVUs are largely comprised of resources for staff and equipment 

based on the minutes associated with clinical labor. There are several other codes on the PFS 
105 

established through the same methodology. As we previously stated, we believe that the 

procedure time assumptions for these kinds of services have not been subject to all of the same 

mechanisms recently used by CMS in the valuation of the physician work component of PFS 

payment. In light of observations about publicly available procedure times for CPT codes 77418 

(IMRT treatment delivery) and 77373 (SBRT treatment delivery) and public awareness of 

potential adverse financial incentives associated with IMRT treatment delivery in particular, we 

believe that similar codes may be potentially misvalued. 

Therefore, consistent with the requirement in section 1848(c)(2)(K)(ii) of the Act to 

examine other codes determined to be appropriate by the Secretary, we proposed to review and 

make adjustments to CPT codes with stand-alone procedure time assumptions used in developing 

nonfacility PE RVUs. These procedure time assumptions are not based on physician time 

assumptions. We prioritized for review CPT codes that have annual Medicare allowed charges 

of $100,000 or more, include direct equipment inputs that amount to $100 or more, and have PE 

procedure times of greater than 5 minutes. We did not propose to include in this category 

services with payment rates subject to the OPPS cap (as specified in the statute under section 

1848(b)(4) of the Act and listed in Addendum G to this proposed rule) or services with PE 

minutes established through code descriptors. (For example, an overnight monitoring code 

might contain 480 minutes of monitoring equipment time to account for 8 hours of overnight 

monitoring.) The CPT codes meeting these criteria appear in Table 8. We recognized that there 

are other CPT codes that are valued in the same manner. We may consider evaluating those 

services as potentially misvalued codes in future rulemaking. 

For the services in Table 8, we requested recommendations from the AMA RUC and 

other public commenters on the appropriate direct PE inputs for these services. We encourage 

the use of valid and reliable alternative data sources when developing recommended values, 

including electronic medical records (with personally-identifiable information redacted) and 
106 

other independent data sources. We note that many of the CPT codes in Table 8 have been 

identified through other potentially misvalued code screens and have been recently reviewed. 

Given our concerns with the inputs for the recently reviewed IMRT and SBRT direct PE inputs 

discussed above, we believe it is necessary to re-review other recently reviewed services with 

stand-alone PE procedure time. 

TABLE 8: Services with Stand-Alone PE Procedure Time 

CPT 

Code Short Descriptor 

77280 Set radiation therapy field 

77285 Set radiation therapy field 

77290 Set radiation therapy field 

77301 Radiotherapy dose plan imrt 

77338 Design mlc device for imrt 

77372 Srs linear based 

77373 Sbrt delivery 

77402 Radiation treatment delivery 

77403 Radiation treatment delivery 

77404 Radiation treatment delivery 

77406 Radiation treatment delivery 

77407 Radiation treatment delivery 

77408 Radiation treatment delivery 

77409 Radiation treatment delivery 

77412 Radiation treatment delivery 

77413 Radiation treatment delivery 

77414 Radiation treatment delivery 

77416 Radiation treatment delivery 

77418 Radiation tx delivery imrt 

77600 Hyperthermia treatment 

77785 Hdr brachytx 1 channel 

77786 Hdr brachytx 2-12 channel 

77787 Hdr brachytx over 12 chan 

88348 Electron microscopy 

Comment: Several commenters objected to our proposal to review these codes. Some of 

these commenters objected to the premise that the procedure time assumptions for these services 

have not been subject to the same scrutiny as for services with procedure time assumptions tied 

directly to physician time. One of these commenters explained that the AMA RUC process of 
107 

reviewing direct practice expense inputs involves three main levels of expert panel review: 

specialty society expert panel review and attestation of the data provided; RUC Practice Expense 

Subcommittee review; and full RUC member review. Other commenters suggested that many of 

the identified services have procedure time assumptions related to physician time and therefore 

should be removed from the list. Another commenter claimed that services with professional 

and technical components should be removed from the list since services with professional 

components ought not to be considered “stand-alone.” Another commenter suggested that CPT 

code CPT Code 77600 should be removed from the list since few -TC claims had been 

submitted. One commenter claimed that the AMA RUC had extensive discussions regarding the 

procedure time assumptions used in developing direct PE inputs for some of the codes, so that 

those codes should be removed from the list. 

Response: As we stated in the proposal, we believe that the procedure time assumptions 

used in developing direct PE inputs for these services have not been subject to the same rigor as 

other recently-reviewed services. Procedure time assumptions developed and validated by a 

series of expert panels have not generally been subject to the same scrutiny as the times 

developed through survey data or data gathered through electronic health records, for example. 

We identified the services by calling the services “stand-alone PE procedure time,” because they 

are services that include significant amounts of time resources allocated outside of physician 

time. We understand that some of these codes may be “technical only” codes and that in other 

cases these codes are used in reporting both the professional and technical component using the –

TC or -26 modifiers, but we do not believe the divergent reporting mechanisms would mean that 

any services should be removed from the list. For CPT code 77600, we note that while few 

services were reported with the -TC modifier, many more services were billed globally in the 

nonfacility setting, so we continue to believe that the procedure time assumption that determines 
108 

the inputs used in valuing the technical component of the payment remains relevant for 

prioritization. 

 While we assume that the AMA RUC deliberated on the procedure time assumptions 

used in developing the direct PE input recommendations for these services, we do not believe 

that extensive committee discussions would mitigate the need for more extensive review of these 

services as potentially misvalued since the assumptions that were developed through discussion 

could benefit from the objective data of many kinds. 

 Comment: MedPAC supported CMS’s proposal to review these services. However, it 

expressed concern that CMS exempted imaging services that are subject to the OPPS cap from 

this review. MedPAC pointed out that the procedure time assumptions used in several highpriced and high-expenditure imaging codes have not been reviewed by the AMA RUC since 

2002 or 2003 and may be too high. MedPAC also noted that recent advances in CT and MRI 

machines have made it possible to scan patients faster and that even practitioners who are using 

older equipment could be performing studies in less time as they become more familiar with the 

procedures and equipment. 

 Response: We appreciate MedPAC’s support for this proposal. We agree that the 

procedure time assumptions used in imaging codes subject to the OPPS cap may be inaccurate or 

outdated. We did not propose to prioritize review of these procedure time assumptions since the 

services are subject to the OPPS payment caps, but we will consider the appropriate means for 

reviewing the procedure time assumptions for those services in future rulemaking. 

 Based on the comments we received, we are finalizing our proposal to review and make 

adjustments to CPT codes with stand-alone procedure time assumptions used in developing 

nonfacility PE RVUs. 

c. Services with Anomalous Time 
109 

Each year when we publish the PFS proposed and final rules, we publish on the CMS 

website several files that support annual PFS ratesetting. One of these supporting files is the 

physician time file, which lists the physician time associated with the HCPCS codes on the PFS. 

The physician time file associated with the CY 2013 PFS final rule with comment period is 

available on the CMS website under the downloads for the CY 2013 PFS final rule with 

comment period at http://www.cms.gov/PhysicianFeeSched/. 

As we stated in the CY 2013 PFS proposed rule, in our review of potentially misvalued 

codes and their inputs, we became aware of several HCPCS codes that have anomalous times in 

our physician time file. Physician work is a measure of physician time and intensity, so there 

should be no services that have payable physician work RVUs but no time in the physician time 

file, and there should be no payable services with time in the physician time file and no physician 

work RVUs. For CY 2013 we proposed to make the physician time file changes detailed below 

to address these anomalous time file entries. 

(1) Review of Services with Physician Work and No Listed Physician Time 

CPT code 94014 (Patient-initiated spirometric recording per 30-day period of time; 

includes reinforced education, transmission of spirometric tracing, data capture, analysis of 

transmitted data, periodic recalibration and physician review and interpretation) has a physician 

work RVU of 0.52 and for CY 2012 was listed with 0 physician time. CPT code 94014 is a 

global service that includes CPT code 94015 (Patient-initiated spirometric recording per 30-day 

period of time; recording (includes hook-up, reinforced education, data transmission, data 

capture, trend analysis, and periodic recalibration)) (the technical component), and CPT code 

94016 (Patient-initiated spirometric recording per 30-day period of time; physician review and 

interpretation only) (the professional component). We stated that we believe it is appropriate for 

the physician time of CPT code 94014 to match the physician time of the code’s component 

professional service—CPT code 94016. As such, for CPT code 94014 for CY 2013, we 
110 

proposed to assign 2 minutes of pre-service evaluation time, and 20 minutes of intra-service 

time, which matches the times associated with CPT code 94016. 

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) both have physician work 

RVUs (0.45, and 0.17, respectively), but neither code was included in the CY 2012 physician 

time file. HCPCS codes G0117 and G0118 have a PFS procedure status indicator of T indicating 

that these services are only paid if there are no other services payable under the PFS billed on the 

same date by the same provider. 

In the CY 2002 PFS final rule (66 FR 55274), we crosswalked the physician work of 

HCPCS code G0117 from CPT code 99212 (Level 2 office or other outpatient visit, established 

patient), and we crosswalked the physician work of HCPCS code G0118 from CPT code 99211 

(Level 1 office or other outpatient visit, established patient). Based on these finalized physician 

work crosswalks, we proposed to assign HCPCS code G0117 physician times matching CPT 

code 99212, and HCPCS code G0118 physician times matching CPT code 99211. Specifically, 

we proposed 2 minutes of pre-service time, 10 minutes of intra-service time, and 4 minutes of 

immediate post-service time for HCPCS code G0117, and 5 minutes of intra-service time, and 2 

minutes of immediate post-service time for HCPCS code G0118 

HCPCS code G0128 (Direct (face-to-face with patient) skilled nursing services of a 

registered nurse provided in a comprehensive outpatient rehabilitation facility, each 10 minutes 

beyond the first 5 minutes) currently has a physician work RVU ( 0.08), but was not listed in the 

CY 2012 physician time file. In the CY 2013 proposed rule we stated that, after review of this 

HCPCS code, we do not believe that HCPCS code G0128 describes a service that includes 

physician work. Time for a registered nurse to furnish the service is included in the PE for the 
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code. As such, for CY 2013, we proposed to remove the physician work RVU for HCPCS code 

G0128. HCPCS code G0128 continues to have PE and malpractice expense RVUs. 

HCPCS codes G0245 (Initial physician evaluation and management of a diabetic patient 

with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must 

include: (1) the diagnosis of LOPS; (2) a patient history; (3) a physical examination that consists 

of at least the following elements: (a) visual inspection of the forefoot, hindfoot and toe web 

spaces; (b) evaluation of a protective sensation; (c) evaluation of foot structure and 

biomechanics; (d) evaluation of vascular status and skin integrity; and (e) evaluation and 

recommendation of footwear; and (4) patient education), G0246 (Follow-up physician evaluation 

and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of 

protective sensation (LOPS) to include at least the following: (1) a patient history; (2) a physical 

examination that includes: (a) visual inspection of the forefoot, hindfoot and toe web spaces; (b) 

evaluation of protective sensation; (c) evaluation of foot structure and biomechanics; (d) 

evaluation of vascular status and skin integrity; and (e) evaluation and recommendation of 

footwear; and (3) patient education), and G0247 (Routine foot care by a physician of a diabetic 

patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to 

include, the local care of superficial wounds (that is, superficial to muscle and fascia) and at least 

the following if present: (1) local care of superficial wounds; (2) debridement of corns and 

calluses; and (3) trimming and debridement of nails) have physician work RVUs of 0.88, 0.45, 

and 0.50, respectively, but were not listed in the CY 2012 physician time file. HCPCS codes 

G0245, G0246, and G0247 have a procedure status indicator of R on the PFS indicating that 

coverage of these services is restricted. 

In the CY 2003 PFS final rule (67 FR 79990), we crosswalked the physician work of 

HCPCS code G0245 from CPT code 99202 (Level 2 office or other outpatient visits, new 

patient), we crosswalked the physician work of HCPCS code G0246 from CPT code 99212, and 
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we crosswalked the physician work of HCPCS code G0257 from CPT code 11040 

(Debridement; skin; partial thickness). Based on these finalized physician work crosswalks, we 

proposed to assign HCPCS code G0245 physician times matching CPT code 99202, HCPCS 

code G0246 physician times matching CPT code 99212, and HCPCS code G0247 physician 

times matching CPT code 11040. Specifically, for HCPCS code G0245 we proposed 2 minutes 

of pre-service time, 15 minutes of intra-service time, and 5 minutes of immediate post-service 

time. For HCPCS code G0246 we proposed 2 minutes of pre-service time, 10 minutes of intraservice time, and 4 minutes of immediate post-service time. For HCPCS code G0247 we 

proposed 7 minutes of pre-service time, 10 minutes of intra-service time, and 7 minutes of 

immediate post-service time. 

HCPCS code G0250 (Physician review, interpretation, and patient management of home 

INR (International Normalized Ratio) testing for patient with either mechanical heart valve(s), 

chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; 

testing not occurring more frequently than once a week; billing units of service include 4 tests) 

has a physician work RVU of 0.18 but was not listed in the CY 2012 physician time file. 

HCPCS code G0250 has a procedure status indicator of R on the PFS indicating that coverage of 

this service is restricted. In the CY 2003 final rule (67 FR 79991), we assigned HCPCS code 

G0250 a work RVU of 0.18, which corresponds to the work RVU of CPT code 99211. While 

we did not articulate this as a direct crosswalk in the CY 2003 final rule, after clinical review we 

believe that HCPCS code G0250 continues to require similar work as CPT code 99211, and 

should have the same amount of physician time as CPT code 99211. As such, we proposed to 

assign HCPCS code G0250 the same physician time as CPT code 99211. Specifically, for 

HCPCS code G0250 we proposed 5 minutes of intra-service time and 2 minutes of immediate 

post-service time. 
113 

During our annual review of new, revised, and potentially misvalued CPT codes, the 

assessment of physician time used to furnish a service is an important part of the clinical review 

when determining the appropriate work RVU for a service. However, the time in the physician 

time file is not used to automatically adjust the physician work RVUs outside of that clinical 

review process. As such, the proposed addition of physician time to the HCPCS codes discussed 

above will have no impact on the current physician work RVUs for these services. 

The time data in the physician time file is used in the PE methodology described in 

section II.A.2. In creating the indirect practice cost index (IPCI), we calculate specialty-specific 

aggregate pools of indirect PE for all PFS services for that specialty by adding the product of the 

indirect PE/HR for the specialty, the physician time for the service, and the specialty’s utilization 

for the service across all services furnished by the specialty. The proposed addition of physician 

time to the HCPCS codes discussed above will affect the aggregate pools of indirect PE at the 

specialty level. However because the services discussed above have low utilization and low total 

time, the impact of the physician time changes on the IPCI is negligible, and likely would have a 

modest impact if any on the PE RVUs at the individual code level. 

 Below is a summary of the comments we received on our proposed changes for PFS 

services with physician work and no listed time in the physician time file. 

Comment: Commenters agreed with our proposed time changes for these services. The 

AMA RUC noted that historically the AMA RUC has not provided work or time 

recommendations for HCPCS G-codes, but that they will update the AMA RUC database to 

reflect these new physician time components. 

Response: We thank commenters for their input on the times associated with these 

services. We are finalizing our proposals without modification. These proposed adjustments are 

reflected in the physician time file associated with this CY 2013 final rule with comment period, 
114 

available on the CMS website under the downloads for the CY 2013 PFS final rule with 

comment period at http://www.cms.gov/PhysicianFeeSched/.

(2) Review of Services with No Physician Work and Listed Time in the Physician Time File 

There are a number of services that have no physician work RVUs, yet include time in 

the physician time file. Many of these services are not payable under the PFS or are contractor 

priced services where the physician time is not used to nationally price the services on the PFS. 

We did not propose to remove the physician time from the time file for these services as the time 

has no effect on the calculation of RVUs for the PFS. However, there are several CPT codes, 

listed in Table 9, that are payable under the PFS and have no physician work RVUs yet include 

time in the physician time file. We proposed to remove the physician time from the time file for 

these seven CPT codes. 

TABLE 9: Payable CPT Codes with Physician Time and No Physician Work 

CPT 

Code 

Short Descriptor PFS Procedure Status CY 2012 Total 

Physician Time 

22841 Insert spine fixation 

device 

B (Bundled, not separately 

payable) 

5 minutes 

51798 Us urine capacity measure A (Active, payable) 9 minutes 

95990 Spin/brain pump refill & 

main 

A (Active, payable) 40 minutes 

96904 Whole body photography R (Restricted coverage) 80 minutes 

96913 Photochemotherapy uv-a 

or b 

A (Active, payable) 90 minutes 

97545 Work hardening R(Restricted coverage) 120 minutes 

97602 Wound(s) care nonselective B (Bundled, not separately 

payable) 

36 minutes 

As mentioned above and as discussed in section II.A.2. of this final rule with comment 

period, to create the IPCI used in the PE methodology, we calculated specialty-specific aggregate 

pools of indirect PE for all PFS services for that specialty by adding the product of the indirect 

PE/HR for the specialty, the physician time for the service, and the specialty’s utilization for the 

service across all services performed by the specialty. As we stated in the CY 2013 PFS 
115 

proposed rule, the proposed removal of physician time from the CPT codes discussed above will 

affect the aggregate pools of indirect PE at the specialty level. However because the services 

discussed above have low utilization and/or low total time, the impact of the physician time 

changes on the IPCI is negligible, and likely will have a modest impact if any on the PE RVUs at 

the individual code level. 

Below is a summary of the comments we received on our proposed changes for PFS 

services with no physician work and listed time in the physician time file. 

Comment: Commenters agreed with our proposal to remove the time listed in the 

physician time file for CPT codes 22841 (Internal spinal fixation by wiring of spinous processes 

(List separately in addition to code for primary procedure)), 95990 (Refilling and maintenance of 

implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain 

(intraventricular), includes electronic analysis of pump, when performed;), 96904 (Whole body 

integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome 

or a history of dysplastic nevi, or patients with a personal or familial history of melanoma), and 

96913 (Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses 

requiring at least 4-8 hours of care under direct supervision of the physician (includes application 

of medication and dressings)). Commenters noted that CPT code 51798 (Measurement of postvoiding residual urine and/or bladder capacity by ultrasound, non-imaging) likely had time listed 

in the physician time file because the AMA RUC had recommended work RVUs for the service 

however CMS assigned only practice expense. Similarly, commenters noted that CPT code 

97602 (Removal of devitalized tissue from wound(s), non-selective debridement, without 

anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), 

wound assessment, and instruction(s) for ongoing care, per session) likely had time included in 

the physician time final because the AMA RUC HCPAC recommended work RVUs for the 

service, however CMS assigned CPT code 97602 a bundled procedure status. Commenters noted 
116 

that CPT code 97545 (Work hardening/conditioning; initial 2 hours) has a restricted procedure 

status, but inherently involves 2 hours of work, and requested that CMS maintain the time entry 

in the physician time file for this service to assist other payers and stakeholder in making 

payment policy decisions. 

Response: We thank commenters for their input on the times associated with these 

services. After reviewing the comments, we are finalizing our proposal to remove the time from 

the physician time file for CPT codes 22841, 51798, 95990, 96913, and 97602. We will 

maintain the time entry in the physician time file for CPT code 97545, as requested; while this 

CPT code has a restricted procedure status indicator, it is still payable in some circumstances. 

CPT code 96904 also has a restricted procedure status indicator and is payable in some 

circumstances. For consistent treatment of these two CPT codes, we will also maintain the time 

entry in the physician time file for CPT code 96904. These adjustments are reflected in the 

physician time file associated with this CY 2013 PFS final rule with comment period, available 

on the CMS website under the downloads for the CY 2013 PFS final rule with comment period 

at http://www.cms.gov/PhysicianFeeSched/.

4. Expanding the Multiple Procedure Payment Reduction Policy 

Medicare has long employed multiple procedure payment reduction (MPPR) policies to 

adjust payment to more appropriately reflect reduced resources involved with furnishing services 

that are frequently furnished together. Under these policies, we reduce payment for the second 

and subsequent services within the same MPPR category furnished in the same session or same 

day. These payment reductions reflect efficiencies that typically occur in either the practice 

expense (PE) or professional work or both when services are furnished together. With the 

exception of a few codes that are always reported along with another code, the Medicare PFS 

values services independently to recognize relative resources involved when the service is the 

only one furnished in a session. While our general policy for MPPRs precedes the Affordable 
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Care Act, MPPRs address the fourth category of potentially misvalued codes identified in section 

1848(c)(2)(K) of the Act which is “multiple codes that are frequently billed in conjunction with 

furnishing a single service” (see 75 FR 73216). 

For CY 2013, we proposed to continue our work to recognize resource efficiencies when 

certain services are furnished together. We proposed to apply an MPPR to the technical 

component (TC) of certain cardiovascular and ophthalmology diagnostic tests. As discussed in 

the CY 2012 final rule with comment period (76 FR 73079), we are also proceeding with 

applying the current MPPR policy for imaging services to services furnished in the same session 

by physicians in the same group practice. 

a. Background 

Medicare has a longstanding policy to reduce payment by 50 percent for the second and 

subsequent surgical procedures furnished to the same beneficiary by a single physician or 

physicians in the same group practice 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 

MPPR policy, with this 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. 

Consistent with recommendations of MedPAC in its March 2005 Report to the Congress 

on Medicare Payment Policy, for CY 2006 PFS, we extended the MPPR policy to the TC of 

certain diagnostic imaging procedures furnished on contiguous areas of the body in a single 

session (70 FR 70261). This MPPR policy recognizes that for the second and subsequent 

imaging procedures furnished in the same session, there are some efficiencies in clinical labor, 

supplies, and equipment time. In particular, certain clinical labor activities and supplies are not 
118 

duplicated for subsequent imaging services in the same session and, because equipment time and 

indirect costs are allocated based on clinical labor time, we also reduced those accordingly. 

The imaging MPPR policy originally applied 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 and only applied to procedures furnished in a single session 

involving contiguous body areas within a family of codes, not across families. Additionally, the 

MPPR policy originally applied to TC-only services and to the TC of global services, but not to 

professional component (PC) services. 

There have been several revisions to this policy since it was originally adopted. Under 

the current imaging MPPR policy, full payment is made for the TC of the highest paid procedure, 

and payment for the TC is reduced by 50 percent for each additional procedure subject to this 

MPPR policy. We originally planned to phase in the imaging 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 (DRA) (Pub. L. 109–171) amended the statute to 

place a cap on the PFS payment amount for most imaging procedures at the amount paid under 

the hospital outpatient prospective payment system (OPPS). In view of this new OPPS payment 

cap, we decided in the PFS final rule with comment period for CY 2006 that it would be prudent 

to retain the imaging 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 

imaging MPPR policy from the PFS BN provision. Effective July 1, 2010, section 

1848(b)(4)(C) of the Act 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. Section 

1848(c)(2)(B)(v)(IV) of the Act exempted the reduced expenditures attributable to this further 

change from the PFS BN provision. 
119 

In the July 2009 U.S. Government Accountability Office (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 furnished by the 

same physician to the same beneficiary on the same day. The GAO recommended the following: 

(1) expanding the existing imaging MPPR policy for certain services 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 furnished 

together. The GAO report also encouraged us to focus on service pairs that have the most impact 

on Medicare spending. 

In its 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. 

Section 1848(c)(2)(K) of the Act 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, in the CY 2010 final rule with comment period, we 

implemented a limited expansion of the imaging MPPR policy to additional combinations of 

imaging services. 
120 

 Effective January 1, 2011, the imaging MPPR applies regardless of code family; that is, 

the policy applies to multiple imaging services furnished within the same family of codes or 

across families. This policy is consistent with the standard PFS MPPR policy for surgical 

procedures that does not group procedures by body region. The current imaging MPPR policy 

applies to CT and CTA, MRI and MRA, and ultrasound procedures furnished to the same 

beneficiary in the same session, regardless of the imaging modality, and is not limited to 

contiguous body areas. 

As we noted in the CY 2011 PFS final rule with comment period (75 FR 73228), while 

section 1848(c)(2)(B)(v)(VI) of the Act specifies that reduced expenditures attributable to the 

increase in the imaging MPPR from 25 to 50 percent (effective for fee schedules established 

beginning with 2010 and for services furnished on or after July 1, 2010) are excluded from the 

PFS BN adjustment, it does not apply to reduced expenditures attributable to our policy change 

regarding additional code combinations across code families (noncontiguous body areas) that are 

subject to BN under the PFS. The complete list of codes subject to the CY 2011 MPPR policy 

for diagnostic imaging services is included in Addendum F. 

As a further step in applying the provisions of section 1848(c)(2)(K) of the Act, on 

January 1, 2011, we implemented an MPPR for therapy services. The MPPR applies to 

separately payable “always therapy” services, that is, services that are only paid by Medicare 

when furnished under a therapy plan of care. As we explained in the CY 2011 PFS final rule 

with comment period (75 FR 73232), the therapy MPPR does not apply to contractor-priced 

codes, bundled codes, and add-on codes. The complete list of codes subject to the MPPR policy 

for therapy services is included in Addendum H. 

This MPPR for therapy services was first proposed in the CY 2011 proposed rule 

(75 FR 44075) as 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 
121 

beneficiary in a single day. It applies to services furnished by an individual or group practice or 

“incident to” a physician’s service. However, in response to public comments, in the CY 2011 

PFS final rule with comment period (75 FR 73232), we adopted a 25 percent payment reduction 

to the PE component of the second and subsequent therapy services for multiple “always 

therapy” services furnished to a single beneficiary in a single day. 

Subsequent to publication of the CY 2011 PFS final rule with comment period, section 3 

of the Physician Payment and Therapy Relief Act of 2010 (PPTRA) (Pub. L. 111-286) revised 

the payment reduction percentage from 25 percent to 20 percent for therapy services for which 

payment is made under a fee schedule under section 1848 of the Act (which are services 

furnished in office settings, or non-institutional services). The payment reduction percentage 

remains at 25 percent for therapy services furnished in institutional settings. Section 4 of the 

PPTRA exempted the reduced expenditures attributable to the therapy MPPR policy from the 

PFS BN provision. Under our current policy as amended by the PPTRA, for institutional 

services, full payment is made for the service or unit with the highest PE and payment for the PE 

component for the second and subsequent procedures or additional units of the same service is 

reduced by 25 percent. For non-institutional services, full payment is made for the service or 

unit with the highest PE and payment for the PE component for the second and subsequent 

procedures or additional units of the same service is reduced by 20 percent. 

This MPPR policy applies to multiple units of the same therapy service, as well as to 

multiple different “always therapy” services, when furnished to the same beneficiary on the same 

day. The MPPR applies when multiple therapy services are billed on the same date of service for 

one beneficiary by the same practitioner or facility under the same National Provider Identifier 

(NPI), regardless of whether the services are furnished in one therapy discipline or multiple 

disciplines, including physical therapy, occupational therapy, or speech-language pathology. 
122 

The MPPR policy applies in all settings where outpatient therapy services are paid under 

Part B. This includes both services that are furnished in the office setting and paid under the 

PFS, as well as institutional services that are furnished by outpatient hospitals, home health 

agencies, comprehensive outpatient rehabilitation facilities (CORFs), and other entities that are 

paid for outpatient therapy services at rates based on the PFS. 

In its June 2011 Report to Congress, MedPAC highlighted continued growth in ancillary 

services subject to the in-office ancillary services exception. The in-office ancillary exception to 

the general prohibition under section 1877 of the Act as amended by the Ethics in Patient 

Referrals Act, also known as the Stark law, allows physicians to refer Medicare beneficiaries for 

designated health services, including imaging, radiation therapy, home health care, durable 

medical equipment, clinical laboratory tests, and physical therapy, to entities with which they 

have a financial relationship under specific conditions. MedPAC recommended that we apply a 

MPPR to the PC of diagnostic imaging services furnished by the same practitioner in the same 

session as one means to curb excess self-referral for these services. The GAO already had made 

a similar recommendation in its July 2009 report. 

In continuing to apply the provisions of section 1848(c)(2)(K) of the Act regarding 

potentially misvalued codes that result from “multiple codes that are frequently billed in 

conjunction with furnishing a single service,” in the CY 2012 final rule (76 FR 73071), we 

expanded the MPPR to the PC of Advanced Imaging Services (CT, MRI, and Ultrasound), that 

is, the same list of codes to which the MPPR on the TC of advanced imaging already applied 

(see Addendum F). Thus, this MPPR policy now applies to the PC and the TC of certain 

diagnostic imaging codes. Specifically, we expanded the payment reduction currently applied to 

the TC to apply also to the PC of the second and subsequent advanced imaging services 

furnished by the same physician (or by two or more physicians in the same group practice) to the 

same beneficiary in the same session on the same day. However, in response to public 
123 

comments, in the CY 2012 PFS final rule with comment period, we adopted a 25 percent 

payment reduction to the PC component of the second and subsequent imaging services. 

Under this policy, full payment is made for the PC of the highest paid advanced imaging 

service, and payment is reduced by 25 percent for the PC for each additional advanced imaging 

service furnished to the same beneficiary in the same session. This policy was based on the 

expected efficiencies in furnishing multiple services in the same session due to duplication of 

physician work, primarily in the pre- and post-service periods, but with some efficiencies in the 

intraservice period. 

This policy 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 1848(c)(2)(K) of the Act. This policy is also consistent both with our 

longstanding policy on surgical and nuclear medicine diagnostic procedures, under which we 

apply a 50 percent payment reduction to second and subsequent procedures. Furthermore, it was 

responsive to continued concerns about significant growth in imaging spending, and to MedPAC 

(March 2010 and June 2011) and GAO (July 2009) recommendations regarding the expansion of 

MPPR policies under the PFS to account for additional efficiencies. 

In the CY 2012 proposed rule (76 FR 42812), we also invited public comment on the 

following MPPR policies under consideration. We noted that any proposals would be presented 

in future rulemaking and subject to further public comment: 

● Apply the MPPR to the TC of All Imaging Services. This approach would apply a 

payment reduction to the TC of the second and subsequent imaging services furnished in the 

same session. Such an approach could define imaging consistent with our existing definition of 

imaging for purposes of the statutory cap on PFS payment at the OPPS rate including X-ray, 

ultrasound (including echocardiography), nuclear medicine (including positron emission 

tomography), magnetic resonance imaging, computed tomography, and fluoroscopy, but 
124 

excluding diagnostic and screening mammography. Add-on codes that are always furnished 

with another service and have been valued accordingly could be excluded. 

Such an approach would be based on the expected efficiencies due to duplication of 

clinical labor activities, supplies, and equipment time when multiple services are furnished 

together. This approach would apply to approximately 530 HCPCS codes, including the 119 

codes to which the current imaging MPPR applies. Savings would be redistributed to other PFS 

services as required by the statutory PFS BN provision. 

● Apply the MPPR to the PC of All Imaging Services. This approach would apply a 

payment reduction to the PC of the second or subsequent imaging services furnished in the 

same encounter. Such an approach could define imaging consistent with our existing definition 

of imaging for the cap on payment at the OPPS rate. Add-on codes that are always furnished 

with another service and have been valued accordingly could be excluded. 

Such an approach would be based on efficiencies due to duplication of physician work 

primarily in the pre- and post-service periods, with smaller efficiencies in the intraservice period, 

when multiple services are furnished together. This approach would apply to approximately 530 

HCPCS codes, including the 119 codes to which the current imaging MPPR applies. Savings 

would be redistributed to other PFS services as required by the statutory PFS BN provision. 

● Apply the MPPR to the TC of All Diagnostic Tests. This approach would apply a 

payment reduction to the TC of the second and subsequent diagnostic tests (such as radiology, 

cardiology, audiology, etc.) furnished in the same encounter. Add-on codes that are always 

furnished with another service and have been valued accordingly could be excluded. 

Such an approach would be based on the expected efficiencies due to duplication of 

clinical labor activities, supplies, and equipment time when multiple services are furnished 

together. The approach would apply to approximately 700 HCPCS codes, including the 

approximately 560 HCPCS codes that are currently subject to the OPPS cap. The savings 
125 

would be redistributed to other PFS services as required by the statutory PFS BN provision. 

b. MPPR Policy Clarifications 

(1) Apply the MPPR to Two Nuclear Medicine Procedures 

As indicated previously, effective January 1, 1995, we implemented an MPPR for six 

nuclear medicine codes. Under the current policy, full payment is made for the highest paid 

procedure, and payment is reduced by 50 percent for the second procedure furnished to the same 

beneficiary on the same day. As noted in the CY 2013 proposed rule (77 FR 44748), due to a 

technical error, the MPPR is not being applied to CPT codes 78306 (Bone imaging; whole body) 

when followed by CPT code 78320 (Bone imaging; SPECT). We will apply the MPPR to these 

procedures effective January 1, 2013. We received the following comment on this provision: 

Comment: A commenter indicated that continuing to apply and extend the MPPR for 

nuclear medicine procedures is unwarranted and inconsistent with CMS’ aim to improve 

payment accuracy. The commenter noted that decisions made in 1995 were based on qualitative 

assessments rather than on rigorous data analysis. The commenter believes that with the wealth 

of data now available, and improved techniques in data analysis, careful evaluation of the 

applicability of the MPPR for all six nuclear medicine procedures is merited. 

Response: We acknowledge the commenter’s concerns, but we neither proposed 

discontinuing the MPPR on nuclear medicine procedures, nor extending it to new codes. Rather, 

we noted that the MPPR under current policy was, for technical reasons, not being applied to 

CPT code 78306 (Bone imaging; whole body) when followed by CPT code 78320 (Bone 

imaging; SPECT), and provided notification that the MPPR would be applied effective January 

1, 2013. Accordingly, we are finalizing this technical correction effective for services furnished 

on or after January 1, 2013. 

(2) Apply the MPPR to the PC and TC of Advanced Imaging Procedures to Physicians in the 

Same Group Practice 
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As indicated in the CY 2012 final rule (76 FR 73077-73079), we finalized a policy to 

apply the MPPR to the PC and TC of the second and subsequent advanced imaging procedures 

furnished to the same beneficiary in the same session by a single physician or by multiple 

physicians in the same group practice. Due to operational limitations, we did not apply this 

MPPR to multiple physicians in the same group practice during CY 2012. In addition, after we 

issued the CY 2012 final rule with comment period, some commenters stated that they had not 

commented on the application of the MPPR to physicians in the same group practice because 

that policy was not explicit in the CY 2012 proposed rule discussion expanding the MPPR for 

advanced imaging to the PC. As noted in the CY 2013 proposed rule (77 FR 44748), we have 

resolved the operational problems and, therefore, for services furnished on or after January 1, 

2013 we will apply the MPPR to both the PC and the TC of advanced imaging procedures to 

multiple physicians in the same group practice (same group NPI). Under this policy, the MPPR 

will apply when one or more physicians in the same group practice furnish services to the same 

beneficiary, in the same session, on the same day. This policy is consistent with other PFS 

MPPR policies for surgical and therapy procedures and, effective January 1, 2013, for diagnostic 

cardiovascular and ophthalmology procedures. We continue to believe that the typical 

efficiencies achieved when the same physician is furnishing multiple procedures also accrue 

when different physicians in the same group furnish multiple procedures involving the same 

beneficiary in the same session. While we agree with commenters that most physicians would 

not change the way they practice in order to avoid application of the MPPR, we believe 

application of the imaging MPPR to physicians in the same group practice will ensure that there 

is no financial incentive for physicians in a group practice to change their behavior to split 

imaging interpretation services for a beneficiary among different physicians in the group. It is 

our intention to apply this and future MPPRs to services furnished by one or more physicians in 

the same group unless we determine for a specific MPPR that the efficiencies associated with an 
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individual physician furnishing multiple procedures do not extend to multiple physicians in the 

same group practice. We received the following comments on this provision: 

 Comment: Most commenters opposed applying the MPPR on diagnostic imaging to 

physicians in the same group practice, specifically to the PC. While many commenters 

acknowledged minimal efficiencies in the PC of second and subsequent procedures when 

furnished by the same physician, they maintained that no such efficiencies exist when furnished 

by multiple physicians. 

Commenters maintained that CMS assumes efficiencies exist, but has not presented any 

clinical evidence or comprehensive resource use analysis to justify claims of efficiency. 

Commenters do not believe that substantial economy of time or of effort exist. According to 

commenters, each physician who reviews a beneficiary’s imaging results must review the 

beneficiary’s medical history, examine the imaging results, make diagnoses, draft a report, and 

enter communications with other physicians in the beneficiary’s medical chart. Commenters 

note that none of these actions would take less time or effort when performed by a second 

physician in the same practice. Commenters do not believe this proposal reflects the true costs 

incurred by a practice when multiple physicians furnish advanced imaging services to the same 

beneficiary on the same day. Another commenter noted that cognitive medicine, such as 

diagnostic imaging cannot have global efficiencies, as every observer needs to independently 

investigate, collect data, formulate an educated opinion, and furnish a professional assessment. 

Commenters maintained that clinical best practice dictates that the images are read by 

subspecialized, fellowship-trained radiologists, trained to read specific body parts. For example, 

they stated, radiologists are trained to read either breast, musculoskeletal, body, neurology or 

oncology images. Commenters indicated that the proposal would penalize or disincentivize 

practices from having the most appropriate radiologist read the study, which may subject 

beneficiaries to undue risks. 
128 

Commenters also noted that beneficiaries suffering from life-threatening conditions such 

as trauma, heart attacks, and cancer often require multiple imaging scans to accurately and fully 

assess extent of injury and monitor disease progression and/or any improvements in condition. 

This is not uncommon in an urban hospital serving high acuity beneficiaries. Commenters 

maintained that as the complexity of the beneficiary case increases, the likelihood that multiple 

scans and/or series will be needed in a given day increases, and thus the number of physicians 

needed to review multiple scans and/or regions of the body in a series of scans increases, 

requiring a variety of sub-specialty-trained radiologists. Commenters concluded that the amount 

of work in the form of time, effort, and skill, does not diminish in this situation but rather has an 

additive effect, reflecting the clinical complexity of the beneficiary situation, not a duplication of 

efforts. 

A commenter noted that multi-modality images on a beneficiary are not always 

interpreted at the same time or by the same physician. According to the commenter, the 

beneficiary encounter that includes multiple TCs is not directly related to the performance of the 

PCs by the interpreting physician(s). The commenter indicated that through the use of 

teleradiology, the interpretations often take place at separate locations and by separate 

physicians. Finally, the commenter noted that this process allows differently specialized 

radiologists to interpret different images. 

A commenter maintained that CMS’ reliance on both the July 2009 GAO report and the 

March 2010 MedPAC report to support its MPPR policies is fundamentally flawed because such 

sources do not appear to justify the proposals. The commenter noted that CMS also cites the 

June 2011 MedPAC report as further support for its MPPR application to the PC of diagnostic 

imaging services furnished by the same physician in the same session. The commenter 

indicated that the report’s policy recommendation is for a multiple procedure payment reduction 

to the professional component of diagnostic imaging services furnished by the same practitioner 
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in the same session. The commenter stated that it could be unfair to apply the MPPR to 

physicians who share a practice. 

A commenter recommended that CMS focus on applying the results of the Medicare 

Imaging Demonstration, and pursuing options to encourage use of appropriateness criteria, as the 

best solution to any problems of under or overutilization of imaging.

Response: The policy of applying the imaging MPPR to physicians in the same group 

practice is consistent with other MPPR policies for surgical procedures and therapy services, and 

effective January 1, 2013, for diagnostic cardiovascular and diagnostic ophthalmology 

procedures under the PFS. We continue to believe that the typical efficiencies achieved when 

the same physician is furnishing multiple procedures also accrue when different physicians in the 

same group furnish multiple procedures involving the same beneficiary. We believe that 

efficiencies exist in the parts of the service that deal directly with patients, such as gowning and 

obtaining consent, as well as in the interpretation, where the first completed interpretation is 

commonly available to the second interpreting physician at the point of interpretation. Although 

efficiencies may be less when one physician is remote, we still believe that efficiencies are 

within the ranges that will typically be seen across the many varied combinations of imaging 

services subject to the MPPR. 

We disagree that radiologists are routinely trained to only read organ specific or 

technology specific images. Radiologists receive broad training that allows them to provide 

services across multiple technologies and organ systems. Some may choose to more narrowly 

focus their practice, but in the typical radiology practice across the country, many radiologists 

continue to provide a broad range of imaging interpretation services. 

We agree with the commenter that higher complexity patients may require multiple 

scans. However, we disagree that this higher complexity negates the efficiencies that are seen 

with less complex patients. Duplication in technical component, such as greeting and gowning, 
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would continue irrespective of patient complexity. Higher complexity patients, receiving 

multiple scans, provide greater support for the proposed MPPR policy changes. Since 

interpretation of an image builds on the clinical framework that the radiologist(s) develops for 

each patient as she reviews each scan, we believe that interpretation of multiple additional scans 

require diminishing marginal effort. 

Finally, while we agree with commenters that most physicians would not change the way 

they practice in order to avoid application of the MPPR, we believe application of the imaging 

MPPR to physicians in the same group practice will ensure that there is no financial incentive for 

physicians in a group practice to change their behavior to split imaging interpretation services for 

a beneficiary among different physicians in the group. 

 

It is our intention to apply this and future MPPR policies to services furnished by one or 

more physicians in the same group. Future modifications may be appropriate if we collect or are 

provided with data that indicates that the efficiencies associated with an individual physician 

furnishing multiple procedures do not extend to multiple physicians in the same group practice. 

 We disagree that we have misinterpreted GAO and MedPAC policy recommendations. 

MedPAC’s June 2011 recommendation for an MPPR on the professional component of imaging 

services is silent on application to the group practice, but since then, MedPAC has not opposed 

our proposal to apply the MPPR on the PC and TC of diagnostic imaging to physicians in the 

same group practice. Finally, the Medicare Imaging Demonstration is designed to test whether 

the use of decision support systems can improve quality of care by diminishing patient exposure 

to potentially harmful radiation caused by unnecessary over-utilization of advanced imaging 

services. The 2-year demonstration has recently completed its first year. The demonstration is a 

separate initiative and does not specifically address MPPR policy. 

Comment: Many commenters noted that administrative considerations prevented us from 
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implementing this policy effective January 1, 2012. Commenters indicated that we have not 

provided a detailed explanation of how such administrative concerns were rectified. 

Response: Our administrative delay in implementing the policy did not involve the 

merits of the policy but the practicality of implementation. Medicare contractors were unable to 

make the necessary changes to their systems to effectively operationalize the policy for CY 

2012. The necessary system changes have now been made in order for this policy to be 

operational beginning on January 1, 2013. 

Comment: Commenters expressed concern that using the NPI to define a group practice 

may be inaccurate. Commenters indicated that some diagnostic imaging practice members may 

belong to more than one NPI group; whereas other practitioners may be part of a smaller NPI 

group than their corporate structure would suggest. Commenters maintained that attempts to 

apply the MPPR to physicians in the same group practice using the NPI could lead to unfair 

application simply due to corporate governance issues. Additionally, commenters noted that 

radiologists in a group practice may also independently contract to furnish outside interpretations 

for other groups. Finally, commenters indicated that reliance on the NPI in these cases may lead 

to confusion and potential compliance concerns. 

Response: We have traditionally relied on the group NPI to identify services furnished in 

the same group practice as a basis for group practice-level edits across the physician fee 

schedule. We plan to use the group NPI for applying the MPPR to advanced imaging services at 

the group practice level beginning in 2013. We appreciate commenter input on this issue and 

understand that physicians do not always furnish services within their group practice and that the 

group NPI may reflect several different organizational arrangements. Accordingly, we intend to 

further explore the issues the commenters raised regarding use of the group NPI to identify 

services furnished in the same group practice. For example, we could consider using a provider 

Tax Identification Number (TIN) as an alternative to the group NPI; however, we would need to 
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determine whether this would create other operational problems. Medicare contractors would 

also require adequate time to make the necessary systems changes. We will consider these issues 

and make any changes in future rulemaking.

Comment: Various commenters had the following concerns about the definition of a 

“session” and the use of modifier 59: 

● Physicians use the 59 modifier appropriately to bypass the MPPR when multiple 

services are furnished to the same beneficiary in separate sessions on the same day. However, 

the 59 modifier is also used for the Correct Coding Initiative (CCI) edits, creating a conflict 

between the two different uses of the modifier. For example, if an MRA of the head and brain 

are furnished to the same beneficiary on the same day, it may be appropriate to report modifier 

59 to bypass the CCI edit. However, the modifier 59 may also be interpreted to bypass the 

MPPR, which would not be appropriate if the services were furnished in the same session. They 

stated that this presents a quandary for both radiology practices and Medicare Administrative 

Contractors. 

● CMS has provided no guidance on what constitutes a separate session for professional 

interpretation, other than “scans interpreted at widely different times,” leaving radiology 

practices vulnerable to differing interpretations by Medicare contractors, including Recovery 

Audit Contractors. 

● Whether CMS’ use of the word “encounter” is synonymous with “session.” 

● Multiple physicians furnishing the PC on different studies to the same beneficiary on 

the same day should constitute separate sessions by definition. 

● Software programs in use for medical billing do not adequately capture interpretation 

times, and therefore, do not track whether the PC was performed in the same or different sessions 

and when the 59 modifier is appropriate. Commenters expressed concern that they will not be 

able to routinely identify when a Medicare beneficiary has had multiple imaging scans on the 
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same day, especially if reports are generated in different locations, by different physicians, at 

different times of day. Radiology workflow systems triage studies to subspecialty radiologists 

who each separately interpret the studies and generate reports. Billing systems submit separate 

claims for each study. If two physicians read studies on the same beneficiary, coders and billing 

systems will have significant difficulty attaching the 59 modifier to the appropriate study, even if 

they are able to recognize that the 59 modifier should be applied. Hospital-based radiologists rely 

on data feeds provided by their hospitals’ information systems. These data-feeds typically 

include beneficiary demographic information but not image interpretation times. Because they 

are unable to track the time of interpretation, coders and billers will be required to re-create the 

timing of interpretative sessions to determine whether or not the interpretation occurred in the 

same session. 

● Radiologists in small practices, or rural hospitals and imaging facilities, are more 

likely to have only a few radiologists in the office. Frequently in small practices, there will be 

instances where beneficiaries have multiple advanced imaging services that are in clinically 

separate sessions, but interpreted by the individual members of the same small group of 

radiologists. It is not clear that there will be a way for coders, CMS contractors and auditors to 

understand and validate that these separate encounters constitute separate sessions. 

● Contrary to CMS’ claim, commenters expect there would be frequent circumstances 

requiring the use of the 59 modifier, that is, a distinct procedural service. 

Response: We are aware of the conflict between use of modifier 59 for CCI edits and for 

purposes of bypassing the MPPR when multiple procedures are furnished. We are considering 

creating a new modifier for the MPPR to resolve this problem. In creating a new MPPR 

modifier, we would refine the definition of what constitutes a session. We believe that radiology 

imaging systems currently capture the time of each image and that image time can be provided to 

the interpreting radiologist(s). We also believe that radiology medical record systems currently 
134 

capture the time of each professional comment or interpretation, and that the interpretation of the 

radiologist should contain any clinical information necessary to identify when a separate session 

has occurred. We believe that where billing systems currently do not capture this information in 

a readily usable form, that they will adapt to this policy and make this necessary billing 

information readily accessible to coders. Thus, we believe that coders will be able to determine 

when a separate session has occurred and will be able to append a 59 modifier (or new MPPR 

modifier for different session) to the claim line when such a modifier is justified. 

Alternatively, we may consider modifying the MPPR policy to apply to procedures 

furnished on the same day, rather than in the same session. This would resolve some of the 

operational difficulties with the use of “session” and conform to the policy for all other MPPRs. 

If we were to modify this MPPR to apply to procedures furnished on the same day rather than in 

the same session, we would do so through future rulemaking and subject to public comment. 

 Comment: Commenters indicated that applying the MPPR for the PC of advanced 

imaging procedures to physicians in the same group practice would result in a payment reduction 

that would adversely affect both the quality of care and access to care. 

 Response: We have no evidence to suggest any adverse impacts on either the quality 

of care or the access to care have resulted from the implementation of the MPPR to the TC of 

imaging in 2006 or the PC of imaging in 2012. We have no evidence that beneficiaries have 

been unable to obtain needed imaging, and we will continue to monitor access to care. 

MedPAC's analysis in its June 2011 report indicates there has been continued high annual 

growth in the use of imaging through 2009. Further, in the absence of any evidence of 

inadequate access or safety and quality concerns, declining growth in imaging services could be 

interpreted as a return to a more appropriate level of imaging utilization. Based on our 

experience with the MPPR on both the TC and PC of advanced diagnostic imaging services, we 
135 

have no reason to believe that extending the imaging MPPR to physicians in the same group 

practice will have a negative impact on quality or access to care. 

c. Proposed MPPR for the TC of Cardiovascular and Ophthalmology Services 

As noted above, we continue to examine whether it would be appropriate to apply MPPR 

policies to other categories of services that are frequently billed together, including the TC for 

diagnostic services other than advanced imaging services. For CY 2013, we examined other 

diagnostic services to determine whether there typically are efficiencies in the technical 

component when multiple diagnostic services are furnished together on the same day. We have 

conducted an analysis of the most frequently furnished code combinations for all diagnostic 

services using CY 2011 claims data. Of the several areas of diagnostic tests that we examined, 

we found that billing patterns and PE inputs indicated that multiple cardiovascular and 

ophthalmology diagnostic procedures, respectively, are frequently furnished together and that 

there is some duplication in PE inputs when this occurs. For cardiovascular diagnostic services, 

we reviewed the code pair/combinations with the highest utilization in the CPT code ranges of 

75600 through 75893, 78414 through 78496, and 93000 through 93990. For ophthalmology 

diagnostic services, we reviewed the code pair/combinations with the highest utilization in the 

CPT code ranges of 76510 through 76529 and 92002 through 92371. The cardiovascular and 

ophthalmology diagnostic code combinations identified as most frequently billed together are 

listed in Tables 14 and 15. 

Under the resource-based PE methodology, specific PE inputs of clinical labor, supplies, 

and equipment are used to calculate PE RVUs for each individual service. When multiple 

diagnostic tests are furnished to the same beneficiary on the same day, most of the clinical labor 

activities and some supplies are not furnished twice. We have identified the following clinical 

labor activities that typically would not be duplicated for subsequent procedures: 

● Greeting and gowning the patient. 
136 

● Preparing the room, equipment and supplies. 

● Education and consent. 

● Completing diagnostic forms. 

● Preparing charts. 

● Taking history. 

● Taking vitals. 

● Preparing and positioning the patient. 

● Cleaning the room. 

● Monitoring the patient. 

● Downloading, filing, identifying and storing photos 

● Developing film. 

● Collating data. 

● Quality Assurance documentation. 

● Making phone calls. 

● Reviewing prior X-rays, lab and echocardiograms. 

We analyzed the CY 2011 claims data for the most frequently billed cardiovascular and 

ophthalmology diagnostic code combinations to determine the level of duplication present when 

multiple services are furnished to the same beneficiary on the same day. Our MPPR 

determination excludes the clinical staff minutes associated with the activities that are not 

duplicated for subsequent procedures. For purposes of this analysis, we retained the higher 

number of minutes for each duplicated clinical activity, regardless of the code in the pair with 

which those clinical labor minutes were associated. For example, , if code A and B had 6 and 3 

minutes, respectively, of clinical labor for preparing and positioning the beneficiary, we 

removed 3 minutes. If code A and B had 2 and 4 minutes, respectively, of clinical labor for 

preparing room, equipment and supplies, we removed 2 minutes. The lower number of minutes 
137 

was removed, regardless of the code. If one code had no minutes for a particular clinical labor 

activity, then no minutes were removed for that activity. Equipment time and indirect costs are 

allocated based on clinical labor time; therefore, these inputs were reduced accordingly. While 

we observed that some supplies are duplicated, we did not factor these into our calculations 

because they were low cost and had little impact on our estimate of the level of duplication for 

each code pair. 

When we removed the PE inputs for activities that are not duplicated, and adjusted the 

equipment time and indirect costs, we found support for payment reductions ranging from 8 to 

57 percent for second and subsequent cardiovascular procedures (volume-adjusted average 

reduction across all code pairs of 25 percent); and payment reductions ranging from 9 to 62 

percent for second and subsequent ophthalmology procedures (volume-adjusted average 

reduction across all code pairs of 32 percent). Because we found a relatively wide range of 

reductions by code pair, we believed that an across-the-board reduction of 25 percent for second 

and subsequent procedures (which is approximately the average reduction supported by our 

analysis) would be appropriate. In the CY 2013 proposed rule (77 FR 44748-44752), we 

proposed to apply an MPPR to TC-only services and to the TC portion of global services for the 

procedures listed in Tables 12 and 13. The MPPR would apply independently to second and 

subsequent cardiovascular services and to second and subsequent ophthalmology services. We 

proposed to make full payment for the TC of the highest priced procedure and to make payment 

at 75 percent (that is, a 25 percent reduction) of the TC for each additional procedure furnished 

by the same physician (or physicians in the same group practice, that is, the same group practice 

NPI) to the same beneficiary on the same day. We did not propose to apply an MPPR to the PC 

for cardiovascular and ophthalmology services at this time. 

We believe that the proposed MPPR percentage represents an appropriate reduction for 

the typical delivery of multiple cardiovascular and ophthalmology services on the same day. 
138 

Because the reduction is based on discounting the specific PE inputs that are not duplicated for 

second and subsequent services, the proposal is consistent with our longstanding policies on 

surgical, nuclear medicine diagnostic procedures, and advanced imaging procedures, which 

apply a 50 percent reduction to second and subsequent procedures, and our more recent policy on 

therapy services, which applies a 20 or 25 percent reduction depending on the setting. 

Furthermore, it is consistent with section 1848(c)(2)(K) of the Act, which 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. 

Finally, it is responsive to continued concerns about significant growth in spending on 

imaging and other diagnostic services, and to MedPAC (March 2010) and GAO (July 2009) 

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

additional efficiencies. Savings resulting from this proposal would be redistributed to other PFS 

services as required by the general statutory PFS BN provision. 

In summary, we proposed that for services furnished on or after January 1, 2013, we will 

apply the MPPR to nuclear medicine procedures to CPT code 78306 (Bone imaging; whole 

body) when followed by CPT code 78320 (Bone imaging; SPECT). We will apply the MPPR to 

the PC and the TC of advanced imaging procedures when furnished by multiple physicians in the 

same group practice (same group NPI). Therefore, the MPPR will apply when one or more 

physicians in the same group practice furnish services to the same beneficiary, in the same 

session, on the same day. Finally, we proposed to apply an MPPR to TC-only services and to the 

TC portion of global services for diagnostic cardiovascular and ophthalmology procedures. The 

reduction would apply independently to cardiovascular and ophthalmology services. We 

proposed to make full payment for the TC of the highest priced procedure and payment at 75 

percent of the TC for each additional procedure furnished by the same physician (or physicians 
139 

in the same group practice, that is, the same group practice NPI) to the same beneficiary on the 

same day. 

The following is a summary of the comments we received on this proposal to apply the 

MPPR to diagnostic cardiovascular and ophthalmology procedures: 

Comment: MedPAC supported the proposal to expand the MPPR to cardiovascular and 

ophthalmology diagnostic services. Furthermore, MedPAC encouraged CMS to examine 

whether there are efficiencies in physician work that occur when multiple tests are furnished in 

the same session that would justify applying the MPPR to the PC of these services. For example, 

when multiple tests are performed together, certain physician activities (such as reviewing the 

beneficiary’s medical records and discussing the findings with the referring physician) are likely 

to occur only once. 

In the PFS proposed rule for CY 2012 (76 FR 42812-42813), CMS solicited comments 

on whether the MPPR should be applied to the TC of all diagnostic tests, rather than just imaging 

procedures. In response, MedPAC examined Part B claims data from 2010 to look for diagnostic 

tests that are frequently furnished more than once on the same day by the same physician for the 

same beneficiary. MedPAC found that several surgical pathology codes are frequently billed 

with more than one unit of service on the same date. For example, one-third of the claims for 

CPT code 88305 (Level IV, surgical pathology, gross and microscopic examination) contained 

more than one unit of service for that code. In addition, 57 percent of the claims for CPT code 

88342 (immunohistochemistry, each antibody) contained more than one unit of service for that 

code. In these cases, it appears that multiple specimens from the same beneficiary were 

examined at the same time by the same pathologist. MedPAC indicated that CMS should 

analyze whether there are efficiencies in practice expense or physician work that occur when 

multiple units of the same test are performed at the same time. If so, MedPAC suggested that 

CMS should consider applying the MPPR policy to these services or creating bundled codes that 
140 

include multiple units of the same test. MedPAC noted that these services account for a 

substantial and growing amount of Medicare spending. In 2010, Medicare spent $1.3 billion on 

CPT code 88305 and $241 million on CPT code 88342. 

MedPAC noted that it has recommended expanding the MPPR to both the TC and PC of 

all imaging services to account for efficiencies in practice expense and physician work that occur 

when multiple studies are furnished in the same session. 

A few additional commenters either agreed with the principle of applying the MPPR to 

cardiovascular and ophthalmology services or concurred with our findings that efficiencies exist 

when multiple diagnostic services are furnished on the same beneficiary on the same day. Those 

commenters agreed that the application of the MPPR to the additional cardiovascular and 

ophthalmic diagnostic procedures is an appropriate way to recognize such efficiencies. 

Response: We appreciate the support of MedPAC and other commenters for our proposal 

to apply the MPPR to cardiovascular and ophthalmology services. We agree that the MPPR is 

an appropriate mechanism to account for efficiencies when multiple procedures are furnished to 

the same beneficiary on the same day in order to ensure more accurate payments. 

Comment: Most commenters opposed applying the MPPR to the TC of diagnostic 

cardiovascular and ophthalmology services. Commenters maintained that the assumption that 

there is major duplication in clinical labor activities is false when two studies are done in the 

same session, and especially when these services are done in separate sessions on the same day. 

Commenters stated that CMS’ methodology of eliminating the smaller number of minutes 

assigned to one code in the frequently performed together code pairs for clinical staff and 

equipment is not appropriate for pairs of services that are: (1) furnished by different types of 

clinical staff, with different expertise and training (for example, radiology technologists and 

sonographers); (2) furnished in different types of rooms (for example, angiography suites and 

vascular ultrasound lab rooms); and (3) stocked with unique equipment. According to 
141 

commenters, many of the clinical labor activities considered redundant are performed multiple 

times, at different times of day, and in different rooms. 

As examples, commenters referenced the sample payment reduction calculations in the 

proposed rule for cardiovascular and ophthalmology services. Concerning CPT code 93306 

(transthoracic echocardiography) and CPT code 78452 (myocardial perfusion single-photon 

emission computed tomography (SPECT)), commenters noted that different physicians, each 

supported by separately specialized clinical staff perform the service in different rooms on two 

different types of equipment. 

Commenters indicated that clinical teams for each test independently greet and gown the 

patient, provide education, obtain consent, review previous exam results and studies and position 

the patient for the test. Commenters noted that the patient is positioned multiple times on 

different exam tables. According to commenters, two different clinical staff will independently 

review prior x-ray, laboratory, echocardiography studies, and other studies. Also, separate notes 

are made in the patient’s records, different diagnostic forms are completed, and different quality 

assurance regulatory compliance information must be documented for each test. Commenters 

noted that two different rooms with different specialized equipment in two different parts of the 

facility are prepared and cleaned for the two unique and different services. Finally, two different 

machines are utilized by two differently credentialed support staff to acquire independent and 

unrelated clinical testing data. 

Concerning CPT code 92235 (Fluorescein Angiography) and CPT code 92250 (Fundus 

Photography), commenters maintained that the proposal was based on an erroneous 

understanding of how services vary. Commenters noted that ophthalmic diagnostic tests are not 

equivalent to x-ray or fluoroscopic imaging, where the technician simply repositions the same 

device over a nearby area of the patient’s body. Commenters noted that ophthalmic diagnostic 

tests range from imaging to psychophysical tests using a number of different technologies and 
142 

instruments that require patient participation by responding to various stimuli to achieve an 

objective functional measurement of the anatomical structures within the eye. For such tests the 

patient must be taken to a second instrument and positioned, substantially reducing any 

redundancy in direct practice expenses. 

Another commenter indicated that visual field testing equipment, and other eye 

diagnostic equipment, do not share interfaces, space or patient information. The commenter 

noted that each machine requires independent input from the testing technician; including patient 

name, date, birth date, verification of the eye being tested, and there is no shared registration of 

data between the two services. 

According to the commenter, visual field testing requires a dedicated space and is 

typically not performed at the same time as other diagnostic tests. Patients need a quiet area 

away from other testing and patients to complete the test. Both eyes are tested, each with their 

own input and varying lenses that must be inserted into the equipment. The commenter 

maintained that these tests require substantial clinical staff time, patient instruction and 

interaction. Ophthalmology patients are typically elderly, often visually impaired and in need of 

mobility and positioning assistance in order to perform diagnostic eye testing. Finally, the 

commenter highlighted that the AMA RUC recently removed clinical staff time from some of the 

codes reviewed in our analysis. 

Commenters disagreed that diagnostic test resource utilization for multiple diagnostic 

tests is comparable to those required for multiple surgeries. Commenters noted that surgical 

procedures generally have a 90-day global period where more than 50 percent of the payment is 

related to postoperative care. Commenters also noted that in large multi-specialty practice, 

technical resources are located in different physical locations. 

Commenters recommended that CMS conduct its study with a new methodology that 

takes into account both the frequency and the different types of clinical staff, and the different 
143 

types of rooms involved in the services that are performed together on the same day. 

Finally, commenters noted that CMS’ own analysis reveals payment reductions as low as 

8 percent, indicating that a payment reduction of 25 percent would be excessive for some of 

these services. A commenter expressed concern that taking this “average” approach would have 

the effect of discouraging cardiologists and ophthalmologists from performing certain low 

overhead diagnostic procedures as the payment will be far less than the practice costs. The 

commenter suggested that in previous cases the identified savings were closer to the mean on 

average and would not result in such dramatic effects. Other commenters recommended that the 

MPPR reduction percentage should be code-specific up to a maximum reduction of 25 percent. 

Response: We appreciate the many comments submitted on this proposal. However, we 

disagree with commenters’ statements that there are minimal or no efficiencies in the TC of 

diagnostic cardiovascular and ophthalmology services. 

Concerning CPT code 93306 (transthoracic echocardiography) and CPT code 78452 

(myocardial perfusion single-photon emission computed tomography (SPECT)) referenced by 

commenters, we agree that some cardiovascular centers might choose to employ two differently 

specialized technicians; that is, nuclear medicine and echocardiography; to allow two different 

clinical staff to independently perform the studies; and to locate the different specialized 

equipment in two different parts of the practice. However, we continue to believe that is not the 

typical cardiovascular center or practice. We believe that the typical cardiovascular center 

performing these diagnostic tests commonly cross-train technicians to perform both procedures 

and that a single cardiologist often performs both tests for a single patient. In addition, we 

continue to believe that much of the pre-service work such as greeting and gowning the patient 

and reviewing medical records and previous images is redundant. We believe that some of the 

equipment used in the top code pairs is portable and can be used in the treatment room or other 

diagnostic room. We also do not believe that multiple rooms dedicated to individual testing 
144 

equipment is typical such that room preparation, greeting and gowning, and cleaning the room 

are never duplicated. Overall, commenters provided general descriptions of practices using 

multiple rooms and technicians to furnish these services, without sufficient information 

supporting a multiple room, dedicated clinical labor model as typical outside the facility setting. 

We would review generalizable, robust data demonstrating that an extensive practice model of 

multiple rooms dedicated to individual tests and distinct dedicated technicians trained is typical 

practice. 

Concerning CPT code 92235 (Fluorescein Angiography) and CPT code 92250 (Fundus 

Photography), we acknowledge that these tests are not equivalent to other imaging procedures. 

However, we believe there are still efficiencies when furnished to the same patient due to some 

duplication of clinical labor. Concerning visual field testing, we agree that this is an interactive 

test, requiring the technician to teach the patient how to perform the test; however, the most 

intense instruction only occurs the first time a patient has visual field testing. Although not 

considered in our analysis, we also note that once a patient is diagnosed with glaucoma the 

patient usually undergo visual field testing for the rest of their life, and their familiarity with the 

test reduces the clinical labor associated with providing this service overtime. As for the other 

ophthalmology tests, we understand them to be mostly passive with minimal patient instruction. 

Commenters expressed concerns that there is wide variation in the potential efficiencies 

among different code pairs; that such variability precludes broad application of a single 

percentage reduction; and, that establishing new combined codes is the only mechanism for 

capturing accurate payment for multiple imaging services. In general, we believe that MPPR 

policies capture efficiencies when several services of the same type are furnished in the same 

session and that it is appropriate to apply a single percentage reduction to second and subsequent 

procedures to capture those efficiencies. Because of the myriad potential combinations of 

diagnostic services, establishing new combined codes for each combination of advanced imaging 
145 

scans is unwieldy and impractical. An MPPR policy reflects efficiencies in the aggregate, such 

as common patient history, application of multiple tests to the same anatomical structures by the 

same clinical labor, frequently with the same modality, for the same patient. 

As previously noted, we found support for payment reductions ranging from 8 to 57 

percent for second and subsequent cardiovascular procedures (volume-adjusted average 

reduction across all code pairs of 25 percent); and payment reductions ranging from 9 to 62 

percent for second and subsequent ophthalmology procedures (volume-adjusted average 

reduction across all code pairs of 32 percent). Based on this analysis, and because we found a 

relatively wide range of reductions by code pair, we believed that an across-the-board reduction 

of 25 percent for second and subsequent procedures, which is approximately the average 

reduction supported by our analysis, would be appropriate. Based on subsequent public 

comments, we have conducted additional analysis on ophthalmology code pairs discussed below. 

In response to comment that this MPPR application to ophthalmic and cardiovascular diagnostic 

testing is not the same as the MPPR for global surgery, we agree. We have provided our analysis 

for why we proposed a 25 percent reduction on second and subsequent diagnostic tests rather 

than a 50 percent reduction. We note that, as with many of our policies, we will continue to 

review this MPPR policy and refine it as needed in future years to ensure that we continue to 

provide accurate payments under the PFS. 

Comment: A commenter noted that several ophthalmology codes included in our analysis 

have been reviewed by the AMA RUC within the last year, which resulted in the recommended 

removal of several minutes of clinical staff time for activities that the AMA RUC determined are 

also included within an accompanying office visit code. The commenter indicated that CMS’ 

acceptance of the AMA RUC recommendation, as well as applying the MPPR, would effectively 

double the practice expense reductions. The codes reviewed by the AMA RUC for CY 2013 

were: CPT codes 92081-92083 (Visual field examinations), CPT code 92235 (Fluorescein 
146 

angiography) and CPT code 92286 (Internal eye photography). As discussed above, commenters 

noted that visual field testing equipment and other eye diagnostic equipment do not share 

interfaces, space or patient information, that there is no shared information with other tests, that 

the tests required separate staff time and clinical instruction, and that visual field testing happens 

in a dedicated space away from other testing. 

The commenter requested that any ophthalmic tests that had their time reduced because 

of duplication with an office visit should be removed from the list of codes subject to the MPPR. 

Specifically, the commenter requested that the three visual field tests CPT codes 92081, 92082 

and 92083 and CPT code 92235 (Fluorescein angiography) and CPT code 92286 (Internal eye 

photography) for which minutes were reduced that were not reflected in the CMS analysis should 

be removed from the list. Additionally, the commenter indicated that CPT codes 92133, 92134 

and 92285 all had their clinical staff labor times previously reduced during the AMA RUC 

consideration and should not be included in the MPPR. 

Commenters also expressed concern about CPT codes that have recently been reviewed 

or are in the process of being reviewed under the various misvalued services screens. 

Commenters noted that these codes have already been subjected to a process where duplicative 

minutes have been reduced. Therefore, they requested that any codes for procedures where the 

AMA RUC has reviewed the PE inputs in the last 2 years be removed from this proposed list of 

services. 

Response: Our original proposed rule analysis for the subject ophthalmology codes was 

based on the latest AMA RUC PE worksheets available at that time. The PE worksheets are the 

basis for the direct practice expense inputs used in the PE methodology. They delineate minutes 

of the clinical staff time, equipment, and supplies for each clinical labor activity, for each CPT 

code. We subsequently reviewed the CY 2013 PE worksheets for the subject codes, which 

appeared in many of the ophthalmology code combinations reviewed. The AMA RUC did not 
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reduce clinical labor minutes for CY 2013 for two of the reviewed code pairs (76514 with 92286 

and 92081 with 92285). The most significant change in clinical labor activities for the other 

reviewed code pairs was the reduction of time for preparing and positioning the patient from 

either 7 or 10 minutes to 2 minutes. Because we never reduced this activity by more than 2 

minutes, the AMA RUC changes to this clinical labor activity had no effect on our calculation. 

In all cases, the subject codes are the highest paid codes in the code combination. The payment 

reductions range from 9 to 62 percent for second and subsequent ophthalmology procedures, 

noted in the proposed rule, remains unchanged. However, the volume-adjusted average 

reduction across all code pairs, originally calculated at 32 percent is revised to 22 percent. 

We disagree that recently reviewed codes should be exempt from the MPPR. However, 

we agree that the analysis establishing an MPPR should be based on the most current practice 

expense data available, and that the recent clinical labor reductions made to the subject codes 

should be taken into account. Therefore, based on our revised analysis, we are reducing the final 

MPPR on ophthalmology services from 25 percent to 20 percent to more accurately reflect the 

new data. 

Comment: Commenters expressed concern about the lack of transparency in the 

methodology and data sets used to develop the proposed MPPR. Commenters noted that CMS 

did not post basic data files on its website until August 10, 2012, less than 30 calendar days from 

the comment deadline. Commenters also indicated that the posted data did not enable them to 

understand the cuts or replicate the data used to form the basis of the proposed MPPR. 

Commenters believed that this unfairly hampered their ability to fully analyze the proposal. 

Commenters urged us not to implement this proposed policy until full access to the data used to 

develop the policy is provided. 

Response: We have provided full access to the data that we used to develop the policy. 

We have listed every code pair reviewed and every clinical labor activity considered for 
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duplication. In addition, we provided a description of how the analysis was conducted, the range 

of reductions found and the adjusted average reduction determined for cardiovascular and 

ophthalmology services. We acknowledge that the PE worksheets were not made available 

simultaneously with the publication of the proposed rule. Upon receiving requests from various 

specialty groups to supplement the information we provided in the proposed rule, we posted the 

PE worksheets used in the analysis on our website. We posted these data in August 2012, 

approximately one month before the comment period ended. We believe the information 

provided in the proposed rule would have been sufficient to permit full consideration of our 

proposed policy, but agreed to provide greater detail to assist commenters in further evaluating 

the proposal. 

Comment: Commenters indicated that we stated in the proposed rule that the code pairs 

published the MPPR analysis are frequently billed together. However, the AMA RUC 

determined that only four of the cardiology pairs (CPT codes 93320-93325, 93320-93351, 

93965-93970 and 78452TC-93017), and only one ophthalmology code pair (CPT codes 92235 

and 92250), are typically reported together on the same date of service. Commenters stated that 

the computerized ophthalmic diagnostic imaging codes (92133 and 923134) were created in 

2011 and were not included in this analysis. 

 Commenters further noted that every other code pair is reported together at or below 40 

percent of the time, with over half below 20 percent. They stated that not only are these services 

not commonly billed together, they are not performed on contiguous body parts and are not 

always performed on the same type of equipment or even in the same room. Further, the 

services would sometimes be performed by different physicians in the same group practice. 

 In addition, commenters indicated that a broader analysis of the claims data for all the 

analyzed codes pairs for cardiovascular and ophthalmology suggest that only roughly four 

percent of the code combinations are typically performed together on the same date of service. 
149 

Given that these services are rarely performed on the same day together, it is unreasonable to 

assume there would be efficiencies gained when these services are performed together. 

Commenters maintained that efficiencies in practice expense are potentially created only 

when the two services are similar, use the same instrument, and are commonly performed 

together. Commenters indicated, however, that for more low-volume code pairs, the practice 

will not have the same level of familiarity, including the office equipment set up, to conduct 

these services. Commenters further noted that the differences between these services are such 

that even if all these services were commonly billed together, physician staff could not provide 

noticeable efficiencies. 

 Response: In the CY 2013 proposed rule (77 FR 44748), we indicated that we 

analyzed the CY 2011 claims data for the most frequently billed cardiovascular and 

ophthalmology diagnostic code combinations to determine the level of duplication present when 

multiple services are furnished to the same patient on the same day. For cardiovascular 

diagnostic services, we reviewed the code pair/combinations with the highest utilization in code 

ranges 75600 through 75893, 78414 through 78496, and 93000 through 93990. For 

ophthalmology diagnostic services, we reviewed the code pair/combinations with the highest 

utilization in code ranges 76510 through 76529 and 92002 through 92371. 

The frequency of code combinations reviewed for cardiovascular services ranged from 

260 to 207,573 and for ophthalmology services from 4,193 to 553,502. Although utilization was 

low for some code combinations reviewed, we examined the top highest frequency code 

combinations for each of the five code groups examined (three for cardiovascular and two for 

ophthalmology). The frequency with which a code combination is furnished does not diminish 

the potential efficiencies in clinical labor activities that will occur when that code combination is 

furnished. All MPPR policies (surgery, diagnostic imaging and therapy) apply to all code 

combinations of procedures subject to the policy, regardless of the frequency that the code 
150 

combination was furnished. Therefore, we believe it is appropriate to apply the MPPR 

regardless of the frequency which the code combination is billed. Applying the MPPR to code 

combinations furnished infrequently will have a minimal effect on overall payments for imaging 

services. Finally, we based our final recommended percent reduction on the volume-adjusted 

average reduction observed in our code pair analysis, which ensures that when the MPPR is 

applied, the reduction adjustment is more likely to reflect the actual reduction for the code pair. 

MPPR policies have been consistently applied to all multiple procedures and are not restricted to 

those with the highest frequency of billings. 

Comment: Commenters noted that the MPPR is partly designed to address the growth in 

imaging and diagnostic services, as noted by MedPAC. Commenters further noted that in recent 

years the rate of imaging growth for both Medicare and private payor patients has slowed 

considerably, and concluded that additional payment reductions are unwarranted and 

unnecessary. Commenters cited an article in the August 2012 issue of Health Affairs further 

confirming this trend, noting that the growth rate of advanced diagnostic imaging slowed to 

single digits beginning in 2006. The study concluded that the use of MRI in Medicare slowed to 

an average 2.6 percent annual growth rate from 2006-2009. In addition, commenters maintained 

that 2008 and 2009 data from MedPAC and the AMA demonstrate that the rate of volume 

growth for diagnostic imaging services overall is now generally lower than the rate of growth for 

all other physicians’ services. Commenters further maintained that the volume of all physicians’ 

services grew by 3.6 percent in 2008 and 2009 while the volume of diagnostic imaging services 

rose by 3.3 percent in 2008 and 2.2 percent in 2009. 

Another commenter noted that ultrasound services have never experienced rapid growth, 

but rather, have experienced only moderate growth. The commenter cited GAO’s September 

2008 report to Congress that found that after the implementation of DRA cap, which for vascular 

ultrasound services resulted in reductions of greater than 40 percent, the disparity in utilization 
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between ultrasound and expensive, advanced imaging modalities continued to grow. The 

commenter noted that this is reflected by the Congressional Budget Office’s (CBO) December 

2008 recommendations to Congress in which it excluded ultrasound and other inexpensive 

imaging modalities from its policy recommendations on advanced imaging services. 

Commenters concluded that imaging has absorbed numerous payment reductions and that it is 

illogical to target procedures for reduction that do not demonstrate a pattern of rapid growth. 

Response: MedPAC's analysis in its June 2011 report indicates there has been continued 

annual growth in the use of imaging. While overall growth may be lower than it was in the last 

decade, declining growth in imaging services could be interpreted as a return to a more 

appropriate level of imaging utilization without any accompanying evidence of inadequate 

access or safety and quality concerns. As indicated previously, MedPAC has expressed support 

for the MPPR on diagnostic cardiovascular and ophthalmology services. 

Comment: A commenter noted that many of the code pair combinations identified by 

CMS for the MPPR on cardiovascular services are not cardiovascular services, specifically, CPT 

75600-75893, 78414-78496, and 93000-93990. The commenter further noted that it is highly 

unlikely that these codes would be furnished to the same patient on the same day by the same 

physician. For example, the AMA RUC database indicates CPT code 93980 for penile vascular 

study was provided by cardiologists less than 1 percent of the time to Medicare patients in 2011. 

The commenter did not recommend removing the codes from the MPPR list because their 

presence produces no impact. However, the commenter indicated that the inclusion of codes 

unrelated to cardiovascular creates doubts about the thoroughness and validity of the analysis 

underlying the proposal. 

Response: In reviewing the group of codes that we refer to as cardiovascular services, we 

looked at services involving the heart and vessels, regardless of the specialty that furnishes 

them. For example, penile vascular services are vascular services. Whereas we would not 
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expect a urologist to perform trans-esophageal echoes, nor would we expect a cardiologist to 

perform penile studies, we would not be surprised to find some generalists, or even general 

vascular surgeons, evaluating the penile vasculature along with, for example, the vasculature of 

the lower extremities. And even if, as the commenter suggested, it would be unlikely for certain 

codes to be billed by the same physician on the same day, then the MPPR simply would not 

apply. 

Comment: Commenters questioned how the MPPR on cardiovascular services would 

apply to remote monitoring CPT codes 93279-93296. Specifically, they indicated that it is 

unclear whether the date of service is: (1) the day the patient transmits their data; (2) the day the 

data is received in the physician’s office for technician review, technical support and distribution 

of results; or (3) the day the physician reviews the data; all of which may represent different 

dates of service. The commenters indicated that because there is no specific identification of the 

date of service within the CPT description, applying the MPPR is likely to create confusion 

among physicians. Commenters recommended that we either remove these codes from the list 

subject to the MPPR or issue instructions that specifically indicate how dates of service within 

the 90-day monitoring period should be addressed. 

Another commenter noted that CPT codes 93293(Transtelephonic rhythm strip 

pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording 

with and without magnet application with analysis, review and report(s) by a physician or other 

qualified health care professional, up to 90 days), 93296 (Interrogation device evaluation(s) 

(remote), up to 90 days; single, dual, or multiple lead pacemaker system or implantable 

cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and 

technician review, technical support and distribution of results), and 93299 (Interrogation device 

evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system or implantable 

loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, 
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technical support and distribution of results) describe the TC for remote interrogation of the 

devices, meaning that the patient is not physically present when the service is furnished. The 

commenter questioned how it is possible for efficiencies to exist in the rare circumstance these 

services were furnished on the same date as a cardiovascular diagnostic service. The commenter 

indicated that the inclusion of these codes demonstrates a lack of understanding of how 

diagnostic services are furnished to beneficiaries. 

Response: The appropriate date of service used to bill codes subject to the MPPR is the 

same as required by Medicare billing instructions. We note that codes in the range of CPT codes 

92293 through 92299 should be consistently treated regarding application of the MPPR. Since 

we did not propose to include all codes in this range for the MPPR, we have removed remote 

monitoring codes CPT codes 93293 and 93296 from the list of procedures subject to the MPPR. 

We note that CPT code 93299 was not on the proposed list. 

Comment: A commenter noted that diagnostic ultrasound offers a number of important 

advantages compared to CT and MRI, in terms of safety and effectiveness. For example, 

ultrasound is non-invasive and offers real-time imaging, allowing for examinations of structures 

at rest and in motion and does not use ionizing radiation. Although not always a good substitute 

for other advanced imaging modalities, ultrasound is an effective diagnostic tool in many cases. 

The commenter further noted that, due to the relatively low payment rates for ultrasound 

procedures, they are one of the most cost-effective diagnostic imaging modalities. The 

commenter indicated that analyses performed by GAO in 2008 and others have shown that lower 

cost imaging modalities such as ultrasound have declined in use relative to more expensive 

imaging modalities, negatively impacting the quality and cost of their health care. 

The commenter concluded that payment reductions to ultrasound services have 

threatened the ability to furnish such services. Therefore, the commenter requested removal of 
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all ultrasound procedures from the list of procedures subject to the MPPR on cardiovascular 

services. 

Another commenter noted that the June 2011 MedPAC report focused on advanced 

diagnostic imaging services and supported increasing, rather than decreasing, the payments for 

ultrasound services. The commenter indicated that the report suggests reforming the Medicare 

fee-for-service system to encourage the use of high-value services and discourage the use of lowvalue services. In describing what is meant by low-valued services, MedPAC points to situations 

where two services may be equally safe and effective, yet one is more expensive than the other. 

The commenter indicates that this is the situation with ultrasound as compared to other, more 

expensive imaging services. Finally, the commenter noted that the report suggested that services 

that can potentially harm patients, for example, overexposure to radiation, should be considered 

low-value. The commenter indicates that ultrasound, which is non-ionizing, poses less risk to 

patients than other modalities. 

Response: The MPPR on diagnostic imaging procedures has included CT, MRI and 

ultrasound since 2006. MedPAC, as noted in its comment above, has supported our previous 

MPPR proposals and has not recommended excluding ultrasound from MPPR on diagnostic 

cardiovascular and ophthalmology services. MPPR policies are resource-based. MPPR policies 

for the TC reduce payment in situations where there is overlap in resources employed in the 

delivery of multiple services, with comparable practice expense inputs, when those resources are 

only employed once. We do not apply the MPPR to ultrasound used in place of other modalities, 

only when it is used in addition to, other modalities in the same session. We do not expect the 

MPPR to encourage radiologists to forego ultrasound imaging in favor of advanced imaging 

modalities. 

Comment: Commenters noted that the AMA RUC and the CPT Editorial Panels have 

been working to combine services frequently billed together into comprehensive codes and to 
155 

remove overlapping physicians’ services from the payment rates. Commenters indicated that the 

effort to combine codes and reduce payment for duplicate services has been accelerated by CMS 

after the threshold for analyzing services billed together was reduced from 95 percent to 75 

percent overlap. 

Commenters urged CMS to be mindful of this work and to fully take into account the 

AMA RUC review of the code pairs. Commenters found it contradictory for CMS to utilize the 

AMA RUC process and accept the PE payment principle, only to disregard the methodology in 

applying an MPPR; and suggested that duplication of work in services performed on the same 

date of service should be addressed at the individual code level rather than through an MPPR. 

Another commenter recommended that CMS ask the AMA RUC to review the codes and 

make code-specific recommendations and claimed that implementing payment reductions that 

are not specific does a disservice to the entire AMA RUC process and all of the physicians who 

are paid under the PFS. 

Commenters disputed the assumption that an MPPR is a valid and accurate mechanism to 

value services when performed on the same date of service. Commenters indicated that, 

historically, the AMA RUC has recognized that efficiencies can be gained when services are 

commonly performed by the same physician on the same date of service, but only when explicit 

criteria are met. The commenters indicated that the proposal fails to meet these criteria because 

the services are not commonly billed together, are not analogous services performed on 

contiguous body parts, and applies to both individual physicians and physicians in the same 

group practice. 

Commenters maintained that the vague justification for selecting particular codes in the 

CY 2013 rule stands in stark contrast to the AMA RUC. According to commenters, the AMA 

RUC process set a clear and distinct threshold for analyzing codes billed together, that is, 75 

percent of the time. In contrast, according to commenters, the proposal fails to define 
156 

“frequently billed” thus creating a substantial barrier to a clear comprehension of the MPPR 

expansion. 

 Response: As we have indicated previously (76 FR 73077-73078), the MPPR is not 

intended to supersede the AMA RUC process of developing recommended values for services 

described by CPT codes. We continue to appreciate the work done by the AMA RUC and 

encourage the AMA RUC to continue examining code pairs for duplication based upon the 

typical case, and appropriately valuing new comprehensive codes for bundled services that are 

established by the CPT Editorial Panel. We view the AMA RUC process and the MPPR policy 

as complimentary and equally reasonable means to the appropriate valuation and payment for 

services under the PFS. We note that as more code combinations are bundled into a single 

complete service reported by one CPT code, the MPPR policy would no longer apply to the 

combined services. At the same time, the adoption of the MPPR for the TC of diagnostic 

cardiovascular and ophthalmology services will address duplications in the PE to ensure that 

Medicare payment for multiple diagnostic services better reflects the resources involved in 

providing those services. 

 As noted previously, although less precise than creating new comprehensive codes to 

capture each unique combination of diagnostic services that could be performed together, we 

believe that an MPPR policy appropriately addresses efficiencies present when multiple 

diagnostic services are furnished together. Moreover, we believe it would be unwieldy and 

impractical to develop unique codes and values for the myriad of procedure combinations that 

could be furnished together. In addition, we believe that the expansion of the MPPR policy to 

the TC of diagnostic cardiovascular and ophthalmology services is consistent with both the GAO 

and MedPAC recommendations. Finally, we already have discussed information on the 

determination of frequently billed services in response to comments on this rule concerning the 

most frequently billed cardiovascular and ophthalmology diagnostic code combinations used in 
157 

our analysis. 

Comment: A commenter indicated that the statutory authority cited by CMS for the 

proposed MPPR expansion and new MPPR policy only grants CMS the authority to modify the 

reimbursement for “codes” and does not provide CMS with the authority to implement multiple 

service reductions. The commenter maintains that Congress bestowed CMS with specific and 

limited authority to implement multiple service reductions in another part of the Act and that this 

confirms that Congress did not intend to provide the authority that CMS claims under the 

“misevaluation” clause. The commenter stated that the misvalued codes section of the Act that 

addresses multiple services frequently billed together as potentially misvalued does not give 

CMS the authority to implement either of its proposed MPPR policies. The commenter did not 

believe that the codes are “misvalued” within the meaning of the statutory provision CMS cites, 

and maintains that CMS has effectively conceded this point, as it continues to use the existing 

relative value units (RVUs) for single services. The commenter maintains that CMS is not 

contending that the activities and items described in the RVUs are not, in fact, part of the service; 

but rather, CMS is attempting to effectively reset the conversion factor based on its assumption 

that costs can be saved in multiple procedure scenarios, but the statute does not permit CMS to 

institute multiple conversion factors. Another commenter merely suggested that there was 

inadequate legal basis for the proposal. 

Another commenter noted that payment rates for x-rays under the OPPS are significantly 

higher than payment rates under the PFS. The commenter indicated that application of the 

MPPR in a non-hospital setting will cause procedures to shift to the hospital setting. The 

commenter recommended paying the lower of (1) full payment under the OPPS rate for 

procedure with the higher fee, and 50 percent of the OPPS rate for the second procedure, or (2) 

full payment for both procedures under the PFS. 

Response: We believe that the application of the MPPR to the PC of second and 
158 

subsequent advanced imaging services furnished in the same session to the same patient is fully 

consistent with section 1848(c)(2)(K) of the Act, especially given our authority to adopt ancillary 

policies under section 1848(c)(4). We also note that we have had several MPPR policies in place 

for many years before the enactment of section 1848(c)(2)(K) of the Act. 

As explained previously, section 1848(c)(2)(K)(i) of the Act requires the Secretary to 

identify services within several specific categories as being potentially misvalued and to make 

appropriate adjustments to their relative values. One of the specific categories listed under 

section 1834(c)(2)(K)(ii) of the Act is ‘‘multiple codes that are frequently billed in conjunction 

with furnishing a single service.’’ Although some code pair combinations will occur 

infrequently, the codes subject to the MPPR are frequently found in groups of multiple codes that 

are billed in conjunction with furnishing a single service. Section 1848(c)(2)(K)(ii) of the Act 

specifies that we should examine not only individual codes, but also families of codes. We

believe the MPPR policy contributes to fulfilling our statutory obligations under section 1848(c) 

of the Act by more appropriately valuing combinations of imaging services furnished to patients 

and paid under the PFS. 

As previously noted, Medicare has a long-standing policy of applying an MPPR to 

surgical procedures. While the various MPPRs have been adopted through notice and comment 

rulemaking as administrative actions, the Congress has acknowledged our authority to adopt 

MPPRs by directly modifying several of them, and by exempting the payment changes relating 

to several others from budget neutrality adjustment under the PFS. For example, section 5102 

(a) of the DRA exempted from the PFS budget neutrality adjustment the changes in expenditures 

resulting from the MPPR on the TC of diagnostic imaging. Section 3135 (b) of the Affordable 

Care Act increased the MPPR reduction percentage on the TC of diagnostic imaging from 25 to 

50 percent. Sections 3 and 4 of the PPATRA decreased the MPPR reduction percentage on the 

PE of therapy services from 25 to 20 percent for therapy services furnished in office settings, and 
159 

exempted from budget neutrality the change in expenditures resulting from the MPPR on therapy 

services from budget neutrality. 

We appreciate the commenter’s suggestions concerning alternate payment 

methodologies, that is, payments based on the OPPS rate, and we will consider them further for 

possible rulemaking in the future. 

Comment: A commenter noted that the proposed list of cardiovascular procedures subject 

to the MPPR did not include the global services that have different procedure codes than the 

corresponding technical services, which are on the list. The commenter specifically mentioned 

CPT codes 93005, 93016, 93040, and 93224, representing global services for 

electrocardiograms, cardiac stress tests, rhythm electrocardiograms, and Holter monitors, 

respectively. Lastly, the commenter noted that, because such codes were not proposed for 

inclusion in the MPPR, it would violate the Administrative Procedure Act to subject them to the 

MPPR through this final rule. 

Response: The commenter is correct that we had not specifically identified global 

services that have different CPT codes than the corresponding TC on the proposed 

cardiovascular MPPR code list. However, we indicated in the proposed rule (77 FR 44749) that 

the MPPR applies to TC services and the TC of global services. As such, it is consistent with the 

proposed policy (which we are finalizing in this final rule with comment period as described 

here), and not inconsistent with the Administrative Procedure Act, to include these codes on the 

list of codes to which the MPPR will apply. In response to the comment, we have added the 

following global services to the cardiovascular MPPR list: CPT code 93000 (Electrocardiogram 

complete); CPT code 93015 (Cardiovascular stress test); CPT code 93040 (Rhythm ECG with 

report); CPT code 93224 (Ecg monit/reprt up to 48 hrs); CPT code 93268 (ECG record/review); 

and CPT code 93784 (Ambulatory BP monitoring). The technical portion(s) of such codes will 

be subject to the MPPR. We note that CPT code 93005 (Electrocardiogram tracing) is a TC 
160 

service already on the list, and CPT code 93016 (Cardiovascular stress test) is a PC service not 

subject to the MPPR. 

Comment: Several commenters noted that the following add-on codes were included on 

the list of procedures subject to the MPPR on cardiovascular procedures: CPT code 75774 

(Artery x-ray each vessel); CPT code 78496 (Heart first pass add-on); CPT code 93320 (Doppler 

echo exam heart); CPT code 93321 (Doppler echo exam heart); and CPT code 93325 (Doppler 

color flow add-on). Commenters indicated that such codes have already been valued to reflect 

efficiencies. 

Response: We agree that these codes should not be subject to the MMPR and have 

removed them from the list. While three of these codes were included in our analysis, their 

inclusion had no effect on the results. For example, CPT codes 93320 and 93325 contain none 

of the clinical labor activities that might be duplicated. While duplicated clinical labor was noted 

in the code combinations including CPT code 77774, it affected neither the payment reduction 

range of 8 to 57 percent for second and subsequent procedures, nor, due to the extremely low 

utilization, the volume-adjusted average reduction across all code pairs of 25 percent. 

Comment: Commenters noted that it was unclear exactly how we adjusted the equipment 

minutes in calculating the MPPR reduction and requested additional details. 

Response: In general, the minutes allocated to particular direct PE equipment items are 

based on the amount of time clinical labor would use the equipment for a typical service. When 

the clinical labor minutes were reduced in our analysis, and those minutes had been used to 

allocate minutes to the equipment, we made corresponding reductions to the equipment minutes 

so that the equipment minutes matched the adjusted clinical labor times. 

Comment: One commenter expressed concern that because pediatric cardiologists assess 

multiple aspects of a patient’s cardiovascular status, the MPPR on cardiovascular services has an 

unjust impact on pediatric cardiology practices in the diagnosis and treatment of congenital heart 
161 

diseases. The commenter noted that the functional and structural assessment of these multiple 

aspects requires the pediatric cardiologist to perform multiple procedures on the pediatric patient. 

It also requires special training and more time than a non-congenital adult assessment. 

According to the commenter, an echocardiogram performed to evaluate for congenital heart 

disease includes multiple types of different procedures/assessments which require a unique level 

of skill, training, and time when compared to the adult non-congenital assessment. 

The commenter urged us to exclude the following codes from the MPPR on 

cardiovascular services: CPT codes 93303 and 93304 (Congenital transthoracic 

echocardiography); CPT code 93308 (Limited non-congenital code used for follow-up studies); 

and CPT codes 93320, 93321 and 93325 (Spectral and Color Doppler). The commenter 

maintained that excluding these codes would have no demonstrable effect on Medicare 

utilization of cardiology services since cardiologists treating adult patients rarely bill the 

congenital echocardiography codes to Medicare. The commenter noted that because most adult 

non-congenital transthoracic echocardiography studies that are billed to Medicare have been 

bundled into CPT code 93306 (including non-congenital echocardiography CPT codes 93307, 

93320 and 93325), the significant decrease in payment for the subject codes would 

disproportionately impact pediatric cardiologists. 

The commenter further noted that state Medicaid agencies and private sector health 

insurance payors use Medicare guidelines and RVU valuations to establish their own payment 

protocols. Therefore, the repercussions of these reductions will extend across all payor sources 

for pediatric cardiology practices and have a materially significant impact on the financial 

viability of many practices. Finally, the commenter indicated that the inclusion of the subject 

codes in the proposed MPPR would exacerbate the current shortage of available fellowship 

positions that recruit medical residents into pediatric cardiology, and will impair their ability to 

provide patient access to this life-saving specialty care, especially to medically underserved 
162 

areas. 

Response: We appreciate the commenter’s concerns as to the impact of this policy on 

pediatricians. While we recognize that echocardiography training for congenital cardiovascular 

abnormalities may be different from that for adults, we are not convinced that the MPPR does is 

not equally applicable to pediatric and adult cardiologists. The purpose of the MPPR policy is to 

account for the efficiencies inherent when multiple procedures are furnished together. We do not 

believe that those efficiencies differ significantly from diagnostic testing on adults versus 

pediatric patients for these code pairs. 

We considered the specific scenarios presented by the commenter’s in the context of 

MPPR methodology and identified the same or similar efficiencies regardless of whether the 

multiple diagnostic procedures were targeted at abnormal flow in response to congenital 

structural abnormalities or were targeted at functional abnormalities in response to primary 

vascular disease. We also noted that, whereas practitioners who perform more services that are 

reported separately will be impacted more by the MPPR, practitioners who report more services 

that have recently been bundled together will have a similar impact due to the efficiencies that 

were considered by CMS in the valuation of those new bundled codes. Finally, we note that the 

codes are not specific to pediatric patients so it is not possible to exclude them for pediatric 

cardiologists alone. 

In response to the commenters concerns that other insurers may adopt our policies, we do 

not modify Medicare payment policy based on the fact that Medicaid and other payors may 

adopt such policies. We understand that other payors have their own unique payment systems 

and consider the appropriateness of CMS valuations in their decisions to accept, modify or 

ignore our payments. We continue to believe that the MPPR policy that we are adopting in this 

final rule with comment period is appropriate for Medicare. Therefore, we are not excluding 

these codes from the MPPR. 
163 

Comment: Several commenters maintained that the policy could result in the following 

unintended consequences: 

● Create a disincentive for specialists to provide efficient, high quality and continuous 

care to their patients. Penalize the use of the appropriate sub-specialist, resulting in generalist 

physicians conducting multiple reads, leading to a degradation of diagnostic interpretation 

quality. 

● Have a negative impact on investment in new advanced imaging technology and stifle 

innovation. New equipment offers more precise images and the addition of highly-trained 

personnel to a medical practice is integral to high quality patient care. Inhibit staff training and 

the addition of staff in a state of uncertainty. 

● Lead to a forced reduction in necessary services, compromising patient access to lifesaving diagnostic imaging services in all settings, including independent practices, community 

hospitals, and large academic medical centers. 

● Drive more services out of physicians’ offices and into more expensive hospital 

settings, fragment care, and increase patient costs. 

● Reduce the efficiency of patient care and inconvenience patients because many would 

be scheduled for multiple procedures over multiple days instead of just one day. This would 

particularly disadvantage patients with serious medical conditions, such as multiple traumas, 

heart attacks, strokes, and cancer, who require frequent and multiple imaging. 

● Disproportionally affect radiologists in academic medical centers who are often part of 

large group practices and who furnish care to a more complex patient population. These patients 

are often suffering from acute trauma or undergoing treatment for cancer and are more likely to 

have multiple examinations on the same day. 

● Contradict the goal to focus more on preventive care, as diagnostic tests enable the 

early detection of potentially serious conditions. 
164 

Response: We have no reason to believe that appropriately valuing services for payment 

under the PFS by revising payment to reflect duplication in the TC of diagnostic cardiovascular 

and ophthalmology multiple services would negatively impact quality of care, be counterproductive to the goal of promoting preventive care, or limit patients’ access to medically 

reasonable and necessary imaging services, or disproportionally affect certain groups. We have 

no evidence to suggest any of the adverse impacts identified by the commenters have resulted 

from the implementation of the MPPR on the TC of imaging in 2006. In fact, to the contrary, the 

analysis in MedPAC’s June 2011 report indicates there has been continued high annual growth in 

the use of imaging. Further, it is worth noting that, without any accompanying evidence of 

inadequate access or safety and quality concerns, declining growth in imaging services could be 

interpreted as a return to a more appropriate level of imaging utilization. 

For the ordering and scheduling of cardiovascular or ophthalmology services for 

Medicare beneficiaries, we require that Medicare-covered services be appropriate to beneficiary 

needs. We would not expect the adoption of an MPPR for the TC of diagnostic cardiovascular 

and ophthalmology services to result in services being furnished on separate days by one 

physician merely so that the physician may garner increased payment. We agree with the 

commenters who noted that such an unprofessional response on the part of practitioners would 

be inefficient and inappropriate care for the beneficiary. We will monitor access to care and 

patterns of delivery for cardiovascular and ophthalmology services to beneficiaries, with 

particular attention focused on identifying any clinically inappropriate changes in timing of the 

delivery of such services. 

In summary, after consideration of the public comments received, we are adopting our 

CY 2013 proposal to apply an MPPR to the TC of diagnostic cardiovascular and ophthalmology 

services, with a modification to apply a 20 percent reduction for diagnostic ophthalmology 

services rather than the 25 percent reduction we had proposed. The reduction percentage for 
165 

diagnostic cardiovascular services remains at 25 percent, as proposed. We continue to believe 

that efficiencies exist in the TC of multiple diagnostic cardiovascular and ophthalmology 

services and we will continue to monitor code combinations for possible future adjustments to 

the reduction percentage applied through this MPPR policy. 

 Specifically, beginning in CY 2013 we are adopting an MPPR that applies a 25 percent 

reduction to the TC of second and subsequent diagnostic cardiovascular, and a 20 percent 

reduction to the TC of second and subsequent diagnostic ophthalmology services, furnished by 

the same physician (or physicians in the same group practice) to the same beneficiary , on the 

same day. In Table 10, we provide examples illustrating the current and CY 2013 payment 

amounts: 

TABLE 10: Illustration of Current and CY 2013 Payments 

Sample Cardiovascular Payment Reduction * 

 Code Code 

Total 

Current 

Total CY 

2013 Payment 

 78452 93306 Payment Payment Calculation 

PC $77.00 $65.00 $142.00 $142.00 no reduction 

TC $427.00 $148.00 $575.00 $538.00 $427 + (.75 x $148) 

Global $504.00 $213.00 $717.00 $680.00

$142 + $427 + (.75 x 

$148) 

 

Sample Ophthalmology Payment Reduction * 

 Code Code 

Total 

Current 

Total CY 

2013 Payment 

 92235 92250 Payment Payment Calculation 

PC $46.00 $23.00 $69.00 $69.00 no reduction 

TC $92.00 $53.00 $145.00 $134.40 $92 + (.80 x $53) 

Global $138.00 $76.00 $214.00 $203.40 $69 + $92 + (.80 x $53) 

*Dollar amounts are for illustrative purposes and do not reflect actual payment amounts. 

 No changes have been made to the proposed list for diagnostic ophthalmology services. 

We have revised the proposed list for diagnostic cardiovascular services by removing codes 

deleted for CY 2013, add-on codes, and remote monitoring codes, and adding global codes 

corresponding to technical-only codes already on the list: 
166 

TABLE 11: Changes to the Proposed List of Procedures Subject to the MPPR on 

Diagnostic Cardiovascular Services

Code Descriptor Added/Deleted Reason

75650 Artery x-rays head & neck Deleted Deleted for CY 2013 

75660 Artery x-rays head & neck Deleted Deleted for CY 2013 

75662 Artery x-rays head & neck Deleted Deleted for CY 2013 

75665 Artery x-rays head & neck Deleted Deleted for CY 2013 

75671 Artery x-rays head & neck Deleted Deleted for CY 2013 

75676 Artery x-rays neck Deleted Deleted for CY 2013 

75680 Artery x-rays neck Deleted Deleted for CY 2013 

75685 Artery x-rays spine Deleted Deleted for CY 2013 

75774 Artery x-ray each vessel Deleted Add-on Code 

78496 Heart first pass add-on Deleted Add-on Code 

93000 Electrocardiogram complete Added Global Code 

93015 Cardiovascular stress test Added Global Code 

93040 Rhythm ECG with report Added Global Code 

93224 Ecg monit/reprt up to 48 hrs Added Global Code 

93268 ECG record/review Added Global Code 

93293 Pm phone r-strip device eval Deleted 

Remote monitoring 

code 

93296 Pm/icd remote tech serv Deleted 

Remote monitoring 

code 

93320 Doppler echo exam heart Deleted Add-on Code 

93321 Doppler echo exam heart Deleted Add-on Code 

93325 Doppler color flow add-on Deleted Add-on Code 

93784 Ambulatory BP monitoring Added Global Code 

 The complete list of services subject to the MPPR for the TC of diagnostic 

cardiovascular and ophthalmology services is shown in Addendum X. The PFS budget neutrality 

provision is applicable to the new MPPR for the TC of diagnostic cardiovascular and 

ophthalmology services. Therefore, the estimated reduced expenditures for such services have 

been redistributed to increase payment for other PFS services. We refer readers to section VIII.C. 

of this final rule with comment period for further discussion of the impact of this policy. 

TABLE 12: Diagnostic Cardiovascular Services Subject to the Multiple Procedure 

Payment Reduction 
167 

Code Short Descriptor 

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 

75658 Artery x-rays arm 

75705 Artery x-rays spine 

75710 Artery x-rays arm/leg 

75716 Artery x-rays arms/legs 

75726 Artery x-rays abdomen 

75731 Artery x-rays adrenal gland 

75733 Artery x-rays adrenals 

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 

75791 Av dialysis shunt imaging 

75809 Nonvascular shunt x-ray 

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 

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 
168 

Code Short Descriptor 

78458 Ven thrombosis images bilat 

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 

78494 Heart image spect 

93000 Electrocardiogram complete 

93005 Electrocardiogram tracing 

93015 Cardiovascular stress test 

93017 Cardiovascular stress test 

93024 Cardiac drug stress test 

93025 Microvolt t-wave assess 

93040 Rhythm ECG with report 

93041 Rhythm ecg tracing 

93224 Ecg monit/reprt up to 48 hrs 

93225 Ecg monit/reprt up to 48 hrs 

93226 Ecg monit/reprt up to 48 hrs 

93229 Remote 30 day ecg tech supp 

93268 ECG record/review 

93270 Remote 30 day ecg rev/report 

93271 Ecg/monitoring and analysis 

93278 ECG/signal-averaged 

93279 Pm device progr eval sngl 

93280 Pm device progr eval dual 

93281 Pm device progr eval multi 

93282 Icd device prog eval 1 sngl 

93283 Icd device progr eval dual 

93284 Icd device progr eval mult 

93285 Ilr device eval progr 

93286 Pre-op pm device eval 

93287 Pre-op icd device eval 

93288 Pm device eval in person 

93289 Icd device interrogate 

93290 Icm device eval 

93291 Ilr device interrogate 

93292 Wcd device interrogate 

93303 Echo transthoracic 

93304 Echo transthoracic 

93306 Tte w/doppler complete 

93307 Tte w/o doppler complete 

93308 Tte f-up or lmtd 
169 

Code Short Descriptor 

93312 Echo transesophageal 

93314 Echo transesophageal 

93318 Echo transesophageal intraop 

93350 Stress tte only 

93351 Stress tte complete 

93701 Bioimpedance cv analysis 

93724 Analyze pacemaker system 

93784 Ambulatory BP monitoring 

93786 Ambulatory BP recording 

93788 Ambulatory BP analysis 

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 

93922 Upr/l xtremity art 2 levels 

93923 Upr/lxtr art stdy 3+ lvls 

93924 Lwr xtr vasc stdy bilat 

93925 Lower extremity study 

93926 Lower extremity study 

93930 Upper extremity study 

93931 Upper extremity study 

93965 Extremity study 

93970 Extremity study 

93971 Extremity study 

93975 Vascular study 

93976 Vascular study 

93978 Vascular study 

93979 Vascular study 

93980 Penile vascular study 

93981 Penile vascular study 

93990 Doppler flow testing 

TABLE 13: Diagnostic Ophthalmology Services Subject to the Multiple Procedure 

Payment Reduction

Code Descriptor 

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 
170 

Code Descriptor 

76519 Echo exam of eye 

92025 Corneal topography 

92060 Special eye evaluation 

92081 Visual field examination(s) 

92082 Visual field examination(s) 

92083 Visual field examination(s) 

92132 Cmptr ophth dx img ant segmt 

92133 Cmptr ophth img optic nerve 

92134 Cptr ophth dx img post segmt 

92136 Ophthalmic biometry 

92228 Remote retinal imaging mgmt 

92235 Eye exam with photos 

92240 Icg angiography 

92250 Eye exam with photos 

92265 Eye muscle evaluation 

92270 Electro-oculography 

92275 Electroretinography 

92283 Color vision examination 

92284 Dark adaptation eye exam 

92285 Eye photography 

92286 Internal eye photography 

TABLE 14: Frequently Billed Diagnostic Cardiovascular Combinations 

Code Range 75600-75893 

Code Descriptor Code Descriptor Code Descriptor Code Desc

75710 Artery x-rays 

arm/leg 

75791 Av dialysis shunt 

imaging 

 

75625 Contrast x-ray 

exam of aorta 

75716 Artery x-rays 

arms/legs 

 

75625 Contrast x-ray 

exam of aorta 

75716 Artery x-rays 

arms/legs 

75774 Artery x-ray 

each vessel 

 

75820 Vein x-ray arm/leg 75827 Vein x-ray chest 

75625 Contrast x-ray 

exam of aorta 

75710 Artery x-rays arm/leg 

75791 Av dialysis shunt 

imaging 

75827 Vein x-ray chest 

75658 Artery x-rays arm 75791 Av dialysis shunt 

imaging 

75820 Vein x-ray 

arm/leg 

75827 Vein

chest

75710 Artery x-rays 

arm/leg 

75774 Artery x-ray each 

vessel 

 

75820 Vein x-ray arm/leg 93931 Upper extremity study 

75791 Av dialysis shunt 

imaging 

75820 Vein x-ray arm/leg 

Code Range 78414-78496 
171 

Code Descriptor Code Descriptor Code Descriptor Code Desc

78452 Ht muscle image 

spect mult 

93306 Tte w/doppler 

complete 

 

78452 Ht muscle image 

spect mult 

93017 Cardiovascular stress 

test 

 

78452 Ht muscle image 

spect mult 

93306 Tte w/doppler 

complete 

93880 Extracranial 

study 

 

78452TC Ht muscle image 

spect mult 

93017 Cardiovascular stress 

test 

 

78452 Ht muscle image 

spect mult 

93880 Extracranial study 

78452TC Ht muscle image 

spect mult 

93306 Tte w/doppler 

complete 

 

78452 Ht muscle image 

spect mult 

93017 Cardiovascular stress 

test 

93306 Tte w/doppler 

complete 

 

78451 Ht muscle image 

spect sing 

93306 Tte w/doppler 

complete 

 

78452TC Ht muscle image 

spect mult 

93306TC Tte w/doppler 

complete 

 

78452 Ht muscle image 

spect mult 

93306 Tte w/doppler 

complete 

93880 Extracranial 

study 

93978 Vasc

study

Code Range 93000-93990 

Code Descriptor Code Descriptor Code Descriptor 

93306 Tte w/doppler 

complete 

93880 Extracranial study 

93320 Doppler echo 

exam heart 

93325 Lower extremity study 93351 Stress tte complete 

93922 Upr/l xtremity art 

2 levels 

93925 Lower extremity study 

93923 Upr/lxtr art stdy 

3+ lvls 

93925 Lower extremity study 

93306TC Tte w/doppler 

complete 

93880TC Extracranial study 

93880 Extracranial study 93978 Vascular study 

93284 Icd device progr 

eval mult 

93290 Icm device eval 

93922 Upr/l xtremity art 

2 levels 

93926 Lower extremity study 

93965 Extremity study 93970 Extremity study 

93925 Lower extremity 

study 

93970 Extremity study 

TABLE 15: Frequently Billed Diagnostic Ophthalmology Combinations 

Code Range 76510-76529 

Code Descriptor Code Descriptor Code Descriptor 

76514 Echo exam of eye 

thickness 

92133 Cmptr ophth img 

optic nerve 

 
172 

76514 Echo exam of eye 

thickness 

92083 Visual field 

examination(s) 

92133 Cmptr ophth img optic 

nerve 

76514 Echo exam of eye 

thickness 

92083 Visual field 

examination(s) 

 

76514 Echo exam of eye 

thickness 

92250 Eye exam with photos 

76514 Echo exam of eye 

thickness 

92083 Visual field 

examination(s) 

92250 Eye exam with photos 

76512 Ophth us b w/nonquant a 92134 Cptr ophth dx img 

post segmt 

 

76512 Ophth us b w/nonquant a 92250 Eye exam with photos 

76514 Echo exam of eye 

thickness 

92286 Internal eye 

photography 

 

76514 Echo exam of eye 

thickness 

92134 Cptr ophth dx img 

post segmt 

 

76512 Ophth us b w/nonquant a 92235 Eye exam with photos 92250 Eye exam with photos 

Code Range 92002-92371 

Code Descriptor Code Descriptor Code Descriptor 

92083 Visual field 

examination(s) 

92133 Cmptr ophth img 

optic nerve 

 

92235 Eye exam with photos 92250 Eye exam with photos 

92083 Visual field 

examination(s) 

92250 Eye exam with photos 

92083 Visual field 

examination(s) 

92134 Cptr ophth dx img 

post segmt 

 

92134 Cptr ophth dx img post 

segmt 

92235 Eye exam with photos 

92134 Cptr ophth dx img post 

segmt 

92250 Eye exam with photos 

92134 Cptr ophth dx img post 

segmt 

92235 Eye exam with photos 92250 Eye exam with photos 

92250 Eye exam with photos 92285 Eye photography 

92082 Visual field 

examination(s) 

92250 Eye exam with photos 

92081 Visual field 

examination(s) 

92285 Eye photography 

d. Procedures Subject to the OPPS Cap 

 We are proposing to add the new codes in Table 16 to the list of procedures subject to the 

OPPS cap, effective January 1, 2013. Some of these codes are replacement codes for codes 

deleted for CY 2013. These procedures meet the definition of imaging under section 5102(b) of 
173 

the DRA. These codes are being added on an interim final basis and their addition as procedures 

subject to the OPPS cap is open to public comment in this final rule with comment period. 

TABLE 16: Additions and Deletions to the List of Procedure Subject to the OPPS CAP on 

Imaging Services 

ADDITIONS DELETIONS 

Code Descriptor Code Descriptor 

31620 Endobronchial us add-on 71040 Contrast x-ray of bronchi 

36221 Place cath thoracic aorta 71060 Contrast x-ray of bronchi 

36222 Place cath carotd/inom art 75650 Artery x-rays head & neck 

36223 Place cath carotd/inom art 75660 Artery x-rays head & neck 

36224 Place cath carotd art 75662 Artery x-rays head & neck 

36225 Place cath subclavian art 75665 Artery x-rays head & neck 

36226 Place cath vertebral art 75671 Artery x-rays head & neck 

36227 Place cath xtrnl carotid 75676 Artery x-rays neck 

36228 Place cath intracranial art 75680 Artery x-rays neck 

43206 Esoph optical endomicroscopy 75685 Artery x-rays spine 

43252 Upper GI optical endomicroscopy 75900 Intravascular cath exchange 

77080 DXA bone density axial 75961 Retrieval broken catheter 

77082 DXA bone density vert fx 77424 Intraoperative radiation 

delivery 

78013 Thyroid imaging w/ blood flow 78006 Thyroid imaging with uptake 

78014 Thyroid imaging w/ blood flow 78007 Thyroid image mult uptakes 

78070 Parathyroid planar imaging 78010 Thyroid imaging 

78071 Parathyroid planar imaging w/o 

subtrj 78011 Thyroid imaging with flow 

78072 Parathyroid imaging w/ spect & ct 

88375 Optical endomicroscopy interp 

91110 GI tract capsule endoscopy 

91111 Esophageal capsule endoscopy 

92287 Internal eye photography 

C. Overview of the Methodology for the Calculation of Malpractice RVUs

Section 1848(c) of the Act requires that each service paid under the PFS be comprised of 

three components: work, PE, and malpractice. From 1992 to 1999, malpractice RVUs were 

charge-based, using weighted specialty-specific malpractice expense percentages and 1991 

average allowed charges. Malpractice RVUs for new codes after 1991 were extrapolated from 

similar existing codes or as a percentage of the corresponding work RVU. Section 4505(f) of the 
174 

BBA, which amended section 1848(c) of the Act, required us to implement resource-based 

malpractice RVUs for services furnished beginning in 2000. Therefore, initial implementation of 

resource-based malpractice RVUs occurred in 2000. 

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

every 5 years. The first review and update of resource-based malpractice RVUs was addressed 

in the CY 2005 PFS final rule with comment period (69 FR 66263). Minor modifications to the 

methodology were addressed in the CY 2006 PFS final rule with comment period 

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

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

update of malpractice RVUs, see the CY 2010 PFS proposed rule (74 FR 33537) and final rule 

with comment period (74 FR 61758). 

As explained in the CY 2011 PFS final rule with comment period (75 FR 73208), 

malpractice RVUs for new and revised codes effective before the next Five-Year Review of 

Malpractice (for example, effective CY 2011 through CY 2014, assuming that the next review of 

malpractice RVUs occurs for CY 2015) are determined either by a direct crosswalk to a similar 

source code or by 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 (or 

‘‘scale’’) the malpractice RVU for the new/revised code to reflect the difference in work RVU 

between the source code and the new/revised work value (or, if greater, the clinical labor portion 

of the fully implemented PE RVU) for the new code. For example, if the proposed work RVU 

for a revised code is 10 percent higher than the work RVU for its source code, the malpractice 

RVU for the revised code would be increased by 10 percent over the source code malpractice 

RVU. This approach presumes the same risk factor for the new/revised code and source code 

but uses the work RVU for the new/revised code to adjust for risk-of-service. 

As we indicated in the CY 2013 PFS proposed rule, we will continue our current 
175 

approach for determining malpractice RVUs for new/revised codes. In section II.M.2. of this 

final rule with comment period, we have published a list of new/revised codes and the 

malpractice crosswalk(s) used for determining their malpractice RVUs. These malpractice 

RVUs for new/revised codes will be implemented for CY 2013 on an interim final basis and the 

malpractice crosswalks are subject to public comment. We will respond to comments and 

finalize the malpractice crosswalks for the majority of these codes in the CY 2014 PFS final rule 

with comment period. 

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, practice expense 

(PE), and malpractice ). While requiring that the PE and MP GPCIs reflect the full relative cost 

differences, section 1848(e)(1)(A)(iii) of the Act requires that the 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 for services furnished in Alaska 

beginning January 1, 2009, and section 1848(e)(1)(I) of the Act sets a permanent 1.0 PE GPCI 

floor for services furnished in frontier states beginning January 1, 2011. 

Section 1848 (e)(1)(E) of the Act provides for a 1.0 floor for the work GPCIs, which was 

set to expire at the end of 2011. The statute was amended by section 303 of the Temporary 

Payroll Tax Cut Continuation Act of 2011 (TPTCCA) (Pub. L. 112-78) to extend the 1.0 floor 

for the work GPCIs through February 29, 2012. The statute was again amended by section 3004 

of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) (P.L. 112-399) to 

extend the 1.0 work floor for GPCIs throughout the remainder of CY 2012 (that is, for services 

furnished no later than December 31, 2012). During the development of the CY 2012 PFS final 
176 

rule with comment period, neither TPTCCA nor MCTRJCA had been enacted and, because the 

work GPCI floor was set to expire at the end of 2011, the GPCIs published in Addendum E of 

the CY 2012 PFS final rule with comment period did not reflect the 1.0 work floor. Following 

the enactment of the legislation, appropriate changes to the CY 2012 GPCIs to reflect the 1.0 

work floor required by section 303 of the TPTCCA and section 3004 of the MCTRJCA. 

Since the 1.0 work GPCI floor provided in section 1848 (e)(1)(E) of the Act is set to 

expire prior to the implementation of the CY 2013 updates to the PFS, the proposed CY 2013 

work GPCIs and summarized geographic adjustment factors (GAFs) published in addendums D 

and E of this CY 2013 PFS proposed rule do not reflect the 1.0 work GPCI floor for CY 2013. 

As required by section 1848 (e)(1)(G) and section1848 (e)(1)(I) of the Act, the 1.5 work GPCI 

floor for Alaska and the 1.0 PE GPCI floor for frontier states are applicable in CY 2013 and are 

reflected in addendums D and E. 

 In the CY 2012 PFS final rule with comment period, we made several refinements to 

the GPCIs (76 FR 73081 through 73092), including revising the sixth GPCI update to reflect the 

most recent data, with modifications. Specifically, we finalized our proposal to change the GPCI 

cost share weights for CY 2012 to reflect the most recent rebased and revised Medicare 

Economic Index (MEI). As a result, the cost share weight for the work GPCI (as a percentage of 

the total) was changed from 52.466 percent to 48.266 percent, and the cost share weight for the 

PE GPCI was revised from 43.669 percent to 47.439 percent with a change in the employee 

compensation component from 18.654 to 19.153 percentage points. The cost share weight for 

the office rent component of the PE GPCI was changed from 12.209 percent to 10.223 

percentage points (fixed capital with utilities), and the medical equipment, supplies, and other 

miscellaneous expenses component was changed from 12.806 percent to 9.968 percentage 

points. In addition, we finalized the weight for purchased services at 8.095 percentage points, of 

which 5.011 percentage points are adjusted for geographic cost differences. Lastly, the cost 
177 

share weight for the malpractice GPCI was revised from 3.865 percent to 4.295 percent. Table 

17 displays the cost share weights that were finalized in the CY 2012 final rule with comment 

period. Note that the employee compensation; office rent; purchased services; and equipment 

supplies and other cost share weights sum to the total PE GPCI cost share weights of 47.439 

percent. 

TABLE 17: Cost Share Weights finalized in CY 2012 GPCI Update 

Expense Category Cost Share 

Weights % 

Work 48.266 

Practice Expense 47.439 

 Employee Compensation 19.153 

 Office Rent 10.223 

 Purchased Services 8.095

 Equipment, Supplies, and Other 9.968

Malpractice Insurance 4.295

 We also finalized several other policies in the CY 2012 final rule with comment period 

including the use of 2006 through 2008 American Community Survey (ACS) two-bedroom 

rental data as a proxy for the relative cost difference in physician office rent. In addition, we 

created a purchased services index to account for labor-related services within the “all other 

services” and “other professional expenses” MEI components. In response to public commenters 

who recommended that we use Bureau of Labor Statistics (BLS) Occupational Employment 

Statistics (OES) data to capture the “full range” of occupations included in the offices of 

physician industry to calculate the nonphysician employee wage component (also referred to as 

the employee wage index) of the PE GPCI, we finalized a policy of using 100 percent of the total 

wage share of nonphysician occupations in the offices of physicians' industry to calculate the 

nonphysician employee wage component of the PE GPCI. 

2. Recommendations from the Institute of Medicine 
178 

 Concurrent with our CY 2012 rulemaking cycle, the Institute of Medicine released the 

final version of its first of two anticipated reports entitled “Geographic Adjustment in Medicare 

Payment: Phase I: Improving Accuracy, Second Edition” on September 28, 2011. This report 

included an evaluation of the accuracy of GAFs for the hospital wage index and the GPCIs, as 

well as the methodology and data used to calculate them. Several of the policies that we 

finalized in CY 2012 rulemaking addressed recommendations contained in the Institute of 

Medicine’s first report. Because we did not have adequate time to completely address the 

Institute of Medicine’s Phase I report recommendations during CY 2012 rulemaking, we 

included a discussion in the CY 2013 proposed rule (77 FR 44756) about the recommendations 

that were not implemented or discussed in the CY 2012 final rule with comment period. 

 As we anticipated in the CY 2013 proposed rule, the Institute of Medicine’s second report, 

entitled “Geographic Adjustment in Medicare Payment - Phase II: Implications for Access, Quality, 

and Efficiency,” was released July 17, 2012. The Phase II report evaluates the effects of GAFs 

(hospital wage index and GPCIs) on the distribution of the healthcare workforce, quality of care, 

population health, and the ability to provide efficient, high value care. Once we have had an 

opportunity to fully evaluate the report and its recommendations we will respond to its 

recommendations in subsequent rulemaking. 

3. GPCI Discussion for CY 2013 

 CY 2013 is the final year of the sixth GPCI update and, because we will propose updates 

next year, we did not include any proposals related to the GPCIs for the CY 2013 PFS. In 

response to public inquiries about exceptions to the calculated GPCIs, we provided a brief 

discussion about the permanent 1.0 PE floor for frontier states, the 1.5 work floor for Alaska, the 

GPCIs for the Puerto Rico payment locality, and the expiration of the GPCI 1.0 work floor 

required under section 1848 (e)(1)(E) of the Act. We also discussed recommendations from the 
179 

first Institute of Medicine report that were not addressed during CY 2012 rulemaking in the CY 

2013 proposed rule. We have included this discussion below. 

a. Alaska Work Floor and PE GPCI Floor for Frontier States 

Section 1848(e)(1)(G) of the Act sets a permanent 1.5 work GPCI floor for services 

furnished in Alaska beginning January 1, 2009. Therefore, the 1.5 work floor for Alaska will 

remain in effect in CY 2013. In addition, section 1848(e) (1)(I) of the Act establishes a 1.0 PE 

GPCI floor for physicians' services furnished in frontier states effective January 1, 2011. In 

accordance with section 1848(e)(1)(I) of the Act, beginning in CY 2011, we applied a 1.0 PE 

GPCI floor for physicians’ services furnished in states determined to be frontier states. The 

following states met the statutory criteria to be considered frontier states for CY 2012: Montana, 

North Dakota, Nevada, South Dakota, and Wyoming. There are no changes to those states 

identified as frontier states for CY 2013. 

b. GPCI Assignments for the Puerto Rico Payment Locality 

 As noted in the CY 2013 proposed rule, we have received inquiries from representatives 

of the Puerto Rico medical community regarding our policies for determining the GPCIs for the 

Puerto Rico payment locality. While we did not make any proposals related to the GPCIs for 

Puerto Rico, in response to those inquiries, we provided the following discussion regarding the 

GPCIs assigned to the Puerto Rico payment locality. We anticipate recalculating all the GPCIs 

in the seventh GPCI update, currently anticipated to be implemented for CY 2014. 

 As noted above, we are required by section 1848(e)(1)(A) of the Act to develop 

separate GPCIs to measure relative resource cost differences among localities compared to the 

national average for each of the three fee schedule components: work, PE and malpractice 

expense. To calculate these GPCI values, we rely on three primary data sources. We currently 

use the 2006-2008 BLS OES data to calculate the work GPCI, the nonphysician employee wage 

component of PE GPCI, and the labor costs associated with the purchased services component of 
180 

PE GPCI. We use 2006-2008 ACS data to calculate the office rent component of the PE GPCI. 

Finally, we use 2006-2007 malpractice premium data to calculate the malpractice GPCI. For all 

localities, including Puerto Rico, we assume equipment, supplies, and other expenses are 

purchased in a national market and that the costs do not vary by geographic location. Therefore, 

we do not use data on the price of equipment, supplies, and expenses across localities in 

calculating PE GPCIs. With the exception of the malpractice GPCI, we have current data from 

the applicable sources allowing us to calculate the work and PE GPCIs for the Puerto Rico 

payment locality. The 2006-2008 BLS OES data and rental values derived from the 2006-2008 

ACS indicate that the costs associated with operating a physician practice in Puerto Rico are the 

lowest among all payment localities. 

 To calculate the malpractice GPCI for the various Medicare PFS localities, we collect 

malpractice insurance market share and premium data from state departments of insurance and 

from state rate filings. As discussed in our contractor’s report (Final Report on the Sixth Update 

of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule page. 41), for 

the fourth, fifth, and sixth GPCI updates we were not able to collect this data for the Puerto Rico 

payment locality. Therefore, we carried over the malpractice GPCI value of 0.249 from previous 

GPCI updates when malpractice premium data were last available. It is important to note that we 

have a source for more current malpractice premium data for Puerto Rico for use in the 

upcoming seventh GPCI update. We are working with the relevant officials in Puerto Rico to 

acquire these data for use in future rulemaking. 

 For a detailed discussion regarding the methodology used to calculate the various 

components of the Puerto Rico GPCIs, we referred readers to our contractor’s report from 

November of 2010 entitled “Final Report on the Sixth Update of the Geographic Practice Cost 

Index for the Medicare Physician Fee Schedule” available on our website at 

www.cms.gov/PhysicianFeeSched/downloads/GPCI_Report.pdf. 
181 

 In the CY 2013 proposed rule, we also encouraged comments from stakeholders 

regarding potential data sources that may be available for calculating the Puerto Rico malpractice 

GPCI. 

Comment: In response to our inquiry regarding potential sources for data that could be 

used in calculating a malpractice GPCI for Puerto Rico, we received numerous comments about 

the costs of practicing medicine in Puerto Rico. The commenters primarily expressed concern 

about the PE GPCI (with emphases on the rent component) and the malpractice GPCI. The 

commenters stated that the current GPCI values for Puerto Rico are low in comparison to other 

PFS localities and that this disparity may create incentives for doctors to move their practices to 

the continental United States. As a result, the commenters explained that access to both primary 

and specialty care for Medicare beneficiaries residing in Puerto Rico could be compromised. 

Several stakeholders provided a report on a comprehensive study entitled “Cost of Medical 

Services in Puerto Rico.” The report included results from a physician survey on the costs of 

operating a medical practice in Puerto Rico, including the cost for obtaining malpractice 

insurance. For example, the report included information about the leading malpractice insurers 

in Puerto Rico, the amount of malpractice insurance coverage typically purchased by physicians, 

and the cost of malpractice insurance by primary and specialty care providers. In addition to 

malpractice insurance costs, the report also included information on the cost of employees, 

contracted services, rent and utilities, medical equipment and supplies in Puerto Rico as well as 

information on the major concerns, demographics, and work patterns of the doctors currently 

practicing medicine in Puerto Rico and the doctors that have moved from Puerto Rico now 

practicing in the United States. 

 Response: As noted in the proposed rule, we will be adjusting the GPCIs for CY 2014. 

Given that we did not make any proposals to modify the malpractice GPCI calculation 

methodology or values for CY 2013, it would not be appropriate to make changes to the GPCIs 
182 

in this final rule. We appreciate the physician survey information on the cost of malpractice 

insurance. We will review the information submitted on the cost of obtaining malpractice 

insurance in Puerto Rico as we prepare for the seventh GPCI update. We would note that the 

GPCIs are based upon changes in the relative costs of obtaining malpractice insurance so any 

changes in the GPCI for Puerto Rico will be based not only on data reflecting the costs on Puerto 

Rico, but also those in other localities. 

c. Expiration of GPCI Work Floor 

The work GPCIs are designed to capture the relative costs of physician labor by Medicare 

PFS locality. Previously, the work GPCIs were developed using the median hourly earnings 

from the 2000 Census of workers in seven professional specialty occupation categories that we 

used as a proxy for physicians’ wages. Physicians’ wages are not included in the occupation 

categories because Medicare payments are a key determinant of physicians’ earnings. That is, 

including physicians’ wages in the work GPCIs would effectively make the indices dependent 

upon Medicare payments. As required by law, the work GPCIs reflect one quarter of the relative 

wage differences for each locality compared to the national average. The work GPCI updates in 

CYs 2001, 2003, 2005, and 2008 were based on professional earnings data from the 2000 

Census. For the sixth GPCI update in CY 2011, we used the 2006 through 2008 BLS OES data 

as a replacement for the 2000 Census data. 

Although we did not propose any changes to the data or methodology used to calculate 

the work GPCI for CY 2013, we note that addenda D and E will reflect the expiration of the 

statutory 1.0 work GPCI floor which as noted above, is set to expire on December 31, 2012 in 

accordance with section 1848 (e)(1)(E) of the Act. 

Comment: A few commenters requested an extension of the 1.0 work GPCI floor stating 

that the statutorily-mandated work GPCI floor will expire on December 31, 2012. 
183 

Response: As discussed above (and noted by the commenters) the 1.0 work GPCI floor 

is set to expire on December 31, 2012 and we do not have authority to extend the 1.0 work GPCI 

floor beyond December 31, 2012. 

4. Institute of Medicine Phase I Report 

a. Background 

 At our request, the Institute of Medicine conducted a study of the geographic 

adjustment factors in Medicare payment. It is a comprehensive empirical study of the 

geographic adjustment factors established under sections 1848(e) (GPCI) and 1886(d)(3)(E) 

(hospital wage index) of the Act. These adjustments are designed to ensure Medicare payments 

reflect differences in input costs across geographic areas. The factors the Institute of Medicine 

evaluated include the following: 

● Accuracy of the adjustment factors; 

● Methodology used to determine the adjustment factors; and 

● Sources of data and the degree to which such data are representative. 

 Within the context of the U.S. healthcare marketplace, the Institute of Medicine also 

evaluated and considered the— 

● Effect of the adjustment factors on the level and distribution of the health care 

workforce and resources, including— 

++ Recruitment and retention taking into account mobility between urban and rural areas; 

++ Ability of hospitals and other facilities to maintain an adequate and skilled workforce; 

and 

++ Patient access to providers and needed medical technologies; 

● Effect of adjustment factors on population health and quality of care; and 

● Effect of the adjustment factors on the ability of providers to furnish efficient, high 

value care. 
184 

 The Institute of Medicine’s first report entitled “Geographic Adjustment in Medicare 

Payment, Phase I: Improving Accuracy” evaluated the accuracy of geographic adjustment factors 

and the methodology and data used to calculate them. The recommendations included in the 

Institute of Medicine’s Phase I report that relate to or would have an effect on the methodologies 

used to calculate the GPCIs and the configuration of Medicare PFS payment locality structure are 

summarized as follows: 

● Recommendation 2-1: The same labor market definition should be used for both the 

hospital wage index and the physician geographic adjustment factor. Metropolitan statistical 

areas and statewide non-metropolitan statistical areas should serve as the basis for defining these 

labor markets. 

● Recommendation 2-2: The data used to construct the hospital wage index and the 

physician geographic adjustment factor should come from all health care employers. 

● Recommendation 5-1: The GPCI cost share weights for adjusting fee-for-service 

payments to practitioners should continue to be national, including the three GPCIs (work, PE, and 

liability insurance) and the categories within the PE (office rent and personnel). 

● Recommendation 5-2: Proxies should continue to be used to measure geographic 

variation in the physician work adjustment, but CMS should determine whether the seven proxies 

currently in use should be modified. 

● Recommendation 5-3: CMS should consider an alternative method for setting the 

percentage of the work adjustment based on a systematic empirical process. 

● Recommendation 5-4: The PE GPCI should be constructed with the full range of 

occupations employed in physicians' offices, each with a fixed national weight based on the hours of 

each occupation employed in physicians' offices nationwide. 

● Recommendation 5-5: CMS and the Bureau of Labor Statistics should develop an 

agreement allowing the Bureau of Labor Statistics to analyze confidential data for CMS. 
185 

● Recommendation 5-6: A new source of information should be developed to determine the 

variation in the price of commercial office rent per square foot. 

● Recommendation 5-7: Nonclinical labor-related expenses currently included under PE 

office expenses should be geographically adjusted as part of the wage component of the PE. 

This report can be accessed on the Institute of Medicine 's website at 

www.iom.edu/Reports/2011/Geographic-Adjustment-in-Medicare-Payment-Phase-I-Improving-Acc

uracy.aspx. 

 As previously noted in this section, the Institute of Medicine also considered the role of 

Medicare payments on matters such as the distribution of the healthcare workforce, population 

health, and the ability of providers to produce high-value, high-quality health care in its final 

report July 17, 2012. We were not able to evaluate the recommendations contained in the 

Institute of Medicine’s Phase II report, in time for discussion in the proposed rule. The Phase II 

report can be accessed on the Institute of Medicine’s website at 

www.iom.edu/Reports/2012/Geographic-Adjustment-in-Medicare-Payment-Phase-II.aspx. 

b. Institute of Medicine Recommendations Implemented in CY 2012 

 In the CY 2012 PFS final rule with comment period, we addressed three of the 

recommendations offered by the Institute of Medicine in its Phase I report. Specifically, the final 

CY 2012 GPCIs utilized the full range of nonphysician occupations in the employee wage 

calculation consistent with Institute of Medicine recommendation 5-4. Additionally, we created 

a new purchased service index to account for nonclinical labor related expenses similar to 

Institute of Medicine recommendation 5-7. Lastly, we have consistently used national cost share 

weights to determine the appropriate weight attributed to each GPCI component, which is 

supported by Institute of Medicine recommendation 5-1 (76 FR 73081 through 73092). In order 

to facilitate a public discussion regarding the Institute of Medicine’s remaining Phase I 

recommendations, we provided a summary analysis of these recommendations in the CY 2013 
186 

proposed rule, which has also been included in this final rule with comment period below. We 

provided our technical analyses of the remaining Institute of Medicine Phase I recommendations 

in a report released on the PFS website at www.cms.gov/PhysicianFeeSched. Since we have not 

yet had an opportunity to review the recommendations in the Institute of Medicine’s Phase II 

report, these analyses focus exclusively on the recommendations as presented in the Institute of 

Medicine’s Phase I report. 

c. Discussion of Remaining Institute of Medicine’s Phase I recommendations 

(1) Institute of Medicine Recommendation Summaries 

(A) Institute of Medicine recommendation 2-1: The same labor market definition should be 

used for both the hospital wage index and the physician geographic adjustment factor. 

Metropolitan statistical areas and statewide non-metropolitan statistical areas should serve as the 

basis for defining these labor markets. (Geographic Adjustment in Medicare Payment, Phase I: 

Improving Accuracy pages 2-1 thru 2-29) 

(i) Locality Background 

The current PFS locality structure was developed and implemented in 1997. There are 

currently 89 total PFS localities; 34 localities are statewide areas (that is, only one locality for the 

entire state). There are 52 localities in the other 16 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). 

 Prior to 1992, Medicare payments for physicians’ services were made under the 

reasonable charge system. Payments were based on the charging patterns of physicians. This 

resulted in large differences among types of services, geographic payment areas, and physician 
187 

specialties. Recognizing this, the Congress replaced the reasonable charge system with the 

Medicare PFS in the Omnibus Budget Reconciliation Act (OBRA) of 1989, effective 

January 1, 1992. Payments under the fee schedule are based on the relative resources used in 

furnishing services and vary among areas as resource costs vary geographically as measured by 

the GPCIs. 

 Payment localities were established under the reasonable charge system by local 

Medicare carriers based on their knowledge of local physician charging patterns and economic 

conditions. These localities changed little between the inception of Medicare in 1967 and the 

beginning of the PFS in 1992. As a result, a study was begun in 1994 that resulted in a 

comprehensive locality revision, which was implemented in 1997 (61 FR 59494). 

 The revised locality structure reduced the number of localities from 210 to the current 89 

and the number of statewide localities increased from 22 to 34. The revised localities were based 

on locality resource cost differences as reflected by the GPCIs. A full discussion of the 

methodology can be found in the CY 1997 PFS final rule with comment period (61 FR 59494). 

The current 89 fee schedule areas are defined alternatively by state boundaries (for example, 

Wisconsin), metropolitan areas (for example, Metropolitan St. Louis, MO), portions of a 

metropolitan area (for example, Manhattan), or rest-of-state areas that exclude metropolitan areas 

(for example, Rest of Missouri). This locality configuration is used to calculate the GPCIs that 

are in turn used to calculate payments for physicians’ services under the PFS. 

 As was stated in the CY 2011 final rule with comment period (75 FR 73261), we 

require that changes to the PFS locality structure be done in a budget neutral manner within a 

state. For many years, we have sought consensus for any locality changes among the 

professionals whose payments would be affected. We have also considered more comprehensive 

changes to locality configurations. In 2008, we issued a draft comprehensive report detailing 

four different locality configuration options 
188 

(www.cms.gov/physicianfeesched/downloads/ReviewOfAltGPCIs.pdf). The alternative locality 

configurations in the report are described below. 

● Option 1: CMS Core-Based Statistical Area (CBSA) Payment Locality Configuration: 

CBSAs are a combination of Office of Management and Budget (OMB’s) Metropolitan 

Statistical Areas (MSAs) and their Micropolitan Statistical Areas. Under this option, MSAs 

would be considered as urban CBSAs. Micropolitan Statistical 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 areas used in the Inpatient Prospective Payment System (IPPS) prereclassification wage index, which is the hospital wage index for a geographic area (CBSA or 

non-CBSA) calculated from submitted hospital cost report data before statutory adjustments 

reconfigure, or “reclassify” a hospital to an area other than its geographic location, to adjust 

payments for difference in local resource costs in other Medicare payment systems. Based on 

data used in the 2008 locality report, 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 
189 

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. 

 For a detailed discussion of the public comments on the contractor’s 2008 draft report 

detailing four different locality configurations, we refer readers to the CY 2010 PFS proposed 

rule (74 FR 33534) and subsequent final rule with comment period (74 FR 61757). There was 

no public consensus on the options, although a number of commenters expressed support for 

Option 3 (separate MSAs from statewide localities) because the commenters believed this 

alternative would improve payment accuracy and could mitigate potential reductions to rural 

areas compared to Option 1 (CMS CBSAs). 

 In response to some public comments regarding the third of the four locality options, we 

had our contractor conduct an analysis of the impacts that would result from the application of 

Option 3. Those results were displayed in the final locality report released in 2011. The final 

report, entitled “Review of Alternative GPCI Payment Locality Structures – Final Report,” may 

be accessed directly from the CMS website at 

www.cms.gov/PhysicianFeeSched/downloads/Alt_GPCI_Payment_Locality_Structures_Review.

pdf. 

(ii) Institute of Medicine Recommendations on PFS Locality Structure Discussion 

 The Institute of Medicine recommends altering the current locality structure that was 

originally based on areas set by local contractors and, in 1996, reduced from 210 to current 89 

using a systematic iterative methodology. Rather than using the current uniform fee schedule 

areas in adjusting for relative cost differences as compared to the national average, the Institute 

of Medicine recommends a three-tiered system for defining fee schedule areas. In the first tier, 

the Institute of Medicine proposes applying county-based fee schedule areas to calculate the 

employee wage component of the PE GPCI. Although the Institute of Medicine’s report states 
190 

that it recommends that “Metropolitan statistical areas and statewide non-metropolitan statistical 

areas should serve as the basis for defining these labor markets,” the Institute of Medicine also 

recommends applying an out-commuting adjustment, which would permit employee wage index 

values to vary by county. Since the employee wage index is one component of the PE GPCI, 

these values also would vary by county under the Institute of Medicine’s proposal. 

 To understand why the employee wage index would vary by county under the Institute of 

Medicine’s recommendation, consider the three steps that would be required to calculate the 

employee wage index. The first step calculates the average hourly wage (AHW) for workers 

employed in each MSA or residual (rest of state) area. The wages of workers in each occupation 

are weighted by the number of workers employed in physicians’ offices nationally. The second 

step applies a commuting-based smoothing adjustment to create area index wages for each 

county. The commuting-adjusted county index wages are equal to a weighted average of the 

AHW values calculated in the first step, where the weights are county-to-MSA out-commuting 

patterns. The Institute of Medicine’s out-commuting-based weights equal the share of health 

care workers that live in a county where a physician’s office is located who commute out of the 

county to work in a physician’s office in each MSA. The third step sets each physician’s 

employee index wage equal to the estimated area index wage (calculated in Step 2) of the county 

in which the physician’s office is located. Because the out-commuting adjustment envisioned by 

the Institute of Medicine in the second step varies by county, the employee wage index value—

and thus the PE GPCI as a whole — would also potentially vary by county depending on the 

smoothing option chosen. If implemented, the number of employee wage index payment areas 

could potentially increase from 89 to over 3,000. 

 The Institute of Medicine’s second tier of fee schedule areas would use an MSA-based 

approach. The Institute of Medicine proposes using the MSA-based system for the work GPCI, 

the office rent index and the purchased services index of the PE GPCI, and the MP GPCI. An 
191 

MSA is made up of one or more counties, including the counties that contain the core urban area 

with a population of 50,000 or more, as well as surrounding counties that exhibit a high degree 

of social and economic integration (as measured by commuting patterns) with the urban core. 

MSAs are designed to be socially and economically integrated units based on the share of 

workers who commute to work within the urban core of each MSA. Implementing an MSAbased locality structure would expand the number of fee schedule areas from 89 to upwards of 

400 plus additional MSAs for U.S. territories (for example, Virgin Islands, American Samoa, 

Guam, Northern Marianna Islands). 

 In its third payment area tier, the Institute of Medicine proposes creating a national 

payment area for the “equipment, supplies and other” index. We currently do not adjust PEs 

associated with supplies and equipment since we believe they are typically purchased in a 

national market. Thus, this approach is equivalent to using a national fee schedule area to define 

this index. The Institute of Medicine proposes no change to the fee schedule area used to 

compute the “equipment, supplies and other” index. 

 Based on our contractor’s analysis, there would be significant redistributive impacts if we 

were to implement a policy that would reconfigure the PFS localities based on the Institute of 

Medicine’s three-tiered recommendation. Many rural areas would see substantial decreases in 

their corresponding GAF and GPCI values as higher cost counties are removed from current 

“rest of state” payment areas. Conversely, many urban areas, especially those areas that are 

currently designated as “rest of state” but reside within higher cost MSAs, would experience 

increases in their applicable GPCIs and GAFs. 

 The localities used to calculate the GPCIs have been a subject of substantial discussion 

and debate since the implementation of the PFS. The intensity of those discussions has increased 

since the last comprehensive update to the locality structure in 1997. Physicians and other 

suppliers in areas such as Santa Cruz County, California and Prince William County, Virginia 
192 

have expressed concern that the current locality structure does not appropriately capture 

economic and demographic shifts that have taken place since the last PFS locality update. On 

the other hand, rural practitioners have argued that revisions to the current PFS payment 

localities will reduce their payments and exacerbate the problems of attracting physicians and 

other practitioners to rural areas. In the past, we have also heard concerns from representatives 

of some statewide localities regarding the potential implications of adopting an alternative 

locality structure that would change their current statewide payment area (74 FR 33536). 

 The Institute of Medicine stated in its Phase I report regarding its locality 

recommendation that, “While the payment areas would stay the same for the HWI (hospital wage 

index), implementing this recommendation would mean that the GPCI payment areas would 

expand from 89 to 441 areas, which would be a significant change. The impact of the change in 

payment areas will be assessed in the Phase II report.” (“Geographic Adjustment in Medicare 

Payment: Phase I: Improving Accuracy, Second Edition” on September 28, 2011 page 5-6.) 

Moreover, the Institute of Medicine’s Phase II report will evaluate the effects of geographic 

adjustment factors on the distribution of the healthcare workforce, quality of care, population 

health, and the ability to provide efficient, high value care. Over the years, commenters that 

have opposed revisions to localities have claimed that changes to the PFS areas could have a 

significant impact on the ability of rural areas to attract physicians. Certainly, one of our major 

goals when we last comprehensively revised the Medicare PFS localities in 1996 was to avoid 

excessively large urban/rural payment differences (61 FR 59494). In 1996, we were hopeful that 

the revisions would improve access to care for rural areas (61 FR 59494). Some areas may have 

experienced both economic and demographic shifts since the last comprehensive locality update. 

Before moving forward with the Institute of Medicine’s three-tiered locality recommendation, or 

any other potential locality revision, we would need to assess, and prepare to inform the public 

of, the impact of any change for all Medicare stakeholders. The Institute of Medicine’s Phase II 
193 

report, released July 17, 2012, contains an evaluation of many of these important factors 

including: 

● The effect of the adjustment factors on the level and distribution of the health care 

workforce and resources, including-- 

++ Recruitment and retention taking into account mobility between urban and rural 

areas; 

++ Ability for hospitals and other facilities to maintain an adequate and skilled 

workforce; 

++ Patient access to providers and needed medical technologies; 

++ Effect of adjustment factors on population health and quality of care; and 

++ Effect of adjustment factors on the ability of providers to furnish efficient, high value 

care. 

To fully assess the broader public policy implications associated with the Institute of 

Medicine’s locality recommendation, we must first fully assess and analyze the 

recommendations contained in the Institute of Medicine’s Phase II report. Accordingly, we 

believe that it would be premature to make any statements about potential changes we would 

consider making to the PFS localities at this time. Any changes to PFS fee schedule areas would 

be made through future notice and comment rulemaking. 

 In the event that we develop a specific proposal for changing the locality configuration 

during future rulemaking, we would provide detailed analysis on the impact of the changes for 

physicians in each county. We would also provide opportunities for public input (for example, 

Town Hall meetings or Open Door Forums), as well as opportunities for public comments 

afforded by the rulemaking process. 

 While we did not propose to change the current locality configuration for CY 2013, we 

requested public comments regarding the Institute of Medicine’s recommended three-tiered PFS 
194 

payment locality definition. In addition, as stated above we, made our technical analyses of the 

Institute of Medicine locality recommendations, specific to the Phase I report, available on the 

CMS website at www.cms.gov/PhysicianFeeSched/. 

The following is a summary of the comments we received regarding the Institute of 

Medicine’s recommended three-tiered PFS payment locality definition. 

Comment: We received several comments on the Institute of Medicine’s 

recommendation for a three-tiered PFS payment locality definition. Commenters from rural 

areas opposed increasing the number of payment localities, as would happen under an MSAbased PFS locality structure, because it would redistribute payments from rural to urban areas. 

Additionally, commenters who opposed the Institute of Medicine’s three-tiered locality approach 

argued that increasing the number of PFS payment localities would reduce their payment 

amounts and exacerbate problems of attracting physicians and other practitioners to rural areas. 

A few commenters supported the Institute of Medicine’s recommendation to move 

toward an MSA-based locality configuration and urged us to make updating the PFS locality 

configuration a priority in CY 2013. Commenters supporting an MSA-based locality 

configuration contend that significant economic and demographic shifts have occurred since the 

last reconfiguration, making the current locality assignments outdated. One state medical 

association expressed disappointment that we did not propose an MSA-based locality structure 

for CY 2013. The commenter urged us “to adopt a transition plan to update the PFS localities” 

and stressed that the “transition plan must take into account the negative impact on physicians 

practicing in rural areas and work to mitigate the reductions in these regions.” 

Response: We appreciate the comments received on the Institute of Medicine’s 

recommendation to adopt an MSA-based approach for defining PFS localities. We will continue 

to evaluate the comments received on the Institute of Medicine’s recommendations for revising 
195 

the PFS locality structure, along with the impacts of such recommendations as discussed in the 

Phase II report. 

(B) Institute of Medicine Recommendation 2-2: Employee Wage Index of the PE GPCI 

The data used to construct the hospital wage index and the physician geographic adjustment 

factor should come from all healthcare employers (Geographic Adjustment in Medicare 

Payment, Phase I: Improving Accuracy pages 2-1 thru 2-29) and Recommendation 5-5: CMS 

and the Bureau of Labor Statistics should develop an agreement allowing the Bureau of Labor 

Statistics to analyze confidential data for the Centers for Medicare and Medicaid Services. 

(Geographic Adjustment in Medicare Payment, Phase I: Improving Accuracy page 5-38.)

 The Institute of Medicine recommends altering the data used to calculate the employee 

wage index. Specifically, Institute of Medicine recommends using wage data for workers in the 

healthcare industry rather than wage data for workers across all-industries. Although all-industry 

wage data has the largest sample size, the Institute of Medicine “...is concerned that the [allindustry] sample does not represent physician offices.” BLS OES occupation wage data by 

MSA, however, are not publicly available for the healthcare industry. Using healthcare-industry 

wages would require the use of confidential BLS OES data. While CMS could potentially secure 

access to the confidential BLS OES data, the general public may not be able to. Although the 

Institute of Medicine recommends that CMS secure an agreement with BLS to use the 

confidential wage data, the current employee wage index relies on publicly-available all-industry 

wage data. 

In the CY 2013 proposed rule we requested comments on the use of confidential 

employee wage index data rather than the publicly available all-industry wage data. However, 

we did not receive specific comments as to whether we should pursue the acquisition of 

confidential employee wage index data (as a replacement for the publically available all-industry 

wage data) for purposes of determining the employee wage index component of the PE GPCI. 
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 Regardless of whether healthcare-industry or all-industry wage data is used, the Institute 

of Medicine recommends following the current approach adopted by CMS in CY 2012 for 

calculating the employee wage index. This approach constructs the employee wage index as a 

weighted average of occupation wages for the full-range of occupations employed in physicians’ 

offices, where the weights are equal to the fixed national weight based on the hours of each 

occupation employed in physicians’ offices nationwide. We adopted this approach for 

calculating the GPCI employee wage index in the CY 2012 PFS final rule with comment period 

(76 FR 73088). 

(C) Institute of Medicine recommendation 5-2: Work GPCI Methodology 

Proxies should continue to be used to measure geographic variation in the physician work 

adjustment, but CMS should determine whether the seven proxies currently in use should be 

modified (Geographic Adjustment in Medicare Payment, Phase I: Improving Accuracy page 

5-36) and; Recommendation 5-3: CMS should consider an alternative method for setting the 

percentage of the work adjustment based on a systematic empirical process. (Geographic 

Adjustment in Medicare Payment, Phase I: Improving Accuracy pages 5-36 thru 5-37) 

 The Institute of Medicine recommends replacing the current work GPCI methodology 

with a regression-based approach. We currently use three steps to calculate the work GPCI. 

These steps include: 

(1) Selecting the proxy occupations and calculating an occupationspecific index for each proxy; 

(2) Assigning weights to each proxy-occupation index based on each 

occupation’s share of total national wages to create an aggregate proxyoccupation index; and 
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(3) Adjusting the aggregate proxy-occupation index by a physician 

inclusion factor to calculate the final work GPCI. 

 By using this approach, the current methodology reduces the circularity problem that 

occurs when work GPCI values are based on direct measurements of physician earnings. 

Because physician earnings are made up of both wages and a return on investment from 

ownership of the physician practice, calculating the work GPCI using physician earnings 

information would assign areas where physician practices are more profitable higher work GPCI 

values. Although the Institute of Medicine recommends that we continue to use proxy 

occupations in the work GPCI methodology, its regression-based approach alters each of the 

three steps described above. 

To modify the first step, the Institute of Medicine recommends that we empirically 

evaluate the validity of seven proxy occupations we currently use. The current proxy 

occupations in the work GPCI are intended to represent highly educated, professional employee 

categories. Although the Institute of Medicine recommends re-evaluating the proxy occupations 

used in the work GPCI, it does not define specific criteria to use for this purpose. 

 To modify the second step, the Institute of Medicine recommends using a regressionbased approach to weight the selected proxy occupation indices based on their correlation with 

physician earnings. This Institute of Medicine proposal would replace the current approach 

where occupations are weighted by the size of their share of total national wages. Such an 

approach presumes that wages for proxy occupations are not related to physician profits. 

Finally, the Institute of Medicine proposes an empirically-based approach to determine 

the inclusion factor for work. The inclusion factor for work refers to section 1848(e)(1)(A)(iii) 

of the Act requiring that the work GPCI reflect only 25 percent of the difference between the 

relative value of physicians’ work effort in each locality and the national average of such work 
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effort. Therefore, under current law, only one quarter of the measured regional variation in 

physician wages is incorporated into the work GPCI. The Institute of Medicine recommends 

calculating an inclusion factor based on the predicted values of the regression described above. 

Under the Institute of Medicine’s approach, the inclusion factor is larger when the proxy 

occupations have a higher correlation with physicians’ earnings and smaller when the proxy 

occupations have a lower correlation with physicians’ earnings. We note that using such an 

empirical approach to weight the proxy occupation indices and to estimate the inclusion factor 

requires the identification of a viable source of physician wage information in addition to the 

wage information of proxy occupations to accurately measure regional variation in physician 

wages. 

We requested comments on the Institute of Medicine’s recommendations to revise the 

work GPCI methodology. 

The following is a summary of the comments we received regarding the Institute of 

Medicine’s recommendations to revise the work GPCI methodology. 

Comment: A few commenters stated that the physician work GPCI should not be 

adjusted at all for geographic cost differences. However, the same commenters stated that if 

geographic payments adjustments must be applied under the PFS, the current proxy occupations 

used for calculating the work GPCI should be replaced with actual physician salary survey data 

to determine the true cost (market price) of physician labor. To that end, the commenters 

suggested that third parties who hire physicians, for example hospitals, would be a good source 

for obtaining “market based” physician salary data. Additionally, one commenter encouraged us 

to work with the AMA and the Medical Group Management Association (MGMA) to evaluate 

the validity of the current proxy occupational data sources and to determine methods for 

gathering reliable physician cost data. 
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Response: We appreciate the comments received on the Institute of Medicine’s 

recommendations to revise the work GPCI methodology. We will continue to evaluate the 

comments received on the methodology used for determining the physician work GPCI in 

preparation for the seventh update to the GPCIs, which is scheduled to be implemented in CY 

2014. We also look forward to the MedPAC study on this issue, which is required under section 

3004 of the MCTRJCA. This study will assess whether any geographic adjustment to physician 

work is appropriate and, if so, what the level should be and where it should be applied. 

(D) Institute of Medicine Recommendation 5-6: Office Rent Component of PE GPCI 

A new source of information should be developed to determine the variation in the price of 

commercial office rent per square foot. (Geographic Adjustment in Medicare Payment, Phase I: 

Improving Accuracy pages 5-38 thru 5-39) 

 The Institute of Medicine recommends the development of a new source of data to 

determine the variation in the price of commercial office rent per square foot. However, the 

Institute of Medicine does not explicitly recommend where the data should come from or how it 

should be collected. Before coming to this recommendation, the Institute of Medicine identified 

and evaluated several public and commercially available sources of data to determine whether an 

accurate alternative is available to replace the residential rent data currently used as a proxy to 

measure regional variation in physicians’ cost to rent office space in the PE GPCI; these sources 

include rental data from the U.S. Department of Housing and Urban Development, American 

Housing Survey, General Services Administration, Basic Allowance for Housing (U.S. 

Department of Defense), U.S. Postal Service, MGMA (MGMA), and REIS, Inc. The Institute of 

Medicine concluded that these sources had substantial limitations, including lack of 

representativeness of the market in which physicians rent space, small sample size, low response 

rates, and sample biases. Although we agree that a suitable source for commercial office rent 

data would be preferable to the use of residential rent data in our PE office rent methodology, we 
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have still been unable to identify an adequate commercial rent source that sufficiently covers 

rural and urban areas. 

We will continue to evaluate possible commercial rent data sources for potential use in 

the office rent calculation. To that end, we encouraged public commenters to notify us of any 

publicly available commercial rent data sources, with adequate data representation of urban and 

rural areas that could potentially be used in the calculation of the office rent component of PE. 

However, we did not receive comments on specific data sources for commercial rent for 

purposes of determining the office rent component of the PE GPCI. 

Comment: We received several comments that were not within the scope of the CY 2013 

proposed rule. For example, a few commenters expressed concerns about the methodology used 

for determining the CY 2012 GPCI values and the impact of the current PFS locality 

configuration on specific PFS localities. 

Response: We appreciate the comments regarding the methodology used for determining 

the CY 2012 GPCI values and the impact they have on specific PFS localities. As discussed 

above, we did not make any proposed changes to the GPCI calculation methodology or values 

for CY 2013. Therefore, it would not be appropriate to consider making new adjustments to the 

GPCI values for a specific locality without providing the public an opportunity to comment. We 

will consider the commenters’ suggestions as we implement the seventh GPCI update anticipated 

in CY 2014. 

Result of Evaluation of Comments

We appreciate the comments received on the Institute of Medicine’s recommendations 

regarding the PFS locality structure and the data sources and methodology used to calculate 

GPCI values. We will consider the commenters’ suggestions as we continue to evaluate options 

for reconfiguring the PFS locality structure and as we implement the seventh update to the 

GPCIs scheduled for CY 2014. We also look forward to conducting a full review and 
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assessment of the Institute of Medicine’s additional PFS locality recommendations (as discussed 

in their Phase II report), as well as the MedPAC study on the physician work GPCI under the 

PFS that is required by section 3004 of the MCTRJCA. 

E. Medicare Telehealth Services for the Physician Fee Schedule

1. Billing and Payment for Telehealth Services 

a. History 

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 

furnished. 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 
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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) of the Act required the 

Secretary to establish a process 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 Act 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 furnished to an eligible telehealth individual 

notwithstanding the fact that the individual practitioner furnishing 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. Under 

the BIPA, originating sites were limited under section 1834(m)(3)(C) of the Act to specified 

medical facilities located in specific geographic areas. The initial list of telehealth originating 
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sites included the office of a practitioner, a critical access hospital (CAH), a rural health clinic 

(RHC), a federally qualified health center (FQHC) and a hospital (as defined in Section 1861(e) 

of the Act). 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 

participates 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 Act does not require the eligible telehealth individual to be 

presented by a practitioner at the originating site. 

b. Current Telehealth Billing and Payment Policies

As noted previously, 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; 

● Hospital-Based or Critical Access Hospital-Based Renal Dialysis Centers (including 

Satellites); 
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● 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 and group medical nutrition therapy (MNT); 

● Neurobehavioral status exam; 

● Individual and group health and behavior assessment and intervention (HBAI); 

● Subsequent hospital care; 

● Subsequent nursing facility care; 

● Individual and group kidney disease education (KDE); 

● Individual and group diabetes self-management training (DSMT); and 

• Smoking cessation services. 

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 via a telecommunications 

system: 

● Physician; 

● Physician assistant (PA); 

● Nurse practitioner (NP); 
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● Clinical nurse specialist (CNS); 

● Nurse-midwife; 

● Clinical psychologist; 

● Clinical social worker; 

● Registered dietitian or nutrition professional. 

Practitioners furnishing Medicare telehealth services 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 certifies that it is located in either a rural HPSA or non-MSA county or is an 
206 

entity that participates 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 

as specified in section 1834(m)(4)(C)(i)(III) of the Act. 

As previously described, 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) of the Act. 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). . 

2. Requests for Adding Services to the List of Medicare Telehealth Services 

As noted previously, 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 
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requests for adding services. We assign any request to make additions to the list of telehealth 

services to one of two categories. In the November 28, 2011 Federal Register (76 FR 73102), 

we finalized revisions to criteria that we use to review requests in the second category. The two 

categories are: 

● Category 1: Services that are similar to professional consultations, office visits, and 

office psychiatry services that are currently on the list of telehealth 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 service is accurately described by 

the corresponding code when delivered via telehealth and whether the use of a 

telecommunications system to deliver the service produces demonstrated clinical benefit to the 

patient. In reviewing these requests, we look for evidence indicating that the use of a 

telecommunications system in delivering the candidate telehealth service produces clinical 

benefit to the patient. Submitted evidence should include both a description of relevant clinical 

studies that demonstrate the service furnished by telehealth to a Medicare beneficiary improves 

the diagnosis or treatment of an illness or injury or improves the functioning of a malformed 

body part, including dates and findings, and a list and copies of published peer reviewed articles 

relevant to the service when furnished via telehealth. Our evidentiary standard of clinical benefit 

does not include minor or incidental benefits. 

Some examples of clinical benefit include the following: 
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● Ability to diagnose a medical condition in a patient population without access to 

clinically appropriate in person diagnostic services. 

● Treatment option for a patient population without access to clinically appropriate inperson treatment options. 

● Reduced rate of complications. 

● Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due 

to reduced rate of recurrence of the disease process). 

● Decreased number of future hospitalizations or physician visits. 

● More rapid beneficial resolution of the disease process treatment. 

● Decreased pain, bleeding, or other quantifiable symptom. 

● Reduced recovery time. 

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 and group 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 to examine the 

vascular access site); individual and group MNT; neurobehavioral status exam; initial and 

follow-up inpatient telehealth consultations for beneficiaries in hospitals and skilled nursing 

facilities (SNFs); subsequent hospital care (with the limitation of one telehealth visit every 

3 days); subsequent nursing facility care (with the limitation of one telehealth visit every 

30 days); individual and group KDE; and individual and group DSMT (with a minimum of 

1 hour of in-person instruction to ensure effective injection training), and smoking cessation 

services. 

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 
209 

rulemaking cycle. For example, requests submitted before the end of CY 2012 will be 

considered for the CY 2014 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 website at 

www.cms.gov/telehealth/. 

3. Submitted Request and Other Additions to the List of Telehealth Services for CY 2013 

We received a request in CY 2011 to add alcohol and/or substance abuse and brief 

intervention services as Medicare telehealth services effective for CY 2013. The following 

presents a discussion of this request, and our proposals for additions to the CY 2013 telehealth 

list. 

a. Alcohol and/or Substance Abuse and Brief Intervention Services 

The American Telemedicine Association submitted a request to add alcohol and/or 

substance abuse and brief intervention services, reported by CPT codes 99408 (Alcohol and/or 

substance (other than tobacco) abuse structured screening (for example, AUDIT, DAST), and 

brief intervention (SBI) services; 15 to 30 minutes) and 99409 (Alcohol and/or substance (other 

than tobacco) abuse structured screening (for example, AUDIT, DAST), and brief intervention 

(SBI) services; greater than 30 minutes) to the list of approved telehealth services for CY 2013 

on a category 1 basis. 

We note that we assigned a status indicator of ‘‘N’’ (Noncovered) to CPT codes 99408 

and 99409 as explained in the CY 2008 PFS final rule with comment period (72 FR 66371). At 

the time, we stated that because Medicare only provides payment for certain screening services 
210 

with an explicit benefit category, and these CPT codes incorporate screening services along with 

intervention services, we believed that these codes were ineligible for payment under the PFS. 

We continue to believe that these codes are ineligible for payment under PFS and, additionally, 

under the telehealth benefit. We do not believe it would be appropriate to make payment for 

claims using these CPT codes for the services furnished via telehealth, but not when furnished in 

person. Because CPT codes 99408 and 99409 are currently assigned a noncovered status 

indicator, and because we continue to believe this assignment is appropriate, we did not propose 

adding these CPT codes to the list of Medicare Telehealth Services for CY 2013. 

However, we created two parallel G-codes for 2008 that allow for appropriate Medicare 

reporting and payment for alcohol and substance abuse assessment and intervention services that 

are not furnished as screening services, but that are furnished in the context of the diagnosis or 

treatment of illness or injury. The codes are HCPCS code G0396 (Alcohol and/or substance 

(other than tobacco) abuse structured assessment (for example, AUDIT, DAST) and brief 

intervention, 15 to 30 minutes) and HCPCS code G0397, (Alcohol and/or substance (other than 

tobacco) abuse structured assessment (for example, AUDIT, DAST) and intervention greater 

than 30 minutes). Since these codes are used to report comparable alcohol and substance abuse 

services under certain conditions, we believed that it would be appropriate to consider the ATA’s 

request as it applies to these services when appropriately reported by the G-codes. The ATA 

asked that CMS consider this request as a category 1 addition based on the similarities between 

these services and CPT codes 99406 (Smoking and tobacco use cessation counseling visit; 

intermediate, greater than 3 minutes up to 10 minutes) and 99407 (Smoking and tobacco use 

cessation counseling visit; intensive, greater than 10 minutes). We agree that the interaction 

between a practitioner and a beneficiary receiving alcohol and substance abuse assessment and 

intervention services is similar to their interaction in smoking cessation services. We also 

believe that the interaction between a practitioner and a beneficiary receiving alcohol and 
211 

substance abuse assessment and intervention services is similar to the assessment and 

intervention elements of CPT code 96152 (health and behavior intervention, each 15 minutes, 

face-to-face; individual), which also is currently on the telehealth list. 

Therefore, we proposed to add HCPCS codes G0396 and G0397 to the list of telehealth 

services for CY 2013 on a category 1 basis. Consistent with this proposal, we also proposed to 

revise our regulations at §410.78(b) and §414.65(a)(1) to include alcohol and substance abuse 

assessment and intervention services as Medicare telehealth services. 

b. Preventive Services 

 Under our existing policy, we add services to the telehealth list on a category 1 basis 

when we determine that they are similar to services on the existing telehealth list with respect to 

the roles of, and interactions among, the beneficiary, physician (or other practitioner) at the 

distant site and, if necessary, the telepresenter. As we stated in the CY 2012 proposed rule 

(76 FR 42826) , we believe that the category 1 criteria not only streamline our review process for 

publically requested services that fall into this category, the criteria also expedite our ability to 

identify codes for the telehealth list that resemble those services already on this list. 

 During CY 2012, CMS added coverage for several preventive services through the 

national coverage determination (NCD) process as authorized by section 1861(ddd) of the Act. 

These services add to Medicare’s existing portfolio of preventive services that are now available 

without cost sharing under the Affordable Care Act. We believe that for several of these 

services, the interactions between the furnishing practitioner and the beneficiary are similar to 

services currently on the list of Medicare telehealth services. Specifically, we believe that the 

assessment, education, and counseling elements of the following services are similar to existing 

telehealth services: 
212 

● Screening and behavioral counseling interventions in primary care to reduce alcohol 

misuse, reported by HCPCS codes G0442 (Annual alcohol misuse screening, 15 minutes) and 

G0443 (Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes). 

● Screening for depression in adults, reported by HCPCS code G0444 (Annual 

Depression Screening, 15 minutes). 

● Screening for sexually transmitted infections (STIs) and high-intensity behavioral 

counseling (HIBC) to prevent STIs, reported by HCPCS code G0445 (High-intensity behavioral 

counseling to prevent sexually transmitted infections, face-to-face, individual, includes: 

education, skills training, and guidance on how to change sexual behavior, performed semiannually, 30 minutes). 

● Intensive behavioral therapy for cardiovascular disease, reported by HCPCS code 

G0446 (Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 

15 minutes). 

● Intensive behavioral therapy for obesity, reported by HCPCS code G0447 (Face-toface behavioral counseling for obesity, 15 minutes). 

We believe that the interactions between practitioners and beneficiaries receiving these 

services are similar to 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), individual MNT reported by HCPCS code G0270 (Medical nutrition therapy; 

reassessment and subsequent intervention(s) following second referral in the 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-to-face 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), and HBAI reported by 
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CPT code 96150 (Health and behavior assessment (for example, health-focused clinical 

interview, behavioral observations, psychophysiological monitoring, health-oriented 

questionnaires), each 15 minutes face-to-face with the patient; initial assessment); CPT code 

96151 (Health and behavior assessment (for example, health-focused clinical interview, 

behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 

15 minutes face-to-face with the patient re-assessment); CPT code 96152 (Health and behavior 

intervention, each 15 minutes, face-to-face; Individual); CPT code 96153 (Health and behavior 

intervention, each 15 minutes, face-to-face; Group (2 or more patients)); CPT code 96154 

(Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient 

present)), all services that are currently on the telehealth list. 

 Therefore, we proposed to add HCPCS codes G0442, G0443, G0444, G0445, G0446, and 

G0447 to the list of telehealth services for CY 2013 on a category 1 basis. We note that all 

coverage guidelines specific to the services would continue to apply when these services are 

furnished via telehealth. For example, when the national coverage determination requires that 

the service be furnished to beneficiaries in a primary care setting, the qualifying originating 

telehealth site must also qualify as a primary care setting. Similarly, when the national coverage 

determination requires that the service be furnished by a primary care practitioner, the qualifying 

primary distant site practitioner must also qualify as primary care practitioner. For more detailed 

information on coverage requirements for these services, we refer readers to the Medicare 

National Coverage Determinations Manual, Pub. 100-03, Chapter 1, Section 210, available at 

http://www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf. Consistent with this proposal, we 

also proposed to revise our regulations at §410.78(b) and §414.65(a)(1) to include these 

preventive services as Medicare telehealth services. 

Comment: All commenters expressed support for CMS’ proposals to add alcohol and/or 

substance abuse structured assessment and brief intervention services and the several preventive 
214 

services established through the national coverage determination (NCD) process to the list of 

Medicare telehealth services for CY 2013. One commenter stated particular support for CMS’ 

approach to ensure that coverage guidelines continue to apply when these services are furnished 

via telehealth and expressed the intention to support CMS’ efforts to help educate practitioners 

about these preventive telehealth services newly available in 2013. Another commenter stated 

that the proposal to add these services to this list was an integral step forward for telehealth, but 

that the current breadth and level of services covered under the telehealth benefit is inadequate to 

support more robust telehealth capabilities sought by some practitioners. 

Response: We appreciate the broad support for the proposed additions to the list of 

Medicare telehealth services and the efforts of stakeholders to ensure that practitioners are 

educated about the addition of these services to the list of Medicare telehealth services. We 

believe that the delivery of services via telehealth can help reduce barriers to health care access 

faced by some beneficiaries, and we remind all interested stakeholders that we are currently 

soliciting public requests to add services to the list of Medicare telehealth services. To be 

considered during PFS rulemaking for CY 2014, these requests must be submitted and received 

by December 31, 2012 or the close of the comment period for this final rule with comment 

period. Each request to add 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. 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 website at 

www.cms.gov/telehealth/. 

After consideration of the public comments received, we are finalizing our CY 2013 

proposal to add HCPCS codes G0396, G0397, G0442, G0443, G0444, G0445, G0446, and 

G0447 to the list of telehealth services for CY 2013 on a category 1 basis. We note that all 

coverage guidelines specific to the services will continue to apply when these services are 
215 

furnished via telehealth. For example, when the national coverage determination requires that 

the service be furnished to beneficiaries in a primary care setting, the telehealth originating site 

must also qualify as a primary care setting under the terms of the national coverage 

determination. Similarly, when the national coverage determination requires that the service be 

furnished by a primary care practitioner, the distant site practitioner who furnishes the telehealth 

service must also qualify as primary care practitioner under the terms of the national coverage 

determination. For more detailed information on coverage requirements for these services, we 

refer readers to the Medicare National Coverage Determinations Manual, Pub. 100-03, Chapter 

1, Section 210, available at www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf. Consistent 

with this proposal, we are also revising our regulations at §410.78(b) and §414.65(a)(1) to 

include alcohol and/or substance abuse structured assessment and intervention services and the 

preventive services as Medicare telehealth services. 

4. Technical Correction to Include Emergency Department Telehealth Consultations in 

Regulation 

In the CY 2012 PFS final rule with comment period (76 FR 73103), we finalized our 

proposal to change the code descriptors for initial inpatient telehealth consultation G-codes to 

reflect telehealth consultations furnished to emergency department patients in addition to 

inpatient telehealth consultations effective January 1, 2012. However, we did not amend the 

description of the services within the regulation at §414.65(a)(1)(i). Therefore, we proposed to 

make a technical revision to our regulation at §414.65(a)(1)(i) to reflect telehealth consultations 

furnished to emergency department patients in addition to hospital and SNF inpatients. 

We received no comments regarding our proposal to make this technical revision. 

Therefore, we are finalizing our proposal to make a technical revision to our regulation at 

§414.65(a)(1)(i) to reflect telehealth consultations furnished to emergency department patients in 

addition to hospital and SNF inpatients. 
216 

5. Telehealth Originating Site Facility Fee Payment Amount Update 

Section 1834(m)(2)(B) of the Act establishes the payment amount for the Medicare 

telehealth originating site facility fee for telehealth services provided from October 1, 2001, 

through December 31 2002, at $20. For telehealth services provided on or after January 1 of 

each subsequent calendar year, the telehealth originating site facility fee is increased by 

the percentage increase in the MEI as defined in section 1842(i)(3) of the Act. The MEI increase 

for 2013 is 0.8 percent. Therefore, for CY 2013, the payment amount for HCPCS code Q3014 

(Telehealth originating site facility fee) is 80 percent of the lesser of the actual charge or $24.43. 

The Medicare telehealth originating site facility fee and MEI increase by the applicable time 

period is shown in Table 18. 

TABLE 18: The Medicare Telehealth Originating Site Facility Fee and MEI Increase by 

the Applicable Time Period 

Facility Fee MEI 

Increase

Period

$20.00 N/A 10/01/2001 – 12/31/2002

$20.60 3.0% 01/01/2003 – 12/31/2003

$21.20 2.9% 01/01/2004 – 12/31/2004

$21.86 3.1% 01/01/2005 – 12/31/2005

$22.47 2.8% 01/01/2006 – 12/31/2006

$22.94 2.1% 01/01/2007 – 12/31/2007

$23.35 1.8% 01/01/2008 – 12/31/2008

$23.72 1.6% 01/01/2009 – 12/31/2009

$24.00 1.2% 01/01/2010 – 12/31/2010

$24.10 0.4% 01/01/2011 – 12/31/2011

$24.24 0.6% 01/01/2012 – 12/31/2012 

$24.43 0.8% 01/01/2013 – 12/31/2013 

F. Extension of Payment for Technical Component of Certain Physician Pathology Services

1. Background and Statutory Authority 

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and 

Protection Act of 2000 (BIPA) (Pub. L. 106–554) provided payment to independent laboratories 

furnishing the technical component (TC) of physician pathology services to fee-for-service 

Medicare beneficiaries who are inpatients or outpatients of a covered hospital for a 2-year period 
217 

beginning on January 1, 2000. This section was subsequently amended by section 732 of the 

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. 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), section 136 of the Medicare Improvements for Patients 

and Providers Act of 2008 (MIPPA) (Pub. L. 110–275), section 3104 of the Affordable Care Act 

(Pub. L. 111–148), section 105 of the Medicare and Medicaid Extenders Act of 2010 (MMEA) 

(Pub. L. 111–309), section 305 of the Temporary Payroll Tax Cut Continuation Act of 2011 

(Pub. L. 112-78) and section 3006 of the Middle Class Tax Relief and Job Creation Act of 2012 

(Pub. L. 112-96) to continue payment to independent laboratories furnishing the technical 

component (TC) of physician pathology services to fee-for-service Medicare beneficiaries who 

are inpatients or outpatients of a covered hospital for various time periods. As discussed in detail 

below, Congress most recently acted to continue this payment through June 30, 2012. The 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 or 

global 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 and 59409), we stated that this policy has contributed to the Medicare 
218 

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 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 of physician 

pathology services 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 PFS final rule with 

comment period (71 FR 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 
219 

MMSEA further extended such payment through the first 6 months of CY 2008. 

Section 136 of the MIPPA extended the payment through CY 2009. Section 3104 of the 

Affordable Care Act amended the prior legislation to extend the payment through CY 2010. 

Section 105 of the MMEA extended the payment through CY 2011. Subsequent to the 

publication of the CY 2012 PFS final rule with comment period, section 305 of the Temporary 

Payroll Tax Cut Continuation Act of 2011 extended the payment through February 29, 2012 and 

section 3006 of the Middle Class Tax Relief and Job Creation Act of 2012 extended the payment 

through June 30, 2012. t15>2010 16:57 Nov 25, 2011 700 E:\FR\FM\28NOR2.SGM 28NOR2 

2. Revisions to Payment for TC of Certain Physician Pathology Services

In the CY 2012 PFS final rule with comment period, we finalized our policy that an 

independent laboratory may not bill the Medicare contractor for the TC of physician pathology 

services furnished after December 31, 2011, to a hospital inpatient or outpatient (76 FR 73278 

through 73279, 73473). As discussed above, subsequent to publication of that final rule with 

comment period, Congress acted to continue payment to independent laboratories through June 

30, 2012. Therefore, the policy that we finalized in the CY 2012 PFS final rule with comment 

period was superseded by statute for 6 months. To be consistent with the statutory changes and 

our current policy, we proposed conforming changes to §415.130(d) such that we continued 

payment under the PFS to independent laboratories furnishing the TC of physician pathology 

services to fee-for-service Medicare beneficiaries who are inpatients or outpatients of a covered 

hospital on or before June 30, 2012 (77 FR 44763). Independent laboratories may not bill the 

Medicare contractor for the TC of physician pathology services furnished after June 30, 2012, to 

a hospital inpatient or outpatient. We received no public comments on the proposed conforming 

changes so we are finalizing the revisions to §415.130(d) without modification. 

G. Therapy Services

1. Outpatient Therapy Caps for CY 2013 
220 

Section 1833(g) of the Act applies annual, per beneficiary, limitations (therapy caps) on 

expenses considered incurred for outpatient therapy services under Medicare Part B. There is 

one therapy cap for outpatient occupational therapy (OT) services and another separate therapy 

cap for physical therapy (PT) and speech-language pathology (SLP) services combined. 

Although therapy services furnished in an outpatient hospital setting have been exempt from the 

application of the therapy caps, section 3005(b) of the MCTRJCA amended section 1833(g) of 

the Act to include therapy services furnished in an outpatient hospital setting in the therapy caps. 

This provision is in effect from October 1, 2012 through December 31, 2012. 

The therapy cap amounts are updated each year based on the Medicare Economic Index 

(MEI). The annual change in the therapy cap amount for CY 2013 is computed by multiplying 

the cap amount for CY 2012 by the MEI for CY 2013 and rounding to the nearest $10. This 

amount is added to the CY 2012 cap, which is $1,880, to obtain the CY 2013 cap amount. The 

MEI for CY 2013 is 0.8 percent, resulting in a therapy cap amount for CY 2013 of $1,900. 

 An exceptions process to the therapy caps has been in effect since January 1, 2006. Since 

originally authorized by section 5107 of the Deficit Reduction Act (DRA), which amended 

section 1833(g)(5) of the Act, the exceptions process for the therapy caps has been extended 

through subsequent legislation (MIEA-TRHCA, MMSEA, MIPPA, the Affordable Care Act, 

MMEA, and TPTCCA). Last amended by section 3005 of the MCTRJCA, the Agency’s 

authority to provide for an exception process to therapy caps expires on December 31, 2012. To 

request an exception to the therapy caps, therapy suppliers and providers use the KX modifier on 

claims for services after the beneficiary’s services for the year have exceeded the therapy cap. 

Use of the KX modifier indicates that the services are reasonable and necessary and that there is 

documentation of medical necessity in the beneficiary’s medical record. 

Section 3005 of the MCTRJCA also required two additional changes to Medicare policies for 

outpatient therapy services. Effective for services furnished from October 1 through December 
221 

31, 2012, after a beneficiary’s incurred expenses for PT and SLP services combined exceed the 

threshold of $3,700 during the calendar year, section 1833(g)(5)(C) of the Act, as amended by 

3005(a)(5) of the MCTRJCA, requires that we apply a manual medical review process as part 

of the therapy caps exceptions process. Similar to the therapy caps, there is a separate $3,700 

threshold for OT services. All requests for exceptions to the therapy caps for services after the 

$3,700 threshold is reached are subject to manual medical review. The manual medical review 

process is being phased in over a 3-month period. Unlike the therapy caps, exceptions are not 

automatically granted for therapy services above the $3,700 threshold based upon the therapist’s 

determination that they services are reasonable and necessary. To request an exception to the 

therapy caps for services after the threshold is reached, the provider sends a request for an 

exception to the Medicare contractor. The contractor then uses the coverage and payment 

requirements contained within Pub. 100-02, Medicare Benefit Policy Manual, section 220 and 

applicable medical review guidelines, and any relevant local coverage determinations to make 

decisions as to whether an exception is approved for the services. For more information on the 

manual medical review process, go to www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medical-Review/TherapyCap.html

2. Claims-Based Data Collection Strategy for Therapy Services 

a. Introduction 

Section 3005(g) of the MCTRJCA requires CMS to implement, beginning on January 1, 

2013, “. . . a claims-based data collection strategy that is designed to assist in reforming the 

Medicare payment system for outpatient therapy services subject to the limitations of section 

1833(g) of the Act. Such strategy shall be designed to provide for the collection of data on 

patient function during the course of therapy services in order to better understand patient 

condition and outcomes.” 

b. History/Background 
222 

In 2011, more than 8 million Medicare beneficiaries received outpatient therapy services, 

including physical therapy (PT), occupational therapy (OT), and speech-language-pathology 

(SLP). Medicare payments for these services exceeded $5.8 billion. Between 1998–2008, 

Medicare expenditures for outpatient therapy services increased at a rate of 10.1 percent per year 

while the number of Medicare beneficiaries receiving therapy services only increased by 2.9 

percent per year. Although a significant number of Medicare beneficiaries benefit from therapy 

services, the rapid growth in Medicare expenditures for these services has long been of concern 

to the Congress and the Agency. To address this concern, efforts have been focused on 

developing Medicare payment incentives that encourage delivery of reasonable and necessary 

care while discouraging overutilization of therapy services and the provision of medically 

unnecessary care. A brief review of these efforts is useful in understanding our policy for CY 

2013. 

(1) Therapy Caps 

 Section 4541 of the Balanced Budget Act of 1997 (Pub. L. 105-33) (BBA) amended 

section 1833(g) of the Act to impose financial limitations on outpatient therapy services (the 

“therapy caps” discussed above) in an attempt to limit Medicare expenditures for therapy 

services. Prior to the BBA amendment, these caps had applied to services furnished by 

therapists in private practice, but the BBA expanded the caps effective January 1, 1999, to 

include all outpatient therapy services except those furnished in hospital outpatient departments. 

Since that time, the Congress has amended the statute several times to impose a moratorium on 

the application of the caps or has required us to implement an exceptions process for the caps. 

The therapy caps have only been in effect without a moratorium or an exceptions process for less 

than 2 years. (See the discussion about the therapy cap exceptions process above.) Almost from 

the inception of the therapy caps, Congress and the Agency have been exploring potential 

alternatives to the therapy caps. 
223 

(2) Multiple Procedure Payment Reduction (MPPR) 

 In the CY 2011 PFS final rule with comment period (75 FR 73232-73242), we adopted a 

MPPR of 25 percent applicable to the practice expense (PE) component of the second and 

subsequent therapy services furnished to a beneficiary when more than one of these services is 

furnished in a single session. This reduction applies to nearly 40 therapy service codes. (For a 

list of therapy service codes to which this policy applies, see Addendum H.) The Physician 

Payment and Therapy Relief Act of 2010 (PPATRA) subsequently revised the reduction to 20 

percent for the second and subsequent therapy services furnished to a beneficiary in an office 

setting, leaving the 25 percent reduction in place for therapy services furnished to a beneficiary 

in institutional settings. We adopted this MPPR as part of our directive under section 

1848(c)(2)(K) of the statute, as added by section 3134(a) of the Affordable Care Act, to identify 

and evaluate potentially misvalued codes. By taking into consideration the expected efficiencies 

in direct PE resources that occur when services are furnished together, this policy results in more 

appropriate payment for therapy services. Although we did not adopt this MPPR policy 

specifically as an alternative to the therapy caps, paying more appropriately for combinations of 

therapy services that are commonly furnished in a single session reduces the number of 

beneficiaries impacted by the therapy caps in a given year. For more details on the MPPR 

policy, see section II.B.4. of this final rule with comment period. 

(3) Studies Performed 

The therapy cap is a uniform dollar amount that sets a limit on the total value of services 

furnished unrelated to the specific services furnished or the beneficiary’s condition or needs. A 

uniform cap does not deter unnecessary care or encourage efficient practice for low complexity 

beneficiaries. In fact, it may even encourage the provision of services up to the level of the cap. 

Conversely, a uniform cap without an exceptions process restricts necessary and appropriate care 

for certain high complexity beneficiaries. Recognizing these limitations in a uniform dollar 
224 

value cap, we have been studying therapy practice patterns and exploring ways to refine payment 

for these services as an alternative to therapy caps. 

On November 9, 2004, the Secretary delivered the Report to Congress, as required by the 

BBA as amended by the BBRA, “Medicare Financial Limitations on Outpatient Therapy 

Services.” This report included two utilization analyses. Although these analyses provided 

details on utilization, neither specifically identified ways to improve therapy payment. In the 

report, we indicated that further study was underway to assess alternatives to the therapy caps. 

The report and the analyses are available on the CMS website at 

www.cms.gov/TherapyServices/. 

Since 2004, we have periodically updated the utilization analyses and posted other 

reports on the CMS website. These reports highlighted the expected effects of limiting services 

in various ways and presented plans to collect data about beneficiary condition, including 

functional limitations, using available tools. Through these efforts, we have made progress in 

identifying the types of outpatient therapy services that are billed to Medicare, the demographics 

of the beneficiaries who utilize these services, the HCPCS codes used to bill the services, the 

allowed and paid amounts of the services, the providers of these services, the therapy utilization 

patterns among states in which the services are furnished, and the type of practitioner furnishing 

services. 

From these and other analyses in our ongoing research effort, we have concluded that 

without the ability to define the services that are typically needed to address specific clinical 

cohorts of beneficiaries (those with similar risk-adjusted conditions), it is not possible to develop 

payment policies that encourage the delivery of reasonable and necessary services while 

discouraging the provision of services that do not produce a clinical benefit. Although there is 

widespread agreement that beneficiary condition and functional limitations are critical to 

developing and evaluating an alternative payment system for therapy services, a system for 
225 

collecting such data uniformly does not exist. Currently diagnosis information is available from 

Medicare claims. However, we believe that the diagnosis on the claim is a poor predictor for the 

type and duration of therapy services required. Additional work is needed to develop an 

appropriate system for classifying clinical cohorts to determine therapy needs. 

A 5-year CMS project titled “Development of Outpatient Therapy Payment Alternatives” 

(DOTPA) is expected to provide some of this information. The purpose of the DOTPA project is 

to identify a set of measures that we could collect routinely and reliably to support the 

development of payment alternatives to the therapy caps. Specifically, the measures being 

collected are assessed for administrative feasibility and usefulness in identifying beneficiary 

need for outpatient therapy services and the outcomes of those services. The data collection 

processes have just been completed and a final DOTPA report is expected in late CY 2013. In 

addition to developing alternatives to the therapy caps, the DOTPA project reflects our interest in 

value-based purchasing by identifying components of value, namely, the beneficiary need and 

the effectiveness of therapy services. Although we expect DOTPA to provide meaningful data 

and practical information to assist in developing improved methods of paying for appropriate 

therapy services, it is unlikely that this one project alone will provide adequate information to 

implement a new payment system for therapy. This study combined with data from a wider 

group of Medicare beneficiaries would enhance our ability to develop alternative payment policy 

for outpatient therapy services. 

(c) System Description and Requirements 

(1) Overview 

Section 3005(g) of MCTRJCA requires CMS to implement a claims-based data 

collection strategy on January 1, 2013 to gather information on beneficiary function and 

condition, therapy services furnished, and outcomes achieved. This information will be used in 

assisting us in reforming the Medicare payment system for outpatient therapy services. By 
226 

collecting data on beneficiary function over an episode of therapy services, we hope to better 

understand the Medicare beneficiary population who uses therapy services, how their functional 

limitations change as a result of therapy services, and the relationship between beneficiary 

functional limitations and furnished therapy. 

The long-term goal is to develop an improved payment system for Medicare therapy 

services. The desired payment system would pay appropriately and similarly for efficient and 

effective services furnished to beneficiaries with similar conditions and functional limitations 

that have potential to benefit from the services furnished. Importantly, such a system would not 

encourage the furnishing of medically unnecessary or excessive services. At this time, the data 

on Medicare beneficiaries’ use and outcomes from therapy services from which to develop an 

improved system does not exist. This data collection effort is the first step towards collecting the 

data needed for this type of payment reform. Once the initial data have been collected and 

analyzed, we expect to identify gaps in information and determine what additional data would be 

needed to develop a new payment policy. Without a better understanding of the diversity of 

beneficiaries receiving therapy services and the variations in type and volume of treatments 

provided, we lack the information to develop a comprehensive strategy to map the way to an 

improved payment policy. While this claims-based data collection is only the first step in a longterm effort, it is an essential step. 

In the CY 2013 proposed rule, we proposed to implement section 3005(g) of MCTRJCA 

by requiring that claims for therapy services include nonpayable G-codes and modifiers. 

Through the use of these codes and modifiers, we proposed to capture data on the beneficiary’s 

functional limitations (a) at the outset of the therapy episode, (b) at specified points during 

treatment and (c) at discharge from the outpatient therapy episode of care. In addition, the 

therapist’s projected goal for functional status at the end of treatment would be reported on the 

first claim for services and periodically throughout an episode of care. 
227 

Specifically, as proposed, G-codes would be used to identify what type of functional 

limitation is being reported and whether the report is on the current status, projected goal status 

or discharge status. Modifiers would indicate the severity/complexity of the functional limitation 

being tracked. The difference between the reported functional status at the start of therapy and 

projected goal status represents any progress the therapist anticipates the beneficiary would make 

during the course of treatment/episode of care. We proposed that these reporting requirements 

would apply to all therapy claims, including those for services above the therapy caps and those 

that include the KX modifier (described above). 

By tracking any changes in functional limitations throughout the therapy episode of care 

and at discharge, we would have information about the therapy services furnished and the 

outcomes of such services. The ICD-9 diagnosis codes reported on the claim form would 

provide some information on the beneficiary’s condition. 

We proposed that these claims-based data collection requirements would apply to 

services furnished under the Medicare Part B outpatient therapy benefit and PT, OT, and SLP 

services under the Comprehensive Outpatient Rehabilitation Facilities (CORF) benefit. We also 

proposed to include therapy services furnished personally and “incident to” the services of 

physicians or nonphysician practitioners (NPPs). As we explained in the proposed rule, this 

broad applicability would include therapy services furnished in hospitals, critical access hospitals 

(CAHs), skilled nursing facilities (SNFs), CORFs, rehabilitation agencies, home health agencies 

(when the beneficiary is not under a home health plan of care), and in private offices of 

therapists, physicians and NPPs. 

When used in this section “therapists” means all practitioners who furnish outpatient 

therapy services, including physical therapists, occupational therapists, and speech-language 

pathologists in private practice and those therapists who furnish services in the institutional 

settings, physicians and NPPs (including, physician assistants (PAs), nurse practitioners (NPs), 
228 

clinical nurse specialists (CNSs), as applicable.) The term “functional limitation” generally 

encompasses both the terms “activity limitations” and “participation restrictions” as described by 

the International Classification of Functioning, Disability and Health (ICF). (For information on 

ICF, see www.who.int/classifications/icf/en/ and for specific ICF nomenclature (including 

activity limitations and participation restrictions), see 

http://apps.who.int/classifications/icfbrowser/.

The CY 2013 proposal was based upon an option for claims-based data collection that 

was developed as part of the Short Term Alternatives for Therapy Services (STATS) project 

under a contract with CMS, which provided three options for alternatives to the therapy caps that 

could be considered in the short-term before completion of the DOTPA project. In developing 

options, the STATS project drew upon the analytical expertise of CMS contractors and the 

clinical expertise of various outpatient therapy stakeholders to consider policies and available 

claims data. The options developed were: 

● Capturing additional clinical information regarding the severity and complexity of 

beneficiary functional impairments on therapy claims in order to facilitate medical review and at 

the same time gather data that would be useful in the long term to develop a better payment 

mechanism; 

● Introducing additional claims edits regarding medical necessity to reduce 

overutilization; and 

● Adopting a per-session bundled payment, the amount of which would vary based on 

beneficiary characteristics and the complexity of evaluation and treatment services furnished in a 

therapy session. 

Although we did not propose to adopt any of these alternatives at that time, we discussed 

and solicited public comments on all aspects of these options during the CY 2011 rulemaking. 

(See 75 FR 40096 through 40100 and 73284 through 73293.) In developing the CY 2013 
229 

claims-based data collection proposal, we used the feedback received from the CY 2011 

rulemaking. 

We noted in the proposal that the proposed claims-based data collection system using Gcodes and severity modifiers builds upon current Medicare requirements for therapy services. 

Section 410.61 requires that a therapy plan of care (POC) be established for every beneficiary 

receiving outpatient therapy services. This POC must include: the type, amount, frequency, and 

duration of services to be furnished to each beneficiary, the diagnosis and the anticipated goals. 

Section 410.105(c) contains similar requirements for services furnished in the CORF setting. 

We have long encouraged therapists, through our manual provisions, to express the POCrequired goals for each beneficiary in functional terms and require that goals be based on 

measureable assessments or objective data and relate to identified functional impairments. See 

Pub 100-02, Chapter 15, Section 220.1.2. We also noted that the evaluation and the goals 

developed as part of the POC would be the foundation for the initial reporting under the 

proposed system. 

The following is a summary of the comments we received regarding the general approach 

proposed in the CY 2013 PFS proposed rule to require nonpayable G-codes and modifiers on 

therapy claims to implement the new statutory requirement. 

Comment: Most commenters supported a new payment system for therapy services and 

recognized that data would be a critical factor in the development of such a system. Others 

recognized that the statute required CMS to implement a claims-based data collection system and 

therefore addressed comments to the specific elements rather than the overall requirement. 

Many commenters expressed concerns that the data we would be collecting under the proposed 

system would not provide adequate data for us to develop a new payment system. Many 

commenters also expressed concern that the system would not provide the means for therapists to 

adequately convey why some beneficiaries needed more treatment. Toward this end, 
230 

commenters suggested that we include a way to risk adjust the data or collect more beneficiary 

information. Some commenters suggested that we establish additional G-codes to report the 

beneficiary’s complexity, such as whether their condition is of low, moderate, or high 

complexity. These G-codes would represent the multiple variables that affect a beneficiary’s 

condition and response to therapy, such as age, comorbidities, prognosis, patient safety 

considerations, and current clinical presentation. One association indicated that it is working on 

an alternative payment system that will define and use three levels of complexity. Many 

commenters pointed out that the data we proposed to collect could only provide information on 

the progress an individual beneficiary made and was not valid for analyzing payment 

alternatives. 

Response: We agree with commenters that the data collected under this system will not 

alone provide all the information that CMS needs to develop, analyze and implement an 

alternative payment system. We agree with the commenters that factors such as the patient’s 

overall condition, including age, comorbidities, etc. are likely to affect the response to therapy; 

and we further agree that being able to analyze the data collected on such variables would 

enhance the usefulness of our data. Although we agree with the commenters’ that it could be 

beneficial to include additional data elements to reflect the patient’s condition and the 

complexity of the case, a meaningful system to use in classifying a beneficiary’s complexity 

does not currently exist. As experience is gained with this new system, we expect that through 

future notice and comment rulemaking we will be able to enhance the system. 

Comment: Many commenters commented on the administrative burden that therapists 

would incur if the proposed system was implemented. Some commented that the administrative 

burden would be particularly significant for physical therapists in private practice who often 

submit claims after each therapy visit. Commenters labeled the proposal “improper,” 

“unreasonable,” and “overly burdensome.” Other commenters indicated that the proposed 
231 

process would not be burdensome stating that the functional assessment tools they use were 

“perfectly suited to comply with CMS rule for data collection points, so we anticipate little or no 

burden in complying with the collection of function at intake, predicting discharge function at 

intake, during care and at discharge from care.” In addition to the many commenters who noted 

the additional work that would be required to comply with this system, one commenter suggested 

that we also add a billable G-code to pay therapists for the additional work that this proposal 

would require. 

Response: While we recognize that complying with these new reporting requirements 

will impose an additional burden on therapists, we believe that having available additional data 

on the therapy services furnished and the beneficiaries who receive them is critical to 

development of an alternative payment system for therapy services. Although we acknowledge 

that there would be work and some additional effort in complying with these reporting 

requirements, we believe that the additional burden is minimal. We designed our proposal to 

mesh closely with information that therapists already include in the medical record. The 

proposal would merely require that the information be translated into the new G-codes and 

modifiers, and included in additional lines on the same claims that would otherwise be 

submitted. We do not believe this reporting requirement would significantly increase the 

resources required to furnish therapy services. 

Comment: A couple of commenters suggested that we abandon our G-code/modifier 

proposal and use diagnosis codes in its place. One recognized that CMS’s assertion that 

diagnosis codes on the claims do not provide the data that we need was valid when only the 

principal diagnosis is used, but stated that if we relied upon principal and secondary diagnosis we 

could obtain the additional information regarding the patient’s clinical condition and functional 

limitations. The commenter provided the example of when hemiparesis was coded as the 

secondary diagnosis. Some suggested that when the ICD-10 system is implemented the 
232 

diagnosis codes would provide better information. 

Response: We continue to believe that diagnosis codes, even when secondary diagnoses 

are included, do not provide the information on functional limitations that the statute requires us 

to collect. In the example the commenter provided, use of the diagnosis code “hemiparesis,” 

would only tell us that the beneficiary needs therapy due to a paralysis or weakness on one side 

of his or her body caused by a stroke or other brain trauma, but not the extent of the beneficiary’s 

functional limitation. With regard to use of ICD-10, the statute requires us to implement a 

functional reporting system by January 1, 2013 so we cannot wait for ICD-10 system to 

implement the reporting requirements. 

Comment: One commenter requested to be exempted from these reporting requirements 

because the organization furnishes such a small amount of Part B outpatient therapy services. 

Another noted that “Given that this policy may affect HOPDs only for 3 months, CMS should 

consider ways to impose minimal administrative burden on HOPDs to implement this policy.” 

One commenter sought assurance that CAHs were included in this data collection effort. 

Response: As we indicated in the proposed rule, our goal is to have data on the complete 

range of therapy services for which payment is made based on the PFS for use in assessing and 

developing potential alternative payment systems for those services. This is important since any 

new payment system would likely apply to all those therapy services that are currently paid at 

rates under the PFS. To meet this goal, we proposed that the reporting requirements apply to all 

providers and suppliers of outpatient therapy services and CORFs. We note that the proposed 

policy would apply to hospital outpatient department services, even if such services are not 

subject to the therapy caps after December 31, 2012, and to services furnished in CAHs. We are 

finalizing without change the proposed policy to apply the reporting requirements to hospitals, 

SNFs, rehabilitation agencies, CORFs, home health agencies (when the beneficiary is not under a 

home health plan of care) and private offices. 
233 

Comment: Several commenters raised concerns about a new payment system based upon 

the data collected without a standardized tool, stating that such data would not provide reliable 

information on which to develop an alternative payment system. Additionally, some 

commenters believed the invalid data would be used to create a payment system based upon 

functional limitations. 

Response: At this time we are not making any changes in the existing payment 

methodology for therapy services, except that therapists will have to comply with the reporting 

requirements to receive payment for furnished therapy services. Therapists will continue to be 

paid in CY 2013 under the existing payment methodology, which includes the therapy caps. We 

will closely monitor and implement any enacted legislation that would amend the current 

statutory provisions, including any amendment to extend the therapy cap exceptions process. At 

this time we are broadly considering options for a revised payment system for therapy services 

and do not have any preconceived ideas as to what such a system would like or what it would be 

based upon. The purpose of the data collection proposal described in the CY 2013 PFS proposed 

rule is to meet the statutory requirement and begin to gather data that will be used, along with 

other data and information that we have, to develop and analyze potential alternative payment 

systems. It is likely that changes will be made in the data collected as we gain experience with 

this system. Therapists and others concerned with Medicare payment for therapy services should 

not draw conclusions about any future payment system for therapy services based upon the 

claims-based data that we proposed to collect. The claims-based data is only one set of 

information that will be used and it is only a beginning step in gathering the information that we 

would need to consider in developing a revised payment system for therapy services. 

Comment: Some commenters suggested that the “preamble language implies that 

improvement is a requirement for ongoing Medicare coverage.” One commenter suggested that 

the preamble language “implies that a measurable improvement in a beneficiary’s functional 
234 

limitation is required during an episode of therapy services.” Others expressed concern that 

some beneficiaries, such as those with spinal cord injuries, will be denied coverage because they 

improve too slowly. 

Response: We did not intend for the preamble language to raise concern about changing 

coverage conditions for beneficiaries who need therapy services. As noted above, the purpose of 

the claims-based data collection system is simply to gather data, and we did not propose, nor are 

we implementing, any changes to coverage or payment policy for therapy services other than to 

require that therapists comply with the reporting requirements to receive payment for therapy 

services they furnish. Under existing IOM requirements, therapists have to establish a long-term 

goal for beneficiaries receiving therapy. What is new under this system is that at the outset of 

treatment, the therapist will need to report on the claim the projected goal for treatment using 

modifiers that describe the percentage of impairment. For beneficiaries who are not expected to 

improve, such as those receiving maintenance therapy, the same modifier would be used for 

current status and for projected goal status. It is possible for some beneficiaries that while 

improvement is expected, it is expected to be limited, and thus it will also be reported using the 

same modifiers. To emphasize, the collection of these data elements will not affect a 

beneficiary’s coverage of therapy services. 

Comment: Some commenters expressed concerns about how this proposal would affect 

individuals suffering from lymphedema. Commenters stated that some clients experience both 

pain and swelling while others seem to have only swelling of a limb. Successful management of 

a beneficiary with lymphedema involves bandaging, compression and skin care instruction, 

manual lymph drainage, decongestive therapy, manual lymph drainage instruction, and exercise. 

These services take lots of valuable practitioner time to perform correctly as does instructing 

caregivers. While lymphedema impacts function to a point of mild to severe disability, many 

commenters told us that lymphedema severity/complexity is very difficult to quantify and show 
235 

significant functional improvements in the lymphatic system when many of these improvements 

are in skin integrity, cellular health and lymphatic flow. Other commenters stated that the 

patient’s functional limitations due to lymphedema (restricted motion and/or mobility) can range 

from profound to minimal. But all lymphedema patients, including those proficient in self-care 

who have minimal functional limitations, are at great risk for developing cellulitis or other major 

medical complications from sustained tissue congestion of the lymphatic system. With ongoing 

or periodic management, as appropriate, therapy services can successfully prevent these medical 

crises. Many commenters expressed concern that coverage for therapy services relating to 

lymphedema would be denied as a result of this proposal. Others questioned which functional 

limitation to use for lymphedema patients. 

Response: As noted earlier, we did not propose to change coverage policy or to use the 

claims-based data reporting system to determine which beneficiaries are entitled to therapy 

services. Instead, our proposal would require those furnishing care to provide certain 

information about the beneficiary and his or her expected response to therapy. We are reiterating 

in this final rule with comment period that the proposed claims-based data collection system 

makes no changes in our therapy coverage policies. 

With regard to how those treating beneficiaries should comply with the data collection 

system, we expect therapists to report the G-code for the functional limitation that most closely 

relates to the functional limitation being treated. As a result of comments on the proposed rule, 

we are clarifying in this final rule with comment period that if the therapy services being 

furnished are not intended to treat a functional limitation, the therapist should use the G-code for 

“other” and the modifier representing zero. 

Comment: Several commenters suggested that significant education will be required for 

therapists to comply with this required reporting. 

Response: We are publishing in this final rule with comment period the claims-based 
236 

reporting requirements that must be met in order to receive payment for therapy services. We 

will also use our usual methods for providing additional information, including revising relevant 

sections of the IOM, publishing Medicare Learning Network (MLN) Matters articles; 

presentations on Open Door Forums, and conducting National Provider Calls on the new 

requirements. We urge therapist to use these tools to assure that they have the information they 

need to comply with these new requirements. 

(2) Nonpayable G-Codes on Beneficiary Functional Status 

We proposed that therapists would report G-codes and modifiers on Medicare claims for 

outpatient therapy services. We discussed and sought comment on two types of G-codes in the 

proposed rule – generic and categorical. Table 19 shows the proposed generic G-codes and 

Table 20 shows the categorical codes discussed in the proposed rule. 

TABLE 19: Proposed Nonpayable G-Codes for Reporting Functional Limitations. 

Functional limitation for primary functional limitation 

Primary Functional limitation, Current status at initial 

treatment/episode outset and at reporting intervals 

GXXX1 

Primary Functional limitation, Projected goal status GXXX2 

Primary Functional limitation, Status at therapy discharge or end of 

reporting 

GXXX3 

Functional limitation for a secondary functional limitation if one exists 

Secondary Functional limitation, Current status at initial 

treatment/outset of therapy 

and at reporting intervals 

GXXX4 

Secondary Functional limitation, Projected goal status GXXX5 

Secondary Functional limitation, Status at therapy discharge or end of 

reporting 

GXXX6 

Provider attestation that functional reporting not required 

Provider confirms functional reporting not required GXXX7 

The proposed G-codes differ from the three separate pairs of G-codes discussed in the 

CY 2011 PFS rulemaking. The CY 2011 discussion included these three pairs of G-codes, all of 

which reflect specific ICF terminology: 

● Impairments of Body Functions and/or Impairments of Body Structures; 
237 

● Activity Limitations and Participation Restrictions; and 

● Environmental Factors Barriers. 

Each pair contained a G-code to represent the beneficiary’s current functional status and another 

G-code to represent the beneficiary’s projected goal status. Each claim would have required all 

three sets of G-codes. Like the G-codes we proposed for CY 2013, the G-codes discussed in the 

CY 2011 PFS rulemaking would have been used with modifiers to reflect the 

severity/complexity of each element. 

In the CY 2013 PFS proposed rule, we indicated that we were not proposing to use these 

specific G-codes because we found them to be potentially redundant and confusing. Instead we 

chose to use G-codes to define “functional limitations” synonymously with the ICF terminology 

“activity limitations and participation restrictions.” We noted that requiring separate reporting 

on three elements would have imposed a greater burden on therapists without providing a 

meaningful benefit in the value of the data provided. We added that because environmental 

barriers as discussed in CY 2011 are contextual, we did not believe collecting information on 

them would contribute to developing an improved payment system. 

To create the select categories of G-codes discussed in the proposed rule (See Table 20) 

we used the two most frequently reported functional limitations in the DOTPA project by each of 

the three therapy disciplines. We noted that should we decide to use a system with categoryspecific reporting, we would expect to develop specific nonpayable G-codes for select categories 

of functional limitations in the final rule. We explained that if one of the select categories of 

functional limitations describes the functional limitation being reported, that G-code set would 

be used to report the current, projected goal, and discharge status of the beneficiary. When 

reporting a functional limitation not described by one of categorical G-codes, one of the generic 

G-codes previously described would be used. 

TABLE 20: Select Categories of G-Codes Discussed in Proposed Rule 
238 

Walking & Moving Around 

Walking & moving around functional limitation, current status at time of initial 

therapy treatment/episode outset and reporting intervals 

GXXX8 

Walking & moving around functional limitation, projected goal status, at initial 

therapy treatment/outset and at discharge from therapy 

GXXX9 

Walking & moving around functional limitation, discharge status, at discharge 

from therapy/end of reporting on limitation 

GXX10 

Changing & Maintaining Body Position 

Changing & maintaining body position functional limitation, current status at 

time of initial therapy treatment/episode outset and reporting intervals 

GXX11 

Changing & maintaining body position functional limitation, projected goal 

status at initial therapy treatment/outset and at discharge from therapy 

GXX12 

Changing & maintaining body position functional limitation, discharge status 

at discharge from therapy/end of reporting on limitation 

GXX13 

Carrying, Moving & Handling Objects 

Carrying, moving & handling objects functional limitation, current status at 

time of initial therapy treatment/episode outset and reporting intervals 

GXX14 

Carrying, moving & handling objects functional limitation, projected goal 

status at initial therapy treatment/outset and at discharge from therapy 

GXX15 

Carrying, moving & handling objects functional limitation, discharge status at 

discharge from therapy/end of reporting on limitation 

GXX16 

Self Care (washing oneself, toileting, dressing, eating, drinking) 

Self care functional limitation, current status at time of initial therapy 

treatment/episode outset and reporting intervals 

GXX17 

Self care functional limitation, projected goal status at initial therapy 

treatment/outset and at discharge from therapy 

GXX18 

Self care functional limitation, discharge status at discharge from therapy/end 

of reporting on limitation 

GXX19 

Communication: Reception (spoken, nonverbal, sign language, written) 

Communication: Reception functional limitation, current status at time of 

initial therapy treatment/episode outset and reporting intervals 

GXX20 

Communication: Reception functional limitation, projected goal status at initial 

therapy treatment/outset and at discharge from therapy 

GXX21 

Communication: Reception functional limitation, discharge status at discharge 

from therapy/end of reporting on limitation 

GXX22 

Communication: Expression (speaking, nonverbal, sign language, writing) 

Communication: Expression functional limitation, current status at time of 

initial therapy treatment/episode outset and reporting intervals 

GXX23 

Communication: Expression functional limitation, projected goal status at 

initial therapy treatment/outset and at discharge from therapy 

GXX24 

Communication: Expression functional limitation, discharge status at 

discharge from therapy/end of reporting on limitation 

GXX25 

We sought input from therapists on categories of functional limitations, such as those 

described in this section. We specifically requested comments regarding the following questions: 
239 

Would data collected on categories of functional limitations provide more meaningful data on 

therapy services than that collected through use of the generic G-codes in our proposal? Should 

we choose to implement a system that is based on at least some select categories of functional 

limitation, which functional limitations should we collect data on in 2013? Is it more, less or the 

same burden to report on categories of functional limitations or generic ones? The categories of 

functional limitations described above are based on the ICF categories, but these ICF categories 

also have subcategories. Should we use subcategories for reporting? Are there specific 

conditions not covered by these ICF categories? Would we need to have G-codes for the same 

categories of secondary limitations? We sought public comment on whether these proposed Gcodes allow adequate reporting on beneficiary’s functional limitations. We also noted that we 

would particularly appreciate receiving specific suggestions for any missing elements. 

The following is a summary of the comments we received on the G-codes, generic and 

categorical, whether these proposed G-codes allow adequate reporting on beneficiary’s 

functional limitations, and specific suggestions for any missing elements. 

Comment: Two commenters disagreed with our proposal to develop new G-codes and 

instead encouraged us to use the three pairs of G-codes (activities and participation restrictions, 

impairments to body functions/structures and environmental barriers) from the STATs project to 

report functional limitations. These commenters agreed that adding these domains might be 

more burdensome, but one commenter suggested that without these data elements we would 

likely miss integral beneficiary data in relation to health and wellness benefits, such as increased 

muscle function, improved quality of life, decreased depression, improved bowel/bladder 

function, improved respiratory function, improved autonomic function and improved circulation. 

Another commenter specifically agreed with our decision to use only the one ICF-defined Gcode from the STATS for activity impairments and participation restrictions. They noted that it 

would be potentially redundant and confusing to adopt the two additional G-codes for body 
240 

functions/structures and environmental barriers and noted that these other two categories would 

“provide the agency with little meaningful data.” One commenter suggested that if we adopted 

this additional reporting we could minimize the additional burden by eliminating goal reporting. 

Response: We appreciate the views of these commenters about which ICF categories to 

capture in our G-code data collection. We continue to believe that the reporting of functional 

limitations will be less confusing and more defined with the G-codes as described in our 

proposal for activity impairments/participation restrictions. As we move forward with functional 

reporting in following years, we may revisit the addition of other categories. 

Comment: Commenters had divergent views on the categorical and generic G-codes. 

Many found the proposed system complicated, burdensome and stated that it would not provide 

the data we sought. Some criticized the categorical codes as being too broadly defined and 

stated that this will lead to confusion as to what areas of impairment are being reported. For 

example, one commenter stated, “The suggested categories are very broad and, in our view, will 

lead to confusion regarding which areas of impairment would be reported for certain therapy 

activities.” One commenter opposed the use of generic G-codes saying that data from these 

codes would be “useless.” On the other hand, we received much support for the proposed Gcodes. Many commenters supported the use of categorical G-codes codes saying their use will 

provide more useful information than the generic ones. One commenter stated, “We believe 

having therapists report on these categories will provide CMS with more useful information than 

generic reporting on a functional limitation.” Many favored use of the categorical G-codes in 

addition to using “generic” or “other” codes only for functional limitations that did not fit in one 

of the categorical ones. Several commenters gave us specific guidance, recommending that 

instead of the generic G-codes, we add an “other” G-code to the categorical codes for functional 

limitations that don’t fit into one of the defined categories. 

Response: Based upon the comments we received suggesting that we use the categorical 
241 

codes, but include an “other” category to use when one of the categorical codes does not apply, 

we are modifying our proposal to adopt categorical G-codes to define functional limitations and 

including within the categorical G-codes “other” G-codes to use when one of the more specific 

categorical codes does not apply. In addition to this change, as discussed below, we are 

replacing the two SLP categorical codes with eight new ones to better reflect the diversity of 

services furnished. Table 21 provides a complete list of the codes that will be available for 

reporting functional limitations. With regard to the commenters’ concern that the categories are 

too broad and this will lead to confusion as to what is being reported, we acknowledge that the 

categories are broad, but disagree that the use of broad categories will result in confusion. 

Instead, we believe that the result will be the collection of data that includes information on 

broadly defined functional limitations. Without more specific input and greater support from the 

commenters, we do not believe we should create these in this final rule with comment period. 

Moreover, we believe it is important to gain experience with a limited number of codes in this 

new reporting system before we vastly expand the number of codes that are used. We sought 

comment on ways to better define the categories and where we received specific suggestions for 

additional G-codes that were sufficiently developed, such as those for SLP (explained below), 

we included them in our final set of G-codes. We anticipate that we will continue to refine the 

categories through future notice and comment rulemaking as we get more information and 

experience with this system. 

Comment: Several commenters pointed out that there were many functional limitations 

for which there was not a categorical G-code. The American Speech-Language and Hearing 

Association pointed out the lack of appropriate SLP categories and suggested that we take 

advantage of the experience that has been gained through the use of its system for collecting data 

on functional limitations in this area. Specifically, they urged us to assign G-codes to the top 

seven reported functional communication measures used in National Outcomes Measurement 
242 

System (NOMS). This commenter stated that, using this system, we would be able to collect 

“consistent” and “meaningful” ratings across all settings nationally. 

Others told us that there were many conditions and situations that our system did not 

address and that some of these beneficiaries did not exhibit functional limitations that could be 

easily measured or reported. They cited, as examples, beneficiaries seen for lymphedema 

management, wound care, wheelchair assessment/fitting, cognitive impairments, and 

incontinence training. 

Response: We agree with commenters that the G-codes discussed in the proposed rule 

did not go far enough in addressing SLP functional limitations. After consideration of the 

comments, we also agree that adoption of the most frequently used NOMS measures would be 

the best way to address this issue and would significantly improve our system in several ways. 

By using a system familiar to many speech-language pathologists, the quality of our data 

collection will be enhanced and the burden on those reporting will be less. We agree that it is 

reasonable to incorporate categories that are more specific, when appropriate, and note that this 

is an opportunity to align with existing measurement systems. 

Accordingly, we are replacing the two of the categorical codes relating to SLP with seven 

categorical codes and one “other” code for SLP. (See Table 21.) The seven categorical codes 

mirror the seven most frequently reported NOMS categories and should be used when 

appropriate. For all other SLP treatments, the “SLP Other” category should be used. 

For functional limitations not defined by the specific categorical codes and for therapy 

services that are not addressing a particular functional limitation; the “other” G-codes should be 

used. As we begin collecting data in this initial year, we will continue to assess the need for 

additional G-codes, refinement of existing ones, and examine ways to address those situations 

for which beneficiaries do not have functional limitations. 

 We have addressed in this final rule with comment period those areas for which we have 
243 

adequate information to do so at this time and for which an additional burden will not be created. 

We will continue to refine this system through further notice and comment rulemaking in future 

years. 

 Comment: We received mixed feedback in response to our request for comment 

regarding the use of the ICF subcategories. Some commenters noted that adding more 

subcategories would result in too many codes and only add to the confusion. At least one other 

commenter supported subcategory reporting, but did not suggest which subcategories we should 

use. 

 Response: Given the comments received, we will not be implementing reporting by 

subcategories at this time. Once the system is operational, we will reassess whether subcategory 

reporting is necessary to provide the data that we need. 

Comment: Some commenters interpreted our proposal to limit each therapy discipline to 

using only the two codes that represented the top two reported functional limitations for that 

discipline and suggested that we allow therapists to use any appropriate functional limitation. 

Response: We agree with commenters that therapists should be able to use any 

appropriate functional limitation. In the proposed rule, we indicated that we developed the 6 

categorical codes to correspond with the two most commonly reported functional limitations for 

each of the three therapy disciplines. However, this was only a way of identifying the functional 

limitations for which we needed codes. To be clear, therapists are to use the most appropriate 

categorical G-code that describes the functional limitation that is the primary reason for 

treatment without restriction by discipline. 

Comment: A few commenters urged us to clarify that therapists using Patient Inquiry by 

Focus on Therapeutic Outcomes, Inc (FOTO), or another measurement system that provides a 

composite functional status score, did not need to report on secondary limitations. 

Response: In assessing this comment, we recognized the need to clarify how composite 
244 

functional scores should be reported. We are clarifying that a composite score should be 

reported using G8990 (Other physical or occupational primary functional limitation, current 

status, at therapy episode outset and at reporting intervals), G8991(Other physical or 

occupational primary functional limitation, projected goal status, at therapy episode outset, at 

reporting intervals, and at discharge or to end reporting) and G8992 (Other physical or 

occupational primary functional limitation, discharge status, at discharge from therapy or to end 

reporting). Should there be the occasion to report on a second condition after the reporting on 

the first had ended, the therapist would use the G-code set for “other subsequent” functional 

limitation, G8993 - G8896. 

(3) Number of Functional Limitations On Which Reporting Occurs

We proposed that, using a set of G-codes with appropriate modifiers, the therapist would 

report the beneficiary’s primary functional limitation defined as the most clinically relevant 

functional limitation at the time of the initial therapy evaluation and the establishment of the 

POC. The projected goal would also be reported at this time. At specified intervals during 

treatment, claims would also include the current functional status and the goal functional status, 

which would not typically change during therapy, except as described below. On the final claim 

for an episode of care, the therapist would report the status at this time for this functional 

limitation and the goal status.. 

Early results from the DOTPA project suggest that most beneficiaries have more than one 

functional limitation at treatment outset. In fact, only 21 percent of the DOTPA assessments 

reported just one functional limitation. Slightly more than half (54 percent) reported two, three 

or four functional limitations. 

To the extent that the DOTPA finding is typical, the therapist may need to make a 

determination as to which functional limitation is primary for reporting purposes. In cases where 

this is unclear, the therapist may choose the functional limitation that is most clinically relevant 
245 

to a successful outcome for the beneficiary, the one that would yield the quickest and/or greatest 

mobility, or the one that is the greatest priority for the beneficiary. In all cases, this primary 

functional limitation should reflect the predominant limitation that the furnished therapy services 

are intended to address. 

We sought comment on specific issues regarding reporting data on a secondary 

limitation. Specifically, we requested comments regarding whether reporting on secondary 

functional limitations should be required or optional. 

The following is a summary of the comments we received on the percentage of Medicare 

therapy beneficiaries with more than one functional limitation at the outset of therapy and 

whether reporting on secondary functional limitations should be required or optional. 

Comment: The responses on the number of functional limitations being treated showed a 

wide variation. One commenter treating beneficiaries with spinal cord injuries indicated that 100 

percent had more than one functional limitation, with an average of 10 functional limitations. 

Another respondent told us that 50 percent of SLP patients have two or more functional 

limitations. Another respondent indicated that nearly 98 percent of patients seen by therapists 

using FOTO were surveyed for only one condition. Most commenters recommended that 

therapists be required to report only one functional limitation, especially as we are just beginning 

to require functional reporting. The commenters stated that it would be burdensome and would 

pose clinical challenges to require reporting both a primary and secondary functional limitation. 

Others suggested that it would be costly, time intensive and burdensome to report numerous 

secondary functional limitations. Some stated that reporting on only one functional limitation 

would not capture sufficient information since treatment of multiple functional limitations is 

interrelated and treatment for these occurs simultaneously, not sequentially. Some commenters 

suggested allowing the optional reporting of a second or third functional limitation. Some 

commenters questioned how functional reporting would be handled when the beneficiary was 
246 

being treated by more than one discipline or when a substitute therapist treats a beneficiary. 

Response: In response to comments, we have decided to limit reporting to one functional 

limitation at this time. Recognizing that therapists treat the patient as a whole and work on more 

than one functional limitation at a time, we believe that limiting reporting in this way will make 

it less burdensome in the situations involving more than one functional limitation. Although 

many commenters favored the option of reporting on additional functional limitations when 

appropriate, we believe that allowing additional optional reporting would not produce consistent 

or useful data on beneficiaries who have more than one functional limitation that is being treated, 

and could potentially complicate the use of the data we collect for the development of future 

therapy payment policy. As we seek to improve reporting in future years, we may reconsider 

whether to permit or require reporting on additional functional limitations. We note that this is a 

new reporting system designed to gather data on the changes in beneficiary function throughout 

an episode of care. We are not expecting therapists to change the way they treat patients because 

of our reporting requirements. 

We also explained that in situations where treatment continues after the treatment goal is 

achieved and reporting ended on the primary functional limitation, reporting will be required for 

another functional limitation. Thus, reporting on more than one functional limitation may be 

required for some patients, but not simultaneously. Instead, once reporting on the primary 

functional limitation is complete, the therapist will begin reporting on a subsequent functional 

limitation using another set of G-codes. If this additional functional limitation is not described 

by one of the specific categorical codes, one of the three “other” codes should be used depending 

on the circumstances. 

 In response to the comments, we are making several modifications in the G-codes that 

we proposed, as noted in the responses to comments above. To summarize, the G-codes, and 

their long descriptors, that will be used for reporting functional limitations of beneficiaries are 
247 

listed in Table 21. There are 11 G-codes that describe categorical functional limitation, 

including seven for SLP services, and three more general G-codes for functional limitations that 

do not fit within one of the 11 categories. The general categorical codes would be used when 

none of the specific categories apply or when an assessment tool is used that yields a composite 

score that combines several or many functional measures, such as is done with the FOTO Patient 

Inquiry tool, for example. Two of these general G-code sets are to be used for “other” PT and 

OT services and one for “other” SLP services. In addition, we deleted the requirement to report 

a G-code to signal that no reporting was required and thus deleted the G-code that would have 

been used for this. (For discussion about the comments on this G-code and our decision to 

remove this reporting requirement, see section II.F.2.(b).(6).) Therapists would use the code that 

best describes the functional limitation that is primary to the therapy plan of care. 

TABLE 21: G-Codes for Claims-Based Functional Reporting for CY 2013 

Mobility: Walking & Moving Around 

G8978 Mobility: walking & moving around functional limitation, current status, at 

therapy episode outset and at reporting intervals 

G8979 Mobility: walking & moving around functional limitation, projected goal status, 

at therapy episode outset, at reporting intervals, and at discharge or to end 

reporting 

G8980 Mobility: walking & moving around functional limitation, discharge status, at 

discharge from therapy or to end reporting 

Changing & Maintaining Body Position 

G8981 Changing & maintaining body position functional limitation, current status, at 

therapy episode outset and at reporting intervals 

G8982 Changing & maintaining body position functional limitation, projected goal 

status, at therapy episode outset, at reporting intervals, and at discharge or to end 

reporting 

G8983 Changing & maintaining body position functional limitation, discharge status, at 

discharge from therapy or to end reporting 

Carrying, Moving & Handling Objects 

G8984 Carrying, moving & handling objects functional limitation, current status, at 

therapy episode outset and at reporting intervals 

G8985 Carrying, moving & handling objects functional limitation, projected goal status, 

at therapy episode outset, at reporting intervals, and at discharge or to end 

reporting 

G8986 Carrying, moving & handling objects functional limitation, discharge status, at 

discharge from therapy or to end reporting 

Self Care 
248 

G8987 Self care functional limitation, current status, at therapy episode outset and at 

reporting intervals 

G8988 Self care functional limitation, projected goal status, at therapy episode outset, at 

reporting intervals, and at discharge or to end reporting 

G8989 Self care functional limitation, discharge status, at discharge from therapy or to 

end reporting 

Other PT/OT Primary Functional Limitation 

G8990 Other physical or occupational primary functional limitation, current status, at 

therapy episode outset and at reporting intervals 

G8991 Other physical or occupational primary functional limitation, projected goal 

status, at therapy episode outset, at reporting intervals, and at discharge or to end 

reporting 

G8992 Other physical or occupational primary functional limitation, discharge status, at 

discharge from therapy or to end reporting 

Other PT/ OT Subsequent Functional Limitation 

G8993 Other physical or occupational subsequent functional limitation, current status, at 

therapy episode outset and at reporting intervals 

G8994 Other physical or occupational subsequent functional limitation, projected goal 

status, at therapy episode outset, at reporting intervals, and at discharge or to end 

reporting 

G8995 Other physical or occupational subsequent functional limitation, discharge status, 

at discharge from therapy or to end reporting 

Swallowing 

G8996 Swallowing functional limitation, current status at time of initial therapy 

treatment/episode outset and reporting intervals 

G8997 Swallowing functional limitation, projected goal status, at initial therapy 

treatment/outset and at discharge from therapy 

G8998 Swallowing functional limitation, discharge status, at discharge from therapy/end 

of reporting on limitation 

Motor Speech 

G8999 Motor speech functional limitation, current status at time of initial therapy 

treatment/episode outset and reporting intervals 

G9157 Motor speech functional limitation, projected goal status at initial therapy 

treatment/outset and at discharge from therapy 

G9158 Motor speech functional limitation, discharge status at discharge from 

therapy/end of reporting on limitation 

Spoken Language Comprehension 

G9159 Spoken language comprehension functional limitation, current status at time of 

initial therapy treatment/episode outset and reporting intervals 

G9160 Spoken language comprehension functional limitation, projected goal status at 

initial therapy treatment/outset and at discharge from therapy 

G9161 Spoken language comprehension functional limitation, discharge status at 

discharge from therapy/end of reporting on limitation 

Spoken Language Expression 

G9162 Spoken language expression functional limitation, current status at time of initial 

therapy treatment/episode outset and reporting intervals 

G9163 Spoken language expression functional limitation, projected goal status at initial 

therapy treatment/outset and at discharge from therapy 
249 

G9164 Spoken language expression functional limitation, discharge status at discharge 

from therapy/end of reporting on limitation 

Attention 

G9165 Attention functional limitation, current status at time of initial therapy 

treatment/episode outset and reporting intervals 

G9166 Attention functional limitation, projected goal status at initial therapy 

treatment/outset and at discharge from therapy 

G9167 Attention functional limitation, discharge status at discharge from therapy/end of 

reporting on limitation 

Memory 

G9168 Memory functional limitation, current status at time of initial therapy 

treatment/episode outset and reporting intervals 

G9169 Memory functional limitation, projected goal status at initial therapy 

treatment/outset and at discharge from therapy 

G9170 Memory functional limitation, discharge status at discharge from therapy/end of 

reporting on limitation 

Voice 

G9171 Voice functional limitation, current status at time of initial therapy 

treatment/episode outset and reporting intervals 

G9172 Voice functional limitation, projected goal status at initial therapy 

treatment/outset and at discharge from therapy 

G9173 Voice functional limitation, discharge status at discharge from therapy/end of 

reporting on limitation 

Other SLP Functional Limitation 

G9174 Other speech language pathology functional limitation, current status at time of 

initial therapy treatment/episode outset and reporting intervals 

G9175 Other speech language pathology functional limitation, projected goal status at 

initial therapy treatment/outset and at discharge from therapy 

G9176 Other speech language pathology functional limitation, discharge status at 

discharge from therapy/end of reporting on limitation 

(4) Severity/Complexity Modifiers 

We proposed that for each functional G-code used on a claim, a modifier would be 

required to report the severity/complexity for that functional limitation. We proposed to adopt a 

12-point scale to report the severity or complexity of the functional limitation involved. The 

proposed modifiers are listed in Table 22. 

TABLE 22: Proposed Modifiers 

Modifier Impairment 

Limitation 

Restriction 

Difficulty 
250 

Modifier Impairment 

Limitation 

Restriction 

Difficulty 

XA 0% 

XB Between 1-9% 

XC Between 10 - 19% 

XD Between 20 - 29% 

XE Between 30 - 39% 

XF Between 40 - 49% 

XG Between 50 - 59% 

XH Between 60 - 69% 

XI Between 70 - 79% 

XJ Between 80 - 89% 

XK Between 90 - 99% 

XL 100% 

We noted that there are many valid and reliable measurement and assessment tools that 

therapists use to inform their clinical decision-making and to quantify functional limitations, 

including the four assessment tools we discussed in CY 2011 PFS rulemaking that produce 

functional scores – namely, the Activity Measure – Post Acute Care (AM-PAC) tool, the FOTO 

Patient Inquiry, OPTIMAL, and NOMS. We list these four tools as recommended for use by 

therapists, though not required, in the outpatient therapy IOM provision of the Benefits Policy 

Manual, Chapter 15, Section 220.3C “Documentation Requirements for Therapy Services.” We 

suggested that the scores from these and other measurement tools already in use by therapists 

that produce numerical or percentage scores be mapped or crosswalked to the proposed 12-point 

severity modifier scale. 

 In assessing the ability of therapists to provide the required severity information 

regardless of what assessment tool or combination of tools they use, if any, we considered the 

comments received on the CY 2011 PFS proposed rule discussion. These indicated that we 

needed greater granularity in our severity scale so that the changes in functional limitation over 

the course of therapy could be more accurately reflected. Specifically, most commenters on the 
251 

CY 2011 proposed rule favored the 7-point scale over the 5-point ICF-based scale. They 

indicated that they preferred a scale with more severity levels and equal increments since it 

would allow the therapist to document smaller changes that many therapy beneficiaries make 

towards their goals. 

 Believing that neither the 5- or 7-point scales would be adequate for this reporting 

system, we developed and proposed a 12-point scale that we believed was an enhancement over 

the 7-point scale. We thought it addressed concerns that those commenting on the CY 2011 

options had raised regarding the 7-point scale. We thought that a more sensitive rating scale 

(one with more increments) had the advantage of demonstrating the progress of beneficiaries 

with conditions that improve slowly, such as those recovering from strokes or with spinal cord 

injuries. In addition, we believed that the proposed scale’s 10-percentage point increments 

would make it easier for therapists to convert composite and overall scores from assessment 

instruments or other measurement tools to this scale. 

The following is a summary of the comments we received regarding our proposal for a 

12-point scale to capture the severity/complexity of beneficiaries’ functional limitations. 

Comment: Several commenters stated that not all tests and measurement tools that 

therapists use could be easily crosswalked to any single numerical scale, stating that, for 

example, some tests and measures of functional limitations use ordinal scales. Further, the 

scores from some tests that are not linear or proportional to each other are not easily translatable 

to the 12-point scale. Some commenters pointed out the problems of developing a single score 

when more than one tool is used. Some commenters noted that there are a wide variety of 

therapy measurement tools that are used to inform clinical decision making and these are not 

measures that typically produce a functional assessment. Further, these commenters told us that 

combining the results of multiple measures make it extremely difficult to quantify beneficiary 

function and, as such, said it will be very difficult to crosswalk this type of information to a 
252 

severity scale. And, many of these commenters expressed concerns about how therapist will 

implement the use of our severity/complexity modifier scale; they noted that much education is 

needed for therapists to understand the selection of a severity modifier. One commenter 

questioned whether aggregated subjective and objective data would be valid or usable by CMS. 

Response: It is essential that the data reported on functional limitations be grouped using 

the same numeric scale. Moreover, we believe that is easier for those reporting data on 

functional limitations to use ranges of percentages rather than the absolute values. We 

acknowledge that therapists will incur some challenges when initially adopting our system as 

they learn how to translate the information obtained through various tests and measures to a 

particular modifier scale. However, as therapists gain experience in doing so, we anticipate that 

these translations will become easier and a normal part of their evaluative and treatment 

processes. Moreover, we are hopeful that forthcoming modifications from tool sponsors or 

others will make it easier for therapists to report the functional limitations measured by these 

tools, such as modifying the tool so the results match the Medicare severity/complexity scale or 

issuing instructions or guidance on translating the results to the Medicare severity/complexity 

scale. We also expect that some translation tools are likely to become available. We are hopeful 

that forthcoming guidance and translation tools from tool sponsors and others will clarify some 

of translation questions therapists have regarding the Medicare severity scale. Given that it is 

essential for our purposes to have a severity/complexity scale, we are adopting one in this final 

rule. With regard to education, CMS will make information about the severity/complexity scale, 

as well as other aspects of our new system, widely available to therapists. It will be incumbent 

upon individual therapists to learn how to translate the score from a singular assessment tool or 

the combined results from multiple tests/measures along with other information regarding their 

patient’s functional limitation to the Medicare scale. Finally, we acknowledge that a system that 

combines objective and subjective data is not ideal. However, at this time it appears that there is 
253 

not an alternative. We will continue to refine and improve this system. 

Comment: Some commenters offered alternative suggestions to the use of a 

severity/complexity scale. Several commenters suggested that we use the secondary diagnoses 

on claims instead. Others suggested capturing the medical complexity of a beneficiary using 

other indicators, such as E/M codes or co-morbidities. 

Response: We appreciate these suggestions. While we are able to collect secondary 

diagnosis data from claims, we know from prior studies that diagnoses alone cannot predict the 

amount of therapy services needed. We do not believe that diagnoses and comorbidities measure 

functional limitations, which the statute requires us to collect. Nor do we believe using existing 

or therapy-specific E/M codes would provide the data on functional limitations that we are 

seeking to collect. We do, however, believe that these elements may provide additional data that 

could contribute to our analysis of payment alternatives. As we consider refinements to the 

claims-based data collection system in future years we will consider these additional data 

elements. 

Comment: Commenters had differing views on the use of the proposed 12-point scale to 

convey the severity of the beneficiary’s functional limitations. Those supporting the use of the 

proposed 12-point scale stated that it was more sensitive and so better reflected change in a 

beneficiary’s functional limitation. For example, commenters using FOTO said that they would 

not have problems adopting our proposed 12-point scale because they receive a composite score 

from FOTO, based on the patient’s functional survey results, which can be easily mapped as a 

percentage of overall beneficiary function. Other commenters suggested that the 12-point scale 

we proposed was too complicated and had too many levels. Some of these commenters also 

stated that therapists were not familiar with such a scale. Several commenters believed that we 

should modify the 12-point scale to a 10-point one by eliminating the separate modifiers for zero 

and 100 percent because they believed it would be more recognizable and easier for therapists to 
254 

use. Many suggested that we use the 7-point scale discussed in the CY 2011 rulemaking. A 

couple of these commenters thought that this 7-point scale was a valid and reliable one. Another 

commenter added that a 7-point scale is used by many outcome tools, such as NOMS, although 

no other examples of a tool using a 7-point scale were provided. One commenter was opposed to 

a severity/complexity scale but suggested that if one was used, it should be a 5- or 7-point scale. 

Response: After reviewing the comments, it is clear to us that, given the diversity of 

views among therapy professionals, the range in functional limitations being measured, the 

variability of beneficiary conditions being treated and the plethora of assessment tools and 

instruments being used, the translation of functional information to any scale used is likely to 

require adjustments by some therapists. Although we proposed a 12-point scale as we thought it 

would be easier to use and provided more sensitivity, a majority of commenters favored the 7-

point scale over the 12-point scale. After consideration of the many comments on the use of a 

12-point scale, we have determined that a 7-point scale as preferred by commenters will provide 

appropriate data for our analysis. Accordingly, are finalizing the 7-point scale in Table 23. 

Comment: Some commenters read our proposal to require that therapists use one of the 

IOM-recommended assessment tools, and thought that we should allow therapists to assign a 

severity/complexity modifier using their clinical judgment when a functional assessment tool is 

not used. Other commenters noted that physical and occupational therapists typically use 

multiple measurement tools during the evaluative process to inform clinical decision making; 

and, that clinical judgment is needed to combine these results to determine a functional limitation 

percentage. One commenter pointed out that the IOM outpatient coverage guidelines 

recommend, but do not mandate, the use of standardized measurement instruments and sought 

guidance as to how the modifier scale would apply to a therapist who satisfies documentation 

guidelines but does not use a standardized measurement instrument that produces a global 

functional score. 
255 

Response: We appreciate commenters’ concerns that our proposed policy would require 

therapists to use a functional assessment tool to determine the overall degree of functional 

impairment. This was not our intent. However, when one of the four functional assessment 

instruments is not utilized, we require as part of our IOM Documentation Guidelines, that the 

therapist documents using objective measures the beneficiary’s physical functioning. We are 

also aware that use of one of the four functional instruments is not widespread; and that physical 

and occupational therapists typically use multiple objective tests and measures to establish and 

compare a beneficiary’s physical function and progress throughout the therapy episode. As such, 

we recognize that a therapist’s judgment is critical in determining how to best measure their 

patient’s functional impairment and how to assimilate the various necessary objective findings 

to ascertain a certain percentage of function that can be translated to the Medicare severity scale. 

Our requirements for documenting the beneficiary’s functional status were established prior to 

this data collection effort, and the primary purpose for measuring functional impairment 

continues to aid the therapist in furnishing therapy services. Our data collection system is 

designed to collect data that is developed in the evaluative process and assessed throughout the 

course of treatment, not to prescribe how or what measures therapists use to assess functional 

impairment or deliver services. Accordingly, it is acceptable for therapists to use their 

professional judgment in the selection of the appropriate modifier. Our IOM provisions already 

assert that when assessing the level of functional impairment, the therapist uses his/her 

professional judgments in addition to the objective measures and accepted methodologies that 

are recognized in the therapy community and in professional practice guidelines. 

Because there will be many cases for which one single functional measurement tool is not 

available or clinically inappropriate, therapists can use their clinical judgment in the assignment 

of the appropriate modifier. Therapists will need to document in the medical record how they 

made the modifier selection so that the same process can be followed at succeeding assessment 
256 

intervals. 

Comment: Many commenters evaluated our proposed 12-point scale as if it was itself to 

be used as an assessment tool, rather than simply a scale to report results of assessments. Some 

of these commenters also warned us that the 12-point scale could not give us valid and reliable 

data to use as an alternative payment system for therapy services unless a single assessment tool 

were used. 

Response: We appreciate the views expressed by the many commenters. However, the 

12-point scale was not intended to be used as an assessment tool. Rather, it was intended to be 

used to express the beneficiary’s functional limitation in terms of a percentage of 100 total points 

so that there is a uniform scale for the degree of functional limitation. In other words, the scale 

that is used to report the degree of impairment would not affect the validity of the data. The 

reported data are as valid and reliable as the assessment tool or instrument (at times in 

combination with the therapist’s judgment) that was used to develop the score. We also realize 

that there are limitations to the data that we will collect, in part because it is not all derived from 

one consistent, assessment tool. 

Comment: Commenters noted that pain is a clinical complexity that is factored in when 

the beneficiary and therapist plan the course of treatment, but is not factored in to the proposed 

scale. 

Response: We believe that the commenter meant that pain is a definite limiter of 

function and is difficult to measure and hard to quantify. However, we believe that pain and the 

functional limitations that it engenders can be captured by our severity scale. There are many 

valid and reliable measures that a therapist can use to quantify the functional limitations of 

painful conditions. 

In response to the comments, we are adopting the following 7-point severity/complexity 

scale to report the severity of the beneficiary’s functional impairment, which is based upon the 
257 

scale developed as part of the STATs project. 

TABLE 23: Severity/Complexity Modifiers for CY 2013 

Modifier Impairment Limitation Restriction 

CH 0 percent impaired, limited or restricted 

CI At least 1 percent but less than 20 percent impaired, limited or restricted 

CJ At least 20 percent but less than 40 percent impaired, limited or restricted 

CK At least 40 percent but less than 60 percent impaired, limited or restricted 

CL At least 60 percent but less than 80 percent impaired, limited or restricted 

CM At least 80 percent but less than 100 percent impaired, limited or restricted 

CN 100 percent impaired, limited or restricted 

(4) Assessment Tools 

In the proposed rule we noted that therapists frequently use assessment tools to quantify 

beneficiary function. FOTO and NOMS are two such assessment tools in the public domain that 

can be used to determine a score for an assessment of beneficiary function. Therapists could use 

the score produced by such instruments to select the appropriate modifier for reporting the 

beneficiary’s functional status. Although we recommend the use of four of these functional 

assessment instruments to determine beneficiary functional limitation in the IOM, we did not 

propose to require the use of a particular functional assessment tool to determine the 

severity/complexity modifier. We explained our reasons for not doing so in the proposed rule 

saying “Some tools are proprietary, and others in the public domain cannot be modified to 

explicitly address this data collection project. Further, this data collection effort spans several 

therapy disciplines. Requiring a specific instrument could create burdens for therapists that 

would have to be considered in light of any potential improvement in data accuracy, consistency 

and appropriateness that such an instrument would generate.” We noted that we might 

reconsider this decision once we have more experience with claims-based data collection on 

beneficiary function associated with furnished therapy services. We sought public comment on 

the use of assessment tools. In particular, we were interested in feedback regarding the benefits 

and burdens associated with use of a specific tool to assess beneficiary functional limitations. 
258 

We requested that those favoring a requirement to use a specific tool provide information on the 

preferred tool and describe why the tool is preferred. 

The following is a summary of the comments we received regarding the use of 

assessment tools and the benefits and burdens associated with use of a specific tool to assess 

beneficiary functional limitations. 

Comment: Many commenters appreciated that we recognized the need to use consistent 

and objective measurement tools to quantify beneficiary function. All commenters who 

addressed assessment tools agreed that there is not currently a single assessment tool that would 

meet the diverse needs of beneficiaries receiving therapy services, and most did not recommend 

requiring the use of a single tool. However, many commenters stated we would be ineffective in 

reaching our data collection goals without prescribing some rules about assessing function; and 

thus suggested alternatives due to concerns of consistency and validity of the data. MedPAC 

noted that collecting data without a tool “would generate large amounts of data, and not provide 

clear information on the patients’ limitations or functional status.” MedPAC elaborated that 

variations among the assessment methods used by therapists “would potentially impede the 

utility of such data for policymakers.” 

Commenters found the following potential drawbacks to our proposal to allow therapists 

to choose the assessment tool(s) (or use their professional judgment) to determine the 

complexity/severity modifier. Commenters stated that the current proposal would collect 

individual level data that is not comparable among groups of beneficiaries or providers. 

Commenters also stated that gathering data on beneficiary condition, functional limitation, and 

progression necessitates the use of one standardized collection tool by all therapists. One 

commenter revealed that the same beneficiary could obtain widely distinct modifier scores 

depending on the tool used. Further, a commenter acknowledged that there are over 400 

different measurement tools used by physical therapists, many of which only measure one 
259 

domain of function. Additionally, another commenter urged us to provide more instruction on 

how each tool interfaces with the complexity/severity scale and provide crosswalks and guidance 

for each tool to promote consistency in the data collected. 

Commenters suggested the following alternatives to our proposal to address the potential 

drawbacks they identified. Commenters supported endorsing a small number of standardized 

tools with proven validity, reliability, and responsiveness that would be distinct for each therapy 

discipline. The American Speech-Language and Hearing Association (ASHA) urged we adopt 

NOMS and a 7-point severity scale specifically for SLP to recognize the distinctiveness of the 

discipline and record meaningful outcomes for SLP beneficiaries. Many commenters supported 

the use of FOTO stating that it measures a broad scope of conditions reliably, results in a 

composite score, and creates little undue burden to report. Those commenters also stated that 

FOTO is already the tool of choice for their respective providers. 

Two commenters suggested developing a list of approved tools for specific beneficiary 

populations and settings. Another commenter suggested assigning G-codes to specific 

assessment tools so that the data could be compared. As a future alternative, a few commenters 

proposed developing core items that could be used in any tool to standardize data collection. 

MedPAC suggested that “CMS consider developing an instrument that collects the necessary 

information that would allow Medicare to categorize beneficiaries by condition and severity in 

order to pay appropriately” and pointed to the “Reason for Therapy” form used in the DOTPA 

study as a starting point, noting that it is “concise, easy to assess and document for clinicians, 

and collects information on function and limitations across three therapy disciplines.” 

Response: We continue to recommend the use of four functional assessment tools to 

determine beneficiaries’ functional limitations. In addition, when these tools are not used, we 

require the use of objective measures to document the functional status of beneficiaries. We 

continue to believe that no one tool currently meets the needs of all three therapy disciplines; 
260 

and, therefore, we are not requiring the use of any one specific assessment tool, or even the use 

of any assessment tool. We acknowledge that because of the use of the variety and kinds of 

assessment tools and other measurement instruments, including the use of a therapist’s 

professional judgment, the value of the data we collect under this system will have limitations. 

However, we believe that the data we gather will assist us in taking a first step towards an 

improved payment system. 

We appreciate the comments providing information on the benefits of using specific 

tools, such as NOMS and FOTO. However, at this time we do not believe that they are 

sufficiently widely used to require the use of one of these tools. In this final rule with comment 

period, we are not requiring the use of a specific assessment tool. We are continuing to 

encourage, but not require, the use of assessment tools in the IOM. 

We did, however, adopt G-codes and a modifier scale for SLP that are consistent with 

NOMS so it is possible to move to a standardized tool for SLP in the future. We will consider 

the possibility using coding to identify the specific functional assessment tool used in subsequent 

refinements. As noted above, therapists can also use their professional judgment in determining 

the percentage of functional limitations in conjunction with objective data from evaluations and 

assessments and the subjective reports from beneficiaries. 

(5) Reporting Projected Goal Status 

 We proposed that the therapist’s projected goal for the beneficiary’s functional status at 

the end of treatment would be reported on the first claim for services, periodically throughout an 

episode of care, and at discharge from therapy. 

The following is a summary of the comments regarding goal reporting. 

Comment: Of those commenting on goal status, most objected to the collection of goal 

data, particularly during the first year of data collection. Commenters noted that reporting on 

goals was not specified as part of the claims-based data collection effort required by MCTRJCA. 
261 

Some stated that it would be a significant practice change to report goal data, involving changes 

to medical documentation, electronic health records, and billing processes. Commenters stated 

the identification and reporting of goals raised several clinical issues, such as the variability in 

goals among therapists, the need to change goals over the course of treatment, and the fact that 

therapists often set several goals (for example, short and long-term goals) for each beneficiary. 

Others noted that using goal data to classify a group of beneficiaries would be flawed because 

therapists create goals specific to the individual. One commenter noted that if goals influence 

payment, therapists could set the goal low or high to induce ongoing therapy and therefore the 

data would not be useful. As a result of these factors, many commenters believed data reporting 

on therapy goals would not provide reliable and useful information. In addition, a number of 

commenters stated that the proposal did not clearly express the intent of collecting goal data and 

many commenters expressed concerns about how we would use this data. Some commenters 

suggested that we clarify that the functional status data would be used only to track a 

beneficiary’s progression rather than for any other purposes, such as making comparisons across 

beneficiaries, therapists, or settings. Several commenters expressed concern that the reporting of 

goals implied an improvement standard and that care would be denied to beneficiaries who 

improved slowly or not at all. Alternatively, one commenter supported our proposal for 

reporting of a projected goal, as well as periodic updates of the beneficiary status in the context 

of that goal. 

 Response: We understand the commenters’ concerns about the complexity and 

intricacies of goal reporting. However, we currently require in the Benefit Policy Manual 

(Chapter 15, section 220.1.2 ) that long-term treatment goals be developed for the entire episode 

of care. Further, we specify that the projected goals should be measurable and pertain to 

identified functional limitations, and that these goals also need to be documented in the medical 

record. Since many of these goal requirements already exist, the additional work imposed by 
262 

this requirement would be for the therapist to establish the percentage of functional limitation for 

projected for this goal at the end of the therapy episode and translate the goal to the Gcode/modifier scale. We understand that the claims-based reporting is a change for therapists; 

however, these adjustments in operations will yield meaningful information on beneficiary 

functional status. We appreciate the recommendation to delay goal reporting for a year, but we 

believe that it is important to include goal data to gather a complete description of a beneficiary’s 

functional status. 

At this time, we intend to use the projected goal to have an understanding of therapists’ 

ability to project the likely progress a beneficiary will make. We ultimately may employ these 

data to help us develop proposals to improve payment for therapy services, but do not anticipate 

using the goal data for purposes of payment or coverage decisions. In cases where the therapist 

does not expect improvement, such as for those individuals receiving maintenance therapy, the 

reported projected goal status will be the same as current status. We appreciate that commenters 

raised concerns about potential ambiguity of the description of the proposal on progress and 

outcomes but, given as we have clarified in this final rule with comment period, goal reporting 

does not establish an improvement standard. In fact, it allows the therapist to state at the outset 

the expectations. We understand there will be wide variability in goals. Since these goals are 

used in beneficiary treatment, as well as for reporting, we do not expect therapists to establish 

goals purely to make themselves look better. Recognizing the limitations of the collected goal 

data, we still believe it will be useful to us. Therefore, we are finalizing our requirement for 

reporting of goal G-codes on the claims form along with the related severity modifier for that 

goal. 

(6) Reporting Frequency 

We proposed to require claims-based reporting in conjunction with the initial service at 

the outset of a therapy episode, at established intervals during treatment, and at discharge. As 
263 

proposed, the number of G-codes required on a particular claim would have varied from one to 

four, depending on the circumstances. We provided the following (Table 24) graphic example of 

which codes would have been used for periodic reporting. This example represents a therapy 

episode of care occurring over an extended period, such as might be typical for a beneficiary 

receiving therapy for the late effects of a stroke. We chose to use an example with a much 

higher than average number of treatment days in order to show a greater variety of reporting 

scenarios. 

TABLE 24: Example of Proposed Reporting Evaluation/Treatment Day 1, Begin Reporting Period #1 End Reporting Period #1 Begin Reporting Period #2 Claim for treatment days 5 and 6 in Period #2 End Reporting Period #2 Begin Reporting Period #3 

Discharge/End of 

reporting on Primary 

Functional Limitation 

End Reporting Period #3 

Primary Function 

Status 

 

GXXX1 – Current X X X X X 

GXXX2 – Goal X X X X 

GXXX3 – Discharge X 

Secondary Function 

GXXX4 – Current X X X X 

GXXX5 – Goal X X 

GXXX6 – Discharge 

No Functional 

Reporting Required 

 

GXXXX7 X 

● Outset. As proposed, the first reporting of G-codes and modifiers would occur when 

the outpatient therapy episode of care begins. This would typically be the date of service when 

the therapist furnishes the evaluation and develops the required plan of care (POC) for the 

beneficiary. At the outset, the therapist would use the G-codes and modifiers to report a current 

status and a projected goal for the primary functional limitation. We indicated in the proposal 
264 

that if a secondary functional limitation would need to be reported, the same information would 

be reported using G-codes and associated modifiers for the secondary functional limitation. 

The following is a summary of comments on the frequency of reporting at the outset. 

Comment: All commenters that addressed frequency of reporting agreed that reporting 

should occur at the outset of the therapy episode of care. Although commenters agreed with 

reporting at the outset, many recommended removing the requirement to report the projected 

goal status. (Comments on reporting projected goal status are discussed above.) 

Response: We are finalizing the requirement to report current status and projected goal 

status at the outset of therapy. 

● Every 10 Treatment Days or 30 Calendar Days, Whichever Is Less. We proposed to 

require reporting once every 10 treatment days or at least once during each 30 calendar days, 

whichever time period is shorter. As we explained in the proposed rule, the first treatment day 

for purposes of reporting would be the day that the initial visit takes place. The date the episode 

of care begins, typically at the evaluation, even when the therapist does not furnish a separately 

billable procedure in addition to the evaluation on this day, would be considered treatment day 

one, effectively beginning the count of treatment days or calendar days for the first reporting 

period. 

A treatment day is defined as a calendar day in which treatment occurs resulting in a 

billable service. Often a treatment day and a therapy “session” (or “visit”) may be the same, but 

the two terms are not interchangeable. For example, a beneficiary might receive certain services 

twice a day, although this is a rare clinical scenario, these two different sessions (or visits) on the 

same day by the same discipline are counted as one treatment day. 

We explained that the proposal would require that on the claim for service on or before 

the 10th treatment day or the 30th calendar day after treatment day one, the therapist would only 

report the G-code and the appropriate modifier to show the beneficiary’s current functional status 
265 

at the end of this reporting period under the proposal. We added that the next reporting period 

begins on the next treatment day and that the time period between the end of one reporting 

period and the next treatment day does not count towards the 30-calendar day period. On the 

claim for services furnished on this date, the therapist would report both the G-code and modifier 

showing the current functional status at this time along with the G-code and modifier reflecting 

the projected goal that was identified at the outset of the therapy episode. This process would 

continue until the beneficiary concludes the course of therapy treatment. 

Further, we proposed that on a claim for a service that does not require specific reporting 

of a G-code with modifier (that is, on a claim for therapy services within the time period for 

which reporting is not required), GXXX7 would be used. By using this code, the therapist would 

be confirming that the claim does not require specific functional reporting. This is the only Gcode that we proposed to be reported without a severity modifier. 

As we noted in the proposed rule, we proposed the 10/30 frequency of reporting to be 

consistent with our existing timing requirements for progress reports. These timing requirements 

are included in the Documentation Requirements for Therapy Services (see Pub. 100-02, Chapter 

15, Section 220.3, Subsection D). By making these reporting timeframes consistent with 

Medicare’s other requirements, therapists who are already furnishing therapy services to 

Medicare outpatients would have a familiar framework for successfully adopting our new 

reporting requirement. In addition to reflecting the Medicare required documentation for 

progress reports, we believe that this simplifies the process and minimizes the new burden on 

therapists since many therapy episodes would be completed by the 10th treatment day. In 2008, 

the average number of days in a therapy episode was 9 treatment days for SLP, 11 treatment days 

for PT, and 12 treatment days for OT. Under the proposal, when reporting on two functional 

limitations, the therapist would report the G-codes and modifiers for the second condition in the 

manner described above. In other words, at the end of the reporting period as proposed, two G-
266 

codes would be reported to show current functional status – one for the primary (GXXX1) and 

one for the secondary (GXXX4) limitation. Similarly as proposed, at the beginning of the 

reporting period four G-codes would be reported. GXXX1 and GXXX4 would be used to report 

current status for the primary and secondary functional limitations, respectively; and, GXXX2 

and GXXX5 would be used to report the goal status for the primary and secondary functional 

limitations, respectively. 

We noted that the proposal required that the same reporting periods be used for both the 

primary and secondary functional limitation. We added that the therapist can accomplish this by 

starting them at the same time or if the secondary functional limitation is added at some point in 

treatment, the primary functional limitation’s reporting period must be re-started by reporting 

GXXX1 and GXXX2 at the same time the new secondary functional limitation is added using 

GXXX4 and GXXX5. 

Further, for those therapy treatment episodes lasting longer periods of time, the periodic 

reporting of the G-codes and associated modifiers would reflect any progress that the beneficiary 

made toward the identified goal. In summary, we proposed to require the reporting of G-codes 

and modifiers at episode outset (evaluation or initial visit), and once every 10th treatment day or 

at least every 30 calendar days, whichever time period is less, and at discharge. 

We noted that we believed it was important that the requirements for this reporting 

system be consistent with the requirements for documenting any progress in the medical record 

as specified in our manual. Given the current proposal for claims-based data collection, we 

believe it is an appropriate time to reassess the manual requirements. We sought comment on 

whether it would be appropriate to modify the periodicity of the progress report requirement in 

the IOM to one based solely on the number of treatment days, such as six or ten. We noted that 

if a timing modification was made for progress reporting, a corresponding change would be 

made in the functional reporting interval. 
267 

The following is a summary of the comments we received on our proposal to require 

reporting every 10 treatment days or 30 calendar days, whichever is less, and whether it would 

be appropriate to modify the progress report requirement in the IOM to one based solely on the 

number of treatment days, such as six or ten, and the clinical impact of such a change. 

Comment: Although many commenters appreciated our effort to align the claims-based 

reporting with existing requirements for a progress report, several commenters requested that we 

recognize the significant time burden of the new reporting frequency and that we ameliorate 

some of the burden with a simplification of the existing manual requirement. Commenters in 

favor of reporting every 10 treatment days explained that using treatment days as compared to 

calendar days is more easily programmed into software systems and in accord with certain 

therapist’s billing practices. A couple of other commenters supported reporting every 30 

calendar days as this accommodates therapists working in settings where claims are required to 

be submitted on a monthly basis, such as hospitals, rehabilitation agencies and SNFs. Several 

commenters objected to the periodic reporting and suggested that reporting only at the outset and 

at discharge of therapy would be sufficient to capture a beneficiary’s functional progression. A 

few of those commenters were okay with the proposed 10 treatment day or 30 calendar day 

reporting timeframe, if periodic claims reporting is necessary. 

A few commenters urged us to eliminate the requirement for functional status reporting at 

the visit subsequent to the progress report because a beneficiary’s status probably would remain 

the same unless there is a significant gap between visits. 

We received many comments concerning the reporting of GXXX7; which we proposed to 

be used to indicate that the therapist confirms functional reporting not required. These 

commenters stated that the reporting of GXXX7, which is required for claims with dates of 

services when a functional status measure is not collected, would be unnecessary and 

burdensome, especially for daily billers. They urged us to require reporting only when a 
268 

functional status is required to be reported. Further commenters stated that there was no purpose 

for this G-code. 

Response: Based on the public comments, we are making several changes. We believe 

that reporting every 10 treatment days would be less burdensome for therapists than the proposed 

10 treatment days/30 calendar days. We believe a 10-

treatment day reporting period is 

straightforward for therapists to track, allows for better monitoring of changes in functional 

status, and is more easily adopted within our current claims processing systems. Therefore, we 

are finalizing the requirement that G-codes and associated modifiers are reported at least once 

every 10 treatment days and we will modify the IOM to establish the same timing requirement 

for progress reports. By making this change, we no longer need the therapist to report functional 

status at the visit subsequent to the end of a reporting period to signal the beginning of a new 

reporting period. So in response to comments, we have eliminated the requirement to report data 

at the start of a new reporting period. 

After assessing the comments, we agree that reporting a G-code (GXXX7) to tell us that 

no reporting is required would not provide meaningful data and would pose an additional burden 

for therapists and therapy providers. When proposed, we believed it would be convenient for 

therapists to use the code to indicate that this was a claim for therapy services that did not require 

the functional reporting because it would assist them in complying with the reporting 

requirements and would assist us in enforcing them. When we reassessed the issue based on 

feedback from commenters, it was clear that the “no report due” code would not aid us in 

enforcing the requirements as we would still have to verify that claims with the proposed 

GXXX7 were in fact claims that did not require reporting. Since commenters pointed out that 

not only would it not assist them, but would in fact burden them, we have decided not to include 

this code. Accordingly, we are also modifying our proposal to remove the requirement to report 

a “no report due” code on claims when functional reporting is not due, such as between the first 
269 

and the tenth day of service. We expect these changes will significantly reduce the frequency of 

required reporting during a therapy episode and believe they will appropriately simplify the 

claims-based reporting system. 

● Discharge. In addition, we proposed to require reporting of the G-code/modifier 

functional data for the current status and for the goal at the conclusion of treatment so that we 

have a complete set of data for the therapy episode of care. Requiring the reporting at discharge 

mirrors the IOM requirement of a discharge note or summary. This set of data would reveal any 

functional progress or improvement the beneficiary made toward the projected therapy goal 

during the entire therapy episode. Specifically, information on the beneficiary’s functional status 

at the time of discharge shows whether the beneficiary made progress towards or met the 

projected therapy goal. As we noted in the proposed rule, the imposition of this reporting 

requirement does not justify scheduling an additional and perhaps medically unnecessary final 

session in order to measure the beneficiary’s function for the sole purpose of reporting. 

Although collection of discharge data is important in achieving our goals, we recognize 

that data on functional status at the time therapy concludes is sometimes likely to be incomplete 

for some beneficiaries receiving outpatient therapy services. The DOTPA project has found this 

to be true. There are various reasons as to why the therapist would not be able to report 

functional status using G-codes and modifiers at the time therapy ends. Sometimes, beneficiaries 

may discontinue therapy without alerting their therapist of their intention to do so; simply 

because they feel better; they can no longer fit therapy into their life, work, or social schedules; a 

physician told them further therapy was not necessary; or their transportation is unavailable. 

Whatever the reason, there would be situations where the therapy ends without the planned 

discharge visit taking place. In these situations, we said that we would not require the reporting 

at discharge. However, we encourage therapists to include discharge reporting whenever 

possible on the final therapy claim for services. 
270 

Since the therapist is typically reassessing the beneficiary during the therapy episode, the 

data critical to the severity/complexity of the functional measure may be available even when the 

final therapy session does not occur. In these instances, the G-codes and modifiers appropriate 

to discharge should be reported when the final claim for therapy services has not already been 

submitted. 

We sought feedback on how often the therapy community finds that beneficiaries 

discontinue therapy without the therapist knowing in advance that it is the last treatment session 

and other situations in which the discharge data would not be available for reporting. 

The following is a summary of the comments we received regarding the proposal to 

require reporting of the G-code/modifier functional data at the conclusion of treatment so that we 

have a complete set of data for the therapy episode of care. 

Comment: In addition to outset reporting, a majority of commenters supported claimsbased reporting at discharge of the therapy episode of care. With regard to the number of 

beneficiaries who stop therapy services without notice, the responses varied from about 12 

percent for beneficiaries being treated for a spinal cord injury to 26 percent of patients with 

orthopedic conditions in a large system of outpatient therapy clinics. Many commenters who 

supported discharge reporting recommended that if the beneficiary misses his or her last visit, the 

therapist should be exempt from reporting the functional status at discharge. Another commenter 

believed, however, that having a separate G-code in each set to report discharge status is 

unnecessary; the commenter further stated that the last reported current status and goal status Gcodes could be used to represent the end of treatment. 

Response: Although we recognize that there may be some challenges with discharge 

reporting, this information is important for our purposes to complete the data set for each therapy 

episode; and, thus, we are maintaining the requirement. We do not agree with the commenter 

who suggested that we could simply use the last reported current status to represent the status at 
271 

discharge since this may not be an accurate representation of the beneficiary’s status at the time 

of discharge. However, in those cases where this functional status is derived from a patient 

survey, for example, FOTO, Am-PAC or OPTIMAL, and the survey is routinely sent to the 

patient who misses his/her final treatment, the therapist should report this data once subsequently 

gained, on the final bill for services unless the bill for the last treatment day has already been 

submitted. There are instances where not reporting the discharge status would make it 

impossible for us to distinguish the start of the reporting for a new or subsequently-reported 

functional limitation or the treatment for a new therapy episode in the data. We are finalizing our 

proposal to require discharge reporting (except in cases where therapy services are discontinued 

by the beneficiary prior to the planned discharge visit) using the discharge G-code, along with 

the goal status G-code, to indicate the end of a therapy episode or to signal the end of reporting 

on one functional limitation, while further therapy is necessary for another one. 

● Significant Change in Beneficiary Condition. We proposed that, in addition to 

reporting at the intervals discussed above, the G-code/modifier measures would be required to be 

reported when a formal and medically necessary re-evaluation of the beneficiary results in an 

alteration of the goals in the beneficiary’s POC. This could result from new clinical findings, an 

added comorbidity, or a failure to respond to treatment. We noted that this reporting affords the 

therapist the opportunity to explain a beneficiary’s failure to progress toward the initially 

established goal(s) and permits either the revision of the severity status of the existing goal or the 

establishment of a new goal or goals. Under the proposal, the therapist would be required to 

begin a new reporting period when submitting a claim containing a CPT code for an evaluation 

or a re-evaluation. This functional reporting of G-codes, along with the associated modifiers, 

could be used to show an increase in the severity of functional limitations; or, they could be used 

to reflect the severity of newly identified functional limitations as delineated in the revised plan 

of care. 
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 The following is a summary of the comments we received regarding the proposal that in 

addition to reporting at the intervals discussed above, the G-code and related modifier would be 

required to be reported when a formal and medically necessary re-evaluation of the beneficiary 

results in an alteration of the goals in the beneficiary’s POC. 

Comment: One commenter recommended that instead of requiring periodic reporting 

throughout a therapy episode that we require it only at the time of a re-evaluation. This 

commenter believed that capturing the functional information using G-codes within the treatment 

episode is burdensome and reporting at the time of the progress report would put unnecessary 

emphasis on a therapist capturing a change in a beneficiary’s assessment. 

Response: We did not receive comments objecting to claims-based reporting at the time 

that a re-evaluation code is billed for PT or OT or a subsequent or second evaluation code is 

billed for SLP. Therefore, we are finalizing the requirement for functional reporting when a 

formal and medically necessary re-evaluation, for PT or OT, or a second or repeat SLP 

evaluation of the beneficiary is furnished. We are requiring claims-based reporting in 

conjunction with the evaluation at the outset of therapy, on or before each 10th treatment day 

throughout therapy, and at therapy discharge (except in cases where therapy services are 

unexpectedly discontinued by the beneficiary prior to the planned discharge visit and the 

necessary information is not available) or to signal the end of reporting on one functional 

limitation. On a claim, two G-codes would be required depending on the reporting interval. 

Table 25 shows a revised example of which codes are used for specified reporting under our final 

policy. We should note that this example utilizes the mobility functional limitation G-codes, 

G8978 - G8980 for “walking and moving around” and the “Other or Primary” G-codes, G8990 - 

G8992 and is for illustrative purposes only. This table not only shows how the final reporting 

works but by comparing it to the table showing the same details for reporting under the proposed 

policy one can see how much less reporting is required. Any of the other functional limitation 
273 

G-code sets listed in Table 21 would also be applicable here. 

TABLE 25: Example of Required Reporting Evaluation/Treatment Day One, Begin Reporting Period #1 End Reporting Period #1 Reporting Period #2 Begins Next Treatment Day Claim for treatment days 5 and 6 in Period #2 End Reporting Period #2 Reporting Period #3 Begins Next Treatment Day 

Discharge /End of reporting on 

Walking & Moving Around 

Functional Limitation 

Begin Reporting Period #1 for 

Other Primary 

Mobility: Walking 

& Moving Around 

 

G8978 – Current X X X 

G 8979– Goal X X X X 

G8980 – Discharge X 

Other Primary 

G8990 – Current X 

G8991 – Goal X 

G8992 – Discharge 

No Functional 

Reporting Required 

 

No coding exists. 

In summary, we maintain that claims-based reporting should occur at the outset of 

therapy episode, on or before every 10 treatment days throughout the course of therapy, and at 

the time of discharge from therapy. Additionally, functional reporting is also required at the time 

the beneficiary’s condition changes significantly enough to clinically warrant a re-evaluation 

such that a HCPCS/CPT code for a re-evaluation or a repeat evaluation is billed. 

(7) Documentation 

We proposed to require that documentation of the information used for reporting under 

this system must be included in the beneficiary’s medical record. As proposed, the therapist 

would need to track in the medical record the G-codes and the corresponding severity modifiers 

that were used to report the status of the functional limitations at the time reporting was required. 
274 

Including G-codes and related modifiers in the medical record creates an auditable record, assists 

in improving the quality of data CMS collects, and allows therapists to track assessment and 

functional information. In the proposed rule, we provided the example of a situation where the 

therapist selects the mobility functional limitation of “walking and moving” as the primary 

functional limitation and determines that at therapy outset the beneficiary has a 60 percent 

limitation and sets the goal to reduce the limitation to 5 percent. We noted that the therapist uses 

GXXX1-XH to report the current status of the functional impairment and GXXX2-XB to report 

the goal. Additionally, we said that the therapist should note in the beneficiary’s medical record 

that the functional limitation is “walking and moving” and document the G-codes and severity 

modifiers used to report this functional limitation on the claim for therapy services. 

The following is a summary of comments we received concerning our documentation 

requirements. 

Comment: Some commenters suggested that the proposal would impose significant 

additional documentation and claims reporting requirements. Further, one commenter objected 

to the requirement to include information in the medical record on the G-codes and modifiers 

used for billing as it would be highly unusual and time intensive to do so. Another commenter 

supported our proposal, agreeing that documentation of the information used for reporting under 

this system must be included in the beneficiary’s medical record. 

 Response: We disagree with the commenters’ statements that the required documentation 

is overly burdensome. In fact, by maintaining the G-code descriptor and related modifier in the 

medical record, therapists may find it easier to link treatment and reporting. Additionally, to 

enforce the reporting requirements on the claims, documentation in the medical record is 

required. In cases where the therapist uses other information in addition to certain measurement 

tools in order to assess functional impairment, he or she would also want to document the 

relevant information used to determine the overall percentage of functional limitation to select 
275 

the severity modifier. In instances where it becomes necessary for a different therapist to furnish 

the therapy services, the substitute therapist can look in the beneficiary’s medical record to note 

previous G-codes and related modifiers reported. We are finalizing the proposed requirement 

that the G-codes and related modifiers must be documented in the beneficiary’s medical record. 

(8) Claims Requirements 

In the proposed rule, we noted that except for the addition of the proposed G-codes and 

the associated modifiers, nothing in this proposal would modify other existing requirements for 

submission of therapy claims. We noted in the proposed rule that, in addition to the new Gcodes and modifiers used for the claims-based data collection system, the therapy modifiers – 

GO, GP, and GN, would still be required on claims to indicate that the therapy services are 

furnished under an OT, PT, or SLP plan of care, respectively; and, therefore, we are designating 

these nonpayable G-codes as “always therapy.” We noted in the proposed rule that institutional 

claims for therapy services would require that a charge be included on the service line for each 

one of these G-codes used in the required functional reporting. We also noted that this charge 

would not be used for payment purposes and would not affect processing. Further, we noted 

claims for professional services do not require that a charge be included for these nonpayable Gcodes, but that reporting a charge for the nonpayable G-codes would not affect claims 

processing. To illustrate this policy, for each nonpayable G-code on the claim, that line of 

service would also need to contain one of the severity modifiers , the corresponding GO, GP, or 

GN therapy modifier to indicate the respective OT, PT, or SLP therapy discipline and related 

POC; and the date of service it references. For each line on the institutional claim submitted by 

hospitals, SNFs, rehabilitation agencies, CORFs and HHAs, a charge of one penny, $0.01, can be 

added. For each line on the professional claim submitted by private practice therapists and 

physician/NPPs, a charge of $0.00 can be added. We believe that many therapists submitting 

professional claims are already submitting nonpayable G-code quality measures under the PQRS 
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and will be familiar with the parameters of nonpayable G-codes on claims for Medicare services. 

Finally, we noted that Medicare does not process claims that do not include a billable 

service. As a result, reporting under this claims-based data collection system would need to be 

included on the same claim as a furnished service that Medicare covers. 

We did not receive any comments specifically on the claims requirements so we are 

finalizing these as proposed. 

(9) Implementation Date 

In accordance with section 3005(g) of the MCTRJCA, we proposed to implement these 

data reporting requirements on January 1, 2013. We recognized that with electronic health 

records and electronic claims submission, therapists might encounter difficulty in including this 

new data on claims. To accommodate those that may experience operational or other difficulties 

with moving to this new reporting system and to assure smooth transition, we proposed a testing 

period from January 1, 2013 until July 1, 2013. We noted that we would expect that all those 

billing for outpatient therapy services would take advantage of this testing period and would 

begin attempting to report the new G-codes and modifiers as close to January 1, 2013, as 

possible, in preparation for required reporting beginning on July 1, 2013. Taking advantage of 

this testing period would help to minimize potential problems after July 1, 2013, when claims 

without the appropriate G-codes and modifiers would be returned unpaid. 

The following is a summary of comments we received concerning our implementation of 

the new system on January 1, 2013 with enforcement beginning after July 1, 2013. 

Comment: Given the statutory deadline, most commenters acknowledged that the new 

program needed to be implemented on January 1, 2013. Many commenters supported the 

proposed testing period. They indicated that a testing period was needed to train therapists, 

change documentation practices, modify electronic health records systems, educate billing 

contractors, and adjust billing systems. However, numerous commenters expressed concern that 
277 

6 months is an insufficient and unrealistic amount of time to transition to the new data reporting 

requirements. Commenters requested that we recognize the significant time and financial burden 

of the new reporting requirement and that we alleviate these concerns with delayed enforcement. 

Commenters requested a longer period to make software adjustments and educate therapists on 

the new reporting and frequency of documentation requirements. Further, commenters believed 

that we, in the limited time period, did not recognize the potential capital changes that would be 

necessary or allow for the typical process for acquiring funds. Commenters proposed various 

alternatives, which included extending the testing period to 9 or 12 months. A few suggested 

that we delay implementation of the mandate until the completion of the DOTPA study. As an 

alternative to nationwide data reporting, a few commenters suggested we consider testing the 

requirement under a pilot program in a small sample of the country, allowing us to analyze 

preliminary data and draw conclusions regarding the effectiveness of reporting through nonpayable G-codes and modifiers before it is implemented nationwide. 

Response: We are required by law to implement the claims-based data collection strategy 

on January 1, 2013. Our contractors and systems will be able to accept and process claims for 

therapy services with functional information at this time. We recognize that therapists may need 

time to adjust their claims processing to accommodate these additional codes but, we believe the 

necessary changes can be accomplished well within the 8 months between the time this final rule 

with comment period is issued and the end of the testing period. We do not believe a small pilot 

as suggested by some commenters would meet the statutory requirement to implement as of 

January 1, 2013 a claims-based data collection strategy to assist in reforming outpatient therapy 

services. Nor would it meet our needs to gather data to assist in developing potential alternative 

payment systems for therapy services. We are finalizing an implementation date of January 1, 

2013 with a 6-month testing period such that claims that do not comply with the data reporting 

requirements will be returned beginning July 1, 2013. 
278 

(10) Compliance Required as a Condition for Payment and Regulatory Changes 

To implement the claims-based data collection system required by MCTRJCA and 

described above, we proposed to amend the regulations establishing the conditions for payment 

governing outpatient and CORF PT, OT, and SLP services to add a requirement that the claims 

include information on beneficiary functional limitations. In addition, we proposed to amend the 

POC requirements set forth in the regulations for outpatient therapy services and CORFs to 

require that the therapy goals, which must be included in the POC, are consistent with the 

beneficiary’s functional limitations and goals reported on claims for services. 

Specifically, we proposed to amend the regulations for outpatient OT, PT, and SLP 

(§410.59, §410.60, and §410.62, respectively) by adding a new paragraph (a)(4) to require that 

claims submitted for services furnished contain the required information on beneficiary 

functional limitations. 

We also proposed to amend the POC requirements set forth at §410.61(c) to require that 

the therapy goals, which must be included in the treatment plan, must be consistent with those 

reported on claims for services. This requirement is in addition to those already existing 

conditions for the POC. 

To achieve consistency in the provision of PT, OT, and SLP services across therapy 

benefits, we proposed to amend §410.105 to include the same requirements for these services 

furnished in CORFs. These proposed revisions would require that the goals specified in the 

treatment plan be consistent with the beneficiary functional limitations and goals reported on 

claims for services and that claims submitted for services furnished contain specified information 

on beneficiary functional limitations, respectively. The requirements do not apply to respiratory 

therapy services. 

 We did not receive any comments on the proposed regulatory changes and are finalizing 

the changes as proposed. 
279 

(11) Consulting with Relevant Stakeholders 

Section 3005(g) of the MCTRJCA requires us to consult with relevant stakeholders as we 

propose and implement this reporting system. In the CY 2013 PFS proposed rule, we indicated 

that we are meeting this requirement through the publication of this proposal and specifically by 

soliciting public comment on the various aspects of our proposal. In addition, we noted that we 

would meet with key stakeholders and discuss this issue in Open Door Forums over the course of 

the summer. 

 During the CY 2013 proposed rule comment period, we met with the various therapy 

professional associations and provider groups in order to solicit their comments on the various 

aspects of this proposal. At the CMS Physicians, Nurses & Allied Health Professionals Open 

Door Forum on July 17, 2012, we discussed the provisions of the proposed rule, including these 

requirements. We also discussed this proposed rule at the CMS Hospital & Hospital Quality 

Open Door Forum on July 18, 2012. In developing the final rule, we took into consideration 

many of the critical issues that were raised by the various stakeholders in these meetings and 

Forums. Accordingly, we believe we have met our obligation to consult with relevant 

stakeholders in proposing and implementing the required claims-based data collection strategy, 

and in developing our final policies, we have taken into consideration the various needs of 

stakeholders affected by this effort. 

H. Primary Care and Care Coordination 

In recent years, we have recognized primary care and care coordination as critical 

components in achieving better care for individuals, better health for individuals, and reduced 

expenditure growth. Accordingly, we have prioritized the development and implementation of a 

series of initiatives designed to improve payment for, and encourage long-term investment in, 

primary care and care management services. These initiatives include the following programs 
280 

and demonstrations: 

● The Medicare Shared Savings Program (described in “Medicare Program; Medicare 

Shared Savings Program: Accountable Care Organizations; Final Rule” which appeared in the 

Federal Register on November 2, 2011 (76 FR 67802)). 

++ The testing of the Pioneer ACO model, designed for experienced health care 

organizations (described on the Center for Medicare and Medicaid Innovation’s (Innovation 

Center’s) website at innovations.cms.gov/initiatives/ACO/Pioneer/index.html). 

++ The testing of the Advance Payment ACO model, designed to support organizations 

participating in the Medicare Shared Savings Program (described on the Innovation Center’s 

website at innovations.cms.gov/initiatives/ACO/Advance-Payment/index.html). 

● The Primary Care Incentive Payment (PCIP) Program (described on the CMS website 

at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/Downloads/PCIP-2011-Payments.pdf). 

● The patient-centered medical home model in the Multi-payer Advanced Primary Care 

Practice (MAPCP) Demonstration designed to test whether the quality and coordination of health 

care services are improved by making advanced primary care practices more broadly available 

(described on the CMS website at www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf). 

● The Federally Qualified Health Center (FQHC) Advanced Primary Care Practice 

demonstration (described on the CMS website at www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf and the Innovation 

Center’s website at innovations.cms.gov/initiatives/FQHCs/index.html). 

● The Comprehensive Primary Care (CPC) initiative (described on the Innovation 

Center’s website at innovations.cms.gov/initiatives/Comprehensive-Primary-CareInitiative/index.html). The CPC initiative is a multi-payer initiative fostering collaboration 
281 

between public and private health care payers to strengthen primary care in certain markets 

across the country. 

In coordination with these initiatives, we also continue to explore other potential 

refinements to the PFS that would appropriately value primary care and care coordination within 

Medicare’s statutory structure for fee-for-service physician payment and quality reporting. We 

believe that improvements in payment for primary care and recognizing care coordination 

initiatives are particularly important as EHR technology diffuses and improves the ability of 

physicians and other providers of health care to work together to improve patient care. We view 

these potential refinements to the PFS as part of a broader strategy that relies on input and 

information gathered from the initiatives described above, research and demonstrations from 

other public and private stakeholders, the work of all parties involved in the potentially 

misvalued code initiative, and from the public at large. 

In the CY 2012 PFS proposed rule (76 FR 42793 through 42794), we initiated a 

discussion to gather information about how primary care services have evolved to focus on 

preventing and managing chronic conditions. We also proposed to review evaluation and 

management (E/M) services as potentially misvalued and suggested that the American Medical 

Association Relative (Value) Update Committee (AMA RUC) might consider changes in the 

practice of chronic conditions management and care coordination as key reason for undertaking 

this review. In the CY 2012 PFS final rule with comment period (76 FR 73062 through 73065), 

we did not finalize our proposal to review E/M codes due to consensus from an overwhelming 

majority of commenters that a review of E/M services using our current processes could not 

appropriately value the evolving practice of chronic care coordination at the time, and therefore, 

would not accomplish the agency’s goal of paying appropriately for primary care services. We 

stated that we would continue to consider ongoing research projects, demonstrations, and the 

numerous policy alternatives suggested by commenters. In addition, in the CY 2012 PFS 
282 

proposed rule (76 FR 42917 through 42920), we initiated a public discussion regarding payments 

for post-discharge care management services. We sought broad public comment on how to 

further improve care management for a beneficiary’s transition from the hospital to the 

community setting within the existing statutory structure for physician payment and quality 

reporting. We specifically discussed how post discharge care management services are coded 

and valued under the current E/M coding structure, and we requested public comment. 

The physician community responded that comprehensive care coordination services are not 

adequately represented in the descriptions of, or payments for, office/outpatient E/M services. 

The American Medical Association (AMA) and the American Academy of Family Physicians 

(AAFP) created workgroups to consider new options for coding and payment for primary care 

services. The AAFP Task Force recommended that CMS create new primary care E/M codes 

and pay separately for non-face-to-face E/M Current Procedural Terminology (CPT) codes. (A 

summary of these recommendations is available at 

www.aafp.org/online/en/home/publications/news/news-now/insideaafp/20120314cmsrecommendations.html.) The AMA workgroup, Chronic Care Coordination 

Workgroup (C3W), has and continues to develop codes to describe care transition and care 

coordination activities. (Several workgroup meeting minutes and other related items are 

available at www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/medicare/care-coordination.page.) Since the publication of the 

proposed rule, the C3W has completed development of two new transitional care management 

(TCM) codes. These new codes are: 

● 99495 Transitional Care Management Services with the following required elements: 

++ Communication (direct contact, telephone, electronic) with the patient and/or 

caregiver within 2 business days of discharge. 

++ Medical decision making of at least moderate complexity during the service period. 
283 

++ Face-to-face visit, within 14 calendar days of discharge. 

● 99496 Transitional Care Management Services with the following required elements: 

++ Communication (direct contact, telephone, electronic) with the patient and/or 

caregiver within 2 business days of discharge. 

++ Medical decision making of high complexity during the service period. 

++ Face-to-face visit, within 7 calendar days of discharge. 

We discuss these codes in greater detail below. 

Under current PFS policy, care coordination is a component of E/M services which are 

generally reported using E/M CPT codes. The pre- and post-encounter non-face-to-face care 

management work is included in calculating the total work for the typical E/M services, and the 

total work for the typical service is used to develop RVUs for the E/M services. In the CY 2012 

PFS proposed rule, we highlighted some of the E/M services that include substantial care 

coordination work. Specifically, we noted that the vignettes that describe a typical service for 

mid-level office/outpatient services (CPT codes 99203 and 99213) include furnishing care 

coordination, communication, and other necessary care management related to the office visit in 

the post-service work. We also highlighted vignettes that describe a typical service for hospital 

discharge day management (CPT codes 99238 and 99239), which include furnishing care 

coordination, communication, and other necessary management related to the hospitalization in 

the post-service work. 

The payment for non-face-to-face care management services is bundled into the payment 

for face-to-face E/M visits. Moreover, Medicare does not pay for services that are furnished to 

parties other than the beneficiary and which Medicare does not cover, for example, 

communication with caregivers. Accordingly, we do not pay separately for CPT codes for 

telephone calls, medical team conferences, prolonged services without patient contact, or 

anticoagulation management services. 
284 

However, the physician community continues to tell us that the care coordination 

included in many of the E/M services, such as office visits, does not adequately describe the nonface-to-face care management work involved in primary care. Because the current E/M 

office/outpatient visit CPT codes were designed to support all office visits and reflect an overall 

orientation toward episodic treatment, we agree that these E/M codes may not reflect all the 

services and resources required to furnish comprehensive, coordinated care management for 

certain categories of beneficiaries such as those who are returning to a community setting 

following discharge from a hospital or SNF stay. As part of our multi-year strategy to recognize 

and support primary care and care management, we proposed in the CY 2013 PFS proposed rule 

(77 FR 44776-44780) to create a HCPCS G code to describe care management involving the 

transition of a beneficiary from care furnished by a treating physician during a hospital stay 

(inpatient, outpatient observation services, or outpatient partial hospitalization), SNF stay, or 

community mental health center (CMHC) partial hospitalization program to care furnished by 

the beneficiary’s primary physician in the community. We also solicited comment on how care 

furnished in these settings might be incorporated into the current fee-for-service structure of the 

PFS. 

Specifically, this HCPCS G code would describe all non-face-to-face services related to 

the TCM furnished by the community physician or qualified nonphysician practitioner within 30 

calendar days following the date of discharge from an inpatient acute care hospital, psychiatric 

hospital, long-term care hospital, skilled nursing facility, and inpatient rehabilitation facility; 

hospital outpatient for observation services or partial hospitalization services; and a partial 

hospitalization program at a CMHC to community-based care. The post-discharge TCM service 

includes non-face-to-face care management services furnished by clinical staff member(s) or 

office-based case manager(s) under the supervision of the community physician or qualified 

nonphysician practitioner. We based the concept of this proposal, in part, on our policy for care 
285 

plan oversight services. We currently pay physicians for the non-face-to-face care plan oversight 

services furnished for beneficiaries under care of home health agencies or hospices. These 

beneficiaries require complex and multidisciplinary care modalities that involve: regular 

physician development and/or revision of care plans, subsequent reports of patient status, review 

of laboratory and other studies, communication with other health professionals not employed in 

the same practice who are involved in the patient’s care, integration of new information into the 

care plan, and/or adjustment of medical therapy. Physicians furnishing these services bill 

HCPCS codes G0181 or G0182 (See the Medicare benefit manual, 100-02, Chapter 15, Section 

30 for detailed description of these services.) 

For CY 2013, we proposed to create a new code to describe post-discharge TCM 

services. This service was proposed to include: 

● Assuming responsibility for the beneficiary’s care without a gap. 

++ Obtaining and reviewing the discharge summary. 

++ Reviewing diagnostic tests and treatments. 

++ Updating of the patient’s medical record based on a discharge summary to 

incorporate changes in health conditions and on-going treatments related to the hospital or 

nursing home stay within 14 business days of the discharge. 

● Establishing or adjusting a plan of care to reflect required and indicated elements, 

particularly in light of the services furnished during the stay at the specified facility and to reflect 

result of communication with beneficiary. 

++ An assessment of the patient’s health status, medical needs, functional status, pain 

control, and psychosocial needs following the discharge. 

● Communication (direct contact, telephone, electronic) with the beneficiary and/or 

caregiver, including education of patient and/or caregiver within 2 business days of discharge 

based on a review of the discharge summary and other available information such as diagnostic 
286 

test results, including each of the following tasks: 

++ An assessment of the patient’s or caregiver’s understanding of the medication 

regimen as well as education to reconcile the medication regimen differences between the preand post-hospital, CMHC, or SNF stay. 

++ Education of the patient or caregiver regarding the on-going care plan and the 

potential complications that should be anticipated and how they should be addressed if they 

arise. 

++ Assessment of the need for and assistance in establishing or re-establishing necessary 

home and community based resources. 

++ Addressing the patient’s medical and psychosocial issues, and medication 

reconciliation and management. 

When indicated for a specific patient, the post-discharge transitional care service was also 

proposed to include: 

● Communication with other health care professionals who will (re)assume care of the 

beneficiary, education of patient, family, guardian, and/or caregiver. 

● Assessment of the need for and assistance in coordinating follow up visits with health 

care providers and other necessary services in the community. 

● Establishment or reestablishment of needed community resources. 

● Assistance in scheduling any required follow-up with community providers and 

services. 

The proposed post-discharge transitional care HCPCS G code was described as follows: 

GXXX1 Post-discharge transitional care management with the following required 

elements: 

● Communication (direct contact, telephone, electronic) with the patient or caregiver 

within 2 business days of discharge. 
287 

● Medical decision making of moderate or high complexity during the service period. 

● To be eligible to bill the service, physicians or qualified nonphysician practitioners 

must have had a face-to-face E/M visit with the patient in the 30 days prior to the transition in 

care or within 14 business days following the transition in care. 

 The post-discharge transitional care services HCPCS G code we proposed would be used 

by the community physician or qualified nonphysician practitioner to report the services 

furnished in the community to ensure the coordination and continuity of care for patients 

discharged from a hospital (inpatient stay, outpatient observation, or outpatient partial 

hospitalization), SNF stay, or CMHC. The post-discharge transitional care service would 

parallel the discharge day management service for the community physician or qualified 

nonphysician practitioner and complement the E/M office/outpatient visit CPT codes. 

We proposed that the post-discharge transitional care service HCPCS G code would be 

used to report physician or qualifying nonphysician practitioner services for a patient whose 

medical and/or psychosocial problems requires moderate or high complexity medical decisionmaking during transitions in care from hospital (inpatient stay, outpatient observation, and partial 

hospitalization), SNF stay, or CMHC settings to community-based care. The Evaluation and 

Management Guidelines define decision-making of moderate and high medical complexity. In 

general, moderate complexity medical decision-making includes multiple diagnoses or 

management options, moderate complexity and amount of data to be reviewed, a moderate 

amount and/or complexity of data to be reviewed; and a moderate risk of significant 

complications, morbidity, and/or mortality. High complexity decision-making includes an 

extensive number of diagnoses or management options, an extensive amount and/or complexity 

of data to be reviewed, and high risk of significant complications, morbidity, and/or mortality 

(See Evaluation and Management Services Guide, Centers for Medicare & Medicaid Services, 

December 2010.) We proposed that the post-discharge transitional care HCPCS code (GXXX1) 
288 

would be payable only once in the 30 days following a discharge, per patient per discharge, to a 

single community physician or qualified nonphysician practitioner (or group practice) who 

assumes responsibility for the patient’s post-discharge TCM services. The service would be 

billable only at 30 days post discharge or thereafter. The post-discharge TCM service would be 

distinct from services furnished by the discharging physician or qualified nonphysician 

practitioner reporting CPT codes 99238 (Hospital discharge day management, 30 minutes or 

less); 99239 (Hospital discharge day management, more than 30 minutes); 99217 (Observation 

care discharge day management); or Observation or Inpatient Care services, CPT codes 99234 -

99236; as appropriate. 

We proposed to pay only one claim for the post-discharge transitional care GXXX1 

billed per beneficiary at the conclusion of the 30 day post-discharge period Given the elements 

of the service and the short window of time following a discharge during which a physician or 

qualifying nonphysician practitioner will need to perform several tasks on behalf of a 

beneficiary, we stated our belief that it would be unlikely that two or more physicians or 

practitioners would have had a face-to-face E/M contact with the beneficiary in the specified 

window of 30 days prior or14 days post discharge and have furnished the proposed postdischarge TCM services listed above. Therefore, we did not believe it necessary to take further 

steps to identify a beneficiary’s community physician or qualified nonphysician practitioner who 

furnished the post-discharge TCM services. We proposed to pay only one claim for the postdischarge transitional care GXXX1 billed per beneficiary at the conclusion of the 30 day postdischarge period. Post-discharge TCM services relating to any subsequent discharges for a 

beneficiary in the same 30-day period would be included in the single payment. Practitioners 

billing this post-discharge transitional care code accept responsibility for managing and 

coordinating the beneficiary’s care over the first 30 days after discharge. 

 Comment: We received many comments on the proposed new code. The vast majority 
289 

supported the concept in whole or in part. Only a handful of comments were generally opposed 

to the proposal to recognize and pay for TCM services. One commenter, while acknowledging 

that our proposal was “well intentioned,” expressed concern about adopting such an important 

proposal without explicit statutory direction. In particular, the commenter recommended that we 

should be more judicious in using the PFS rulemaking process to adopt far-reaching new policies 

requiring sizable BN adjustments. The commenter suggested that, if the proposed policies had 

been mandated by the Congress, the BN adjustment would presumably not be required. Another 

commenter suggested that the proposed new code was duplicative, because pre- and postencounter non-face-to-face care management work is included in the total work for the typical 

E/M services, and the total work for subsequent post-operative visits that accompany surgical 

procedures. 

 Response: We thank the commenters who wrote in support of this proposal. For the 

reasons that we stated in the proposed rule, we do not believe that all the pre- and postencounter non-face-to-face care management work that typically occurs when a beneficiary is 

discharged from a hospital, SNF or CMHC stay is included in the total work for the typical E/M 

services. This is because the E/M codes represent the typical outpatient visit and do not capture 

or reflect the significant care coordination that needs to occur when a beneficiary transitions 

from institutional to community-based care. (77 FR 44776) Therefore, we continue to believe 

that separate payment for TCM services does not duplicate payment for typical E/M services. 

We also believe that adoption of new codes such as our proposed TCM code is consistent with 

our statutory directive to maintain the physician fee schedule by recognizing changes in practice 

patterns and by adjusting codes, relative values, and payment accordingly. We have routinely 

added new codes created by AMA CPT to the fee schedule. As we indicated in the proposed 

rule, our proposal was, in part, a response to work by the AMAs C3W to develop new codes for 

TCM services. Below we discuss the AMA’s recommendation that we adopt the TCM codes 
290 

developed by that workgroup in place of our proposed TCM G-code. 

 Comment: Most comments were generally supportive of the proposal to recognize and 

pay for TCM services. A few commenters merely expressed general support for the proposal. 

However, the great majority of these generally positive comments also recommended adopting 

the proposed TCM G code with revisions to the code description, or adopting the AMA’s new 

CPT TCM codes in place of our proposed TCM G-code. 

 Response: We appreciate the widespread support for our initiative to recognize and pay 

for TCM services. As we discuss below, we are proceeding with our proposal in a modified 

form, adopting some of the commenters’ specific recommendations for revision. Most 

importantly, we are accepting the recommendation of many commenters that we adopt the 

AMA’s CPT TCM codes in place of our proposed TCM G-code. As discussed below, we will 

therefore pay for new CPT TCM codes 99495 and 99496 with some small modifications to the 

code descriptions developed by the AMA’s C3W. The new TCM codes developed by the AMA 

C3W are: 

● 99495 Transitional Care Management Services with the following required elements: 

++ Communication (direct contact, telephone, electronic) with the patient and/or 

caregiver within 2 business days of discharge. 

++ Medical decision making of at least moderate complexity during the service period. 

++ Face-to-face visit, within 14 calendar days of discharge. 

● 99496 Transitional Care Management Services with the following required elements: 

++ Communication (direct contact, telephone, electronic) with the patient and/or 

caregiver within 2 business days of discharge. 

++ Medical decision making of high complexity during the service period. 

++ Face-to-face visit, within 7 calendar days of discharge. 

We discuss these codes in greater detail and respond to these specific recommendations below. 
291 

 Comment: Many commenters, including the AMA and other specialty societies, 

expressed appreciation for our initiative to propose a new G-code and language to describe 

TCM, but urged us instead to implement the new CPT TCM codes. Commenters emphasized 

that these codes represented the consensus of the physician community as represented by the 

AMA’s C3W. Commenters also emphasized that the CPT TCM codes are very similar to our 

proposal, with a few key differences. We summarize the key differences between our proposed 

TCM G-code and the CPT TCM codes in Table 26. 

TABLE 26: Key Differences between Proposed Transitional Care Management (TCM) Gcode and the CPT codes 

 CMS Proposed TCM 

G-code 

CPT TCM Codes 

Code(s) GXXX1—Post-discharge 

transitional care management 

(medical decision making of 

moderate to high complexity) 

99490X—Transitional care 

management services 

(medical decision making of 

moderate complexity), and 

99491X—Transitional care 

management services 

(decision making of high 

complexity) 

Face-to-face visit Separately billed face-to-face 

E/M visit within 30 days prior 

to the hospital discharge or 

within the first 14 days of the 

30-day period of TCM 

services 

Face-to-face visit within 14 

calendar days of discharge 

(99490X), or within 7 

calendar days (99491X). The 

first face-to-face visit is part 

of the TCM service and not 

reported separately. E/M 

services after the first face-toface visit may be reported 

separately. 

Relationship with patient The patient may be new to the 

physician’s practice (provided 

the face-to-face visit 

requirements above are met). 

The reporting physician or 

NPP must have an established 

relationship with the patient. 

Established patient means a 

visit in the past 3 years. 

Discharge management The physician or NPP who 

bills for discharge 

management services during 

the time period covered by 

TCM services may not also 

bill for GXXX1. 

A physician or NPP may 

report both the discharge code 

and appropriate TCM code. 

Global services The physician who reports a 

service with a global period 

The physician who reports a 

service with a global period 
292 

 CMS Proposed TCM 

G-code 

CPT TCM Codes 

of 010 or 090 days may not 

also report the TCM service. 

of 010 or 090 days may not 

also report the TCM service. 

However, the AMA 

recommends that specialties 

work on a CPT proposal for a 

new code to describe 

extensive post-discharge 

TCM services. 

A few commenters from the medical community did not specifically recommend adopting the 

CPT TCM codes. For example, one major medical society supported our proposal on the 

grounds, among other considerations, that it was consistent with the “general direction of 

organized medicine, as evidenced by the fact that the AMA's CPT Editorial Panel has created 

two new codes for transitional care management.” This commenter then expressed support for 

several of the several elements in our proposed G code which differ from the CPT TCM codes, 

such as our “proposal to keep the required post-discharge face-to-face E/M separately 

reportable.” (We discuss this issue in further detail later in this section.) 

 Response: We agree with those commenters who recommended that we should 

acknowledge the physician community’s work on primary care by adopting the CPT TCM codes 

in place of our proposed G-code. With regard to the differences noted above, we agree with the 

AMA’s CPT construction that uses two separate codes to distinguish moderate and high 

complexity services in place of our single proposed G-code, which allowed for reporting services 

of either moderate or high complexity. We discuss the issues connected with the other 

differences between our proposed TCM G-code and the AMA’s CPT TCM codes in responses to 

more specific comments of the AMA and others below. 

 We explicitly constructed this proposal as a payment for non-face-to-face post-discharge 

TCM services separate from payment for E/M or other medical visits. However, we believe that 

it is important to ensure that the community physician or qualified nonphysician practitioner 
293 

furnishing post-discharge TCM services either already have or establish, soon after discharge, a 

relationship with the beneficiary. As such, we proposed that the community physician or 

qualified nonphysician practitioner reporting post-discharge TCM GXXX1 should already have a 

relationship with the beneficiary, or establish one soon after discharge, prior to furnishing TCM 

and billing this code. Therefore, we specifically proposed that the community physician or 

qualified nonphysician practitioner reporting a TCM G-code must have billed an E/M visit for 

that beneficiary within 30 days prior to the hospital discharge (the start of post-discharge TCM 

period), or must conduct an E/M office/outpatient visit (99201 to 99215) within the first 14 days 

of the 30-day post-discharge period of TCM services. In either case, the E/M visit would be 

separately billed under our G-code proposal. While we proposed that the post-discharge TCM 

code would not include a face-to-face visit, and that physicians or qualified nonphysician 

practitioners would bill and be paid for this care management service separately from a medical 

visit, we sought comments about whether we should require a face-to-face visit when billing for 

the post-discharge TCM service: that is, whether we should bundle a required visit into the 

reporting and payment for the TCM codes. We were also concerned about whether beneficiaries 

would understand their coinsurance liability for the post-discharge transitional care service when 

they did not visit the physician’s or qualified nonphysician practitioner’s office. 

 Comment: The AMA and many other commenters recommended that we should require 

a face-to-face visit within 7 to 14 days after discharge when billing for the post-discharge TCM 

service. Under the CPT TCM codes, the first face-to-face visit is part of the TCM service and 

not reported separately. Additional E/M services required for managing the beneficiary’s 

clinical issues in addition to the required face-to-face visit may be reported separately. These 

commenters emphasized that requiring a face-to-face visit within 7 to 14 days of discharge will 

provide for a more successful transition from facility to community. Other commenters 

maintained that we should retain the requirement for a separately billable face-to-face E/M either 
294 

within 30 days before or 14 days after discharge. These commenters emphasized that such a 

requirement acknowledges that an established relationship with the patient is needed to bill the 

new code, and the level of E/M service will not be the same for every patient. A few 

commenters specifically recommended that it was not necessary to adopt any such requirement 

for a face-to-face visit (whether separately billable or not) in the context of a service that is 

essentially non-face-to-face. Some emphasized that it could be inefficient to require a visit that 

may not always be clinically necessary, and that the clinical decision about whether a visit is 

necessary should be left to the physician or qualified nonphysician practitioner. Other 

commenters emphasized that an office visit could be impractical in cases where patients may 

have limited mobility or otherwise have difficulty travelling to a physician office. Some of these 

commenters urged that we not adopt such a requirement, while others recommended that we 

expand the list of acceptable face-to-face visits to include other outpatient visit codes, such as 

home visits (99341-99350) and domiciliary/rest home visits (99324-99337). Still others stated 

that the window in which the post discharge visit must occur should be extended to 30 days postdischarge, not 14 days. 

 Response: The primary driver in creating these new CPT TCM codes has been to 

improve care coordination and to provide better incentives to ensure that these patients are seen 

in a physician’s office, rather than be at risk for readmission. Therefore, we agree that care 

coordination beginning immediately upon discharge and the face-to-face visit within 7 or 14 

days of discharge (as appropriate) will provide for a more successful transition from a facility to 

the community. However, as we indicated in the proposed rule, our adoption of codes for TCM 

services is part of the broader HHS and CMS multi-year strategy to recognize and support 

primary care and care management, and we are committed to considering new options and 

developing future proposals for payment of primary care services under the MPFS. Therefore, 

we consider the requirement for a face-to-face visit in association with the non-face-to-face tasks 
295 

of TCM to be a short-term, transitional strategy while we continue to explore our interest in 

further improvements to advanced primary care payment. 

 We also share the commenters’ concerns about beneficiaries who may have limited 

mobility or otherwise have difficulty travelling to a physician office in the period following a 

discharge. We note that the final CPT TCM codes, 99495 and 99496, which we are adopting in 

this final rule with comment period, requires a face-to-face visit, but does not specify the 

location/setting for that portion of the service. The AMA RUC states in its recommendation that, 

“each code includes a timely face-to-face visit which typically occurs in the office, but can also 

occur at home or other location where the patient resides.” Finally, we agree with those 

commenters who stated that beneficiaries would understand their coinsurance liability better if 

the TCM services included a required E/M visit as part of the service. 

 We also sought comments regarding whether we should incorporate such a required visit 

on the same day into the payment for the proposed code. We considered several reasons for 

requiring a face-to-face visit on the same day as the date of discharge. We wondered whether, 

with a face-to-face visit immediately after discharge, the plan of care would be more accurate 

given that the patient’s medical or psychosocial condition may have changed from the time the 

practitioner last met with the patient and the practitioner could better develop a plan of care 

through an in-person visit and discussion. On the other hand, we contemplated several scenarios 

where it is not possible for a beneficiary to get to the physician’s or qualified nonphysician 

practitioner’s office and welcomed comment on whether an exception process would be 

appropriate if we were to finalize a same day face-to-face visit as a requirement for billing the 

post-discharge TCM code. 

 Comment: Commenters were almost uniformly opposed to a requirement for a same day 

visit. The commenters believed that a same day visit is unrealistic and should not be required 

because hospital discharge records are not always immediately available to the physician who 
296 

would be assuming responsibility for transitional care. Some commenters, including several who 

favor a face-to-face requirement other than a same day requirement, also favored an exception 

for beneficiaries too feeble to travel to an office. Other commenters maintained that a 

requirement for a face-to-face encounter with an exception process could prove confusing and 

administratively challenging as it would require communication of exceptions criteria and 

audit/appeals processes. 

Response: In conjunction with adopting the AMA’s recommendation to require a faceto-face visit within 7 or 14 days of discharge for reporting the CPT TCM codes, we have also 

decided not to proceed with a requirement for a same day face-to-face visit. We agree with 

commenters who stated that such a requirement would be unrealistic in many situations, and 

would require the adoption of an exceptions process that could, unto itself, prove 

administratively difficult and confusing. At the same time, we emphasize that we believe 

physicians should seek to make an assessment and conduct the face-to-face visit as quickly as 

medically necessary after discharge in order to address patient care needs. 

Comment: As we noted above, we proposed to require communication (direct contact, 

telephone, electronic) with the patient or caregiver within 2 business days of discharge. 

Some commenters stated that the specific requirement for the physician to communicate with the 

patient within 2 business days of discharge to begin the coordination of care is unrealistic. Some 

contended that hospital discharge records are not always available that quickly. Several other 

commenters expressed concern about the references to "business days" in this requirement. 

(Other requirements, for length of TCM service and the timing of the required E/M visit are 

established in terms of calendar days for purposes of the TCM codes.) The commenters noted 

that, traditionally, business days are Monday through Friday, except for holidays. However, 

many primary care practices are also open on weekends, making those "business days" for those 

practices. Most importantly, beneficiaries’ need for medical care and care coordination is not 
297 

limited to "business days," nor are their discharges. Thus, the commenters recommended that 

CMS change "business days" to "calendar days" in this context, which, they asserted, would be 

consistent with CMS's proposal to define the code as a 30 calendar day service. The AMA CPT 

TCM codes incorporate a requirement for an interactive contact with the patient or caregiver, as 

appropriate, within 2 business days of discharge. This contact may be direct (face-to-face), 

telephonic, or by electronic means. The AMA CPT TCM codes also specify that, for purposes of 

this requirement, business days are Monday through Friday, except holidays, without respect to 

normal practice hours or date of notification of discharge. If two or more separate attempts are 

made in a timely manner, but are unsuccessful and other TCM criteria are met, the service may 

be reported. We emphasize, however, that we expect attempts to communicate to continue until 

they are successful. 

 Response: Our proposed TCM G-code contained a requirement for communication with 

the patient or caretaker within 2 business days of discharge. We also agree with the AMA’s 

assessment concerning the importance of such a requirement to meeting the goals of successful 

TCM. We also agree with the AMA’s provision to allow for billing of the TCM service if two or 

more separate, unsuccessful attempts at communication are made within a timely fashion. We 

believe that this provision should substantially reduce the concerns of some commenters about 

the tight timeline for making this initial contact. We also believe that concerns about the 

availability of hospital discharge records should decline dramatically as both hospitals and 

physicians respond to the current incentive payments (and the payment reductions beginning in 

2015) to encourage adoption of electronic health records systems. We cannot agree with those 

commenters who suggested that we should substitute “calendar days” for “business days” in this 

requirement. We do not believe that the timeframe for this requirement needs to be expressed in 

calendar days to be consistent with the 30 calendar day timeframe for the service. More 

importantly, establishing a timeframe of 2 calendar days for this initial contact would severely 
298 

disadvantage those practices which do not have regular business hours on the weekends. 

 Comment: In our proposed G-code, we required that physicians or qualified nonphysician 

practitioners must have had a face-to-face E/M visit with the beneficiary in the 30 days prior to 

the transition in care or within 14 business days following the transition in care. However, we 

allowed that, if the physician or qualified nonphysician practitioner met this requirement, the 

patient could otherwise be new to the practice. The AMA recommended that the physician 

reporting the CPT TCM codes must have an established relationship with the patient, as required 

for the those codes, rather than allowing physicians to bill for TCM services furnished to 

patients who are new to their practices. Under CPT TCM definitions, an established relationship 

with a patient exists when a physician has billed a visit with the patient within the last three 

years. Many commenters maintained that a visit within 30 days prior to the discharge was 

largely irrelevant to the actual provision of TCM services. Other commenters maintained that 

defining a pre-existing relationship as a visit within 30 days prior to the discharge is far too 

restrictive. A patient with established disease may only be seen by a physician every 3 to 6 

months. We should therefore allow an E/M service to be furnished any time in the 12 months 

prior to the discharge to be considered evidence of an established relationship. 

 Response: We agree with commenters that a visit within 30 days before the hospital 

discharge might be too restrictive for purposes of establishing an existing relationship with a 

patient. We are therefore accepting the AMA’s recommendation not to include such a 

requirement in the CPT TCM codes and note that the CPT TCM codes also do not require a visit 

within 30 days before discharge. Rather, as the AMA has recommended, we will include a 

requirement for a face-to-face visit with the beneficiary within 14 days (in the case of CPT code 

99495) or 7 days (in the case of CPT code 99495. This required visit is bundled into the 

payment for the codes and is not separately payable. We do not entirely agree with the AMA’s 

recommendation that the physician must have an established relationship prior to the discharge 
299 

with the patient to report the CPT TCM codes. We are concerned that such a requirement would 

make it impossible for an especially vulnerable group of patients, specifically, those who do not 

have an established a relationship with a primary care or other community physician, to receive 

the benefit of post-discharge TCM services. These patients may well be among those who would 

benefit most from these services, particularly because receiving TCM services could provide the 

opportunity for them to establish a continuing relationship with a physician who is able to 

assume overall management of their care. Therefore, , in conjunction with our adoption of the 

CPT TCM codes, we will develop additional Medicare-specific guidance for the use of these 

codes that modifies this element of the CPT TCM prefatory instructions, to allow a physician to 

bill these codes for new patients (provided that the physician meets visit requirement and all 

other requirements for the CPT TCM codes). It is important to note, however, that the payment 

amount for the CPT TCM codes will be the same whether the codes are billed under Medicare 

for treating new or established patients under the TCM codes. For Medicare purposes we are 

modifying the prefatory instructions for the CPT TCM codes because we wish to encourage the 

provision of TCM services to those beneficiaries who can benefit from the services – whether the 

beneficiary is a new or established patient. However, we believe that the typical case will 

involve provision of TCM services to an established patient, and relative values for codes are 

established on the basis of the typical case. Physicians may choose to bill other appropriate 

codes (for example, new patient E/M codes) that better describe the services furnished. 

 Comment: We proposed that a physician or qualified nonphysician practitioner who bills 

for discharge day management during the time period covered by the TCM services code may 

not also bill for HCPCS code GXXX1. The CPT discharge day management codes are 99217, 

99234-99236, 99238-99239, 99281-99285, or 99315-99316. The AMA/RUC and many other 

commenters recommended that a physician reporting the discharge management should also be 

able to report the new TCM service. The AMA/RUC and other commenters noted an AMA data 
300 

analysis that nearly 25 percent of those visits reported within 14 days of discharge were from the 

physician who also furnished the discharge services. The commenters emphasized that discharge 

management services reflect the work done at the time of discharge. The TCM service describes 

the work following discharge. Therefore, the commenters contended that there should be 

minimal or no overlap in the actual work performed in providing these two services. Other 

commenters emphasized that the physician or group practice billing for discharge day 

management could also be the physician or group practice regularly responsible for the patient’s 

primary care and would therefore be the appropriate physician to take responsibility for the 

patient’s transition to the community. 

 Response: We accept the AMA/RUC’s recommendation (as supported by a number of 

commenters) to allow a physician to report both the discharge management code and a CPT TCM 

code. We agree with those commenters who emphasized that the physician billing discharge day 

management could also be the physician who is regularly responsible for the beneficiary’s 

primary care (this may be especially the case in rural communities), and who would therefore be 

the appropriate physician to take responsibility for the patient’s transition to the community. 

However, we continue to be concerned that there could be some overlap in the actual work 

involved in providing these two services and, that payment to one physician for both of these 

services might be excessive as a result. Therefore, we will monitor claims data to ascertain the 

extent to which the same physician bills for both the discharge day management and TCM 

services and analyze whether it may be appropriate to develop a payment adjustment that 

recognizes overlap in resources in the future. 

 In addition, we note that the CPT TCM code prefatory language provides that the TCM 

service period “commences upon the date of discharge and continues for the next 29 days.” 

Subsequent CPT TCM language indicates that the first visit must occur within 7 or 14 calendar 

days of the date of discharge depending on the level of decision-making. We are unclear as to 
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whether the CPT TCM prefatory language intends to allow the first visit to occur on the same date 

as discharge. We note that there is a distinction between the discharge day management and 

TCM services, and we wish to avoid any implication that the E/M services furnished on the day 

of discharge as part of the discharge management service could be considered to meet the 

requirement for the TCM service that the physician or nonphysician practitioner must conduct an 

E/M service within 7 or 14 days of discharge. Therefore, we will specify that the E/M service 

required for the CPT TCM codes cannot be furnished by the same physician or nonphysician 

practitioner on the same day as the discharge management service. 

Comment: A number of commenters suggested that payment for the E/M hospital 

discharge management codes (CPT 99238 or 99239) is inadequate to reflect the discharging 

duties of the physician. While most of these commenters supported enhanced payment for 

community physicians to furnish care coordination services on the receiving end, they stated that 

a corresponding increase in payment to those physicians who are discharging patients is also 

warranted. 

Response: We continue to believe that the current hospital discharge management codes 

(CPT codes 99238 and 99239) and nursing facility discharge services (CPT codes 99315 and 

99316) adequately capture the care coordination services required to discharge a beneficiary 

from hospital or skilled nursing facility care. The work relative values for those discharge 

management services include a number of pre-, post-, and intra-care coordination activities. For 

example, the hospital discharge management codes include the following pre-, intra-, and postservice activities relating to care coordination: 

Pre-service care coordination activities include: 

● Communicate with other professionals and with patient or patient’s family. 

Intra-service care coordination activities include: 

● Discuss aftercare treatment with the patient, family and other healthcare professionals; 
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● Provide care coordination for the transition including instructions for aftercare to 

caregivers; 

● Order/arrange for post discharge follow-up professional services and testing; and 

● Inform the primary care or referring physician or qualified nonphysician practitioner of 

discharge plans. 

Post-service care coordination activities include: 

● Provide necessary care coordination, telephonic or electronic communication 

assistance, and other necessary management related to this hospitalization; and 

● Revise treatment plan(s) and communicate with patient and/or caregiver, as necessary. 

The hospital and nursing facility discharge management codes also include a number of other 

pre-, intra and post-service activities. 

 We certainly recognize that the services of physicians and other practitioners providing 

discharge management services are crucial to the overall success of TCM services. These codes 

have been valued by the AMA/RUC in the past, and these valuations have been reviewed and 

accepted by us. At this time, we are not aware of any substantive evidence that these codes are 

systematically undervalued. 

 Comment: We proposed that a physician or qualified nonphysician practitioner who bills 

for emergency department visits (99281-99285), home health care plan oversight services 

(HCPCS code G0181), or hospice care plan oversight services (HCPCS code G0182) during the 

time period covered by the TCM services code may not also bill for HCPCS code GXXX1. We 

indicated that we believed these codes describe care management services for which Medicare 

makes separate payment and should not be billed in conjunction with GXXX1, which is a 

comprehensive post-discharge TCM service. The AMA noted that for the proposed TCM Gcode we would not allow TCM services to be reported with emergency department visits, home 

health care oversight (G0181), hospice care plan oversight (G0182). The AMA CPT TCM codes 
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allow for reporting of emergency department visits. The AMA also indicated that a physician or 

other qualified health care professional who reports a TCM code may not report the CPT codes 

for care plan oversight services (99339, 99340, 99374-99380). At the same time, the CPT TCM 

codes also specify that many other codes may not be reported with TCM (for example, non-faceto-face services such as telephone calls). 

 Response: In conjunction with adopting the AMA CPT TCM, we accept the 

recommendation to allow reporting of emergency department visits when also billing the CPT 

TCM codes. We also agree with the recommendation not to allow reporting of care plan 

oversight services when also billing the CPT TCM codes. We had proposed to prohibit billing of 

the G-codes that we employ for home health care oversight (G0181), and hospice care plan 

oversight (G0182) with our proposed TCM G-code, on the grounds that such care management 

services duplicate the services provide in TCM. We are including these G-codes in the list of 

codes for such services that are precluded from billing with the CPT TCM codes, because we 

continue to believe that they are duplicative of the CPT care plan management aspects of the 

CPT TCM codes. We will also accept the AMA recommendation specifying many additional 

codes that may not be reported with CPT TCM codes (for example, non-face-to-face services 

such as telephone calls), as specified in the descriptions of CPT TCM codes 99495 or 99496 

below. We are accepting these recommendations because they similarly avoid duplicate 

payment for the same services. 

 Further, we proposed that a physician or qualified nonphysician practitioner billing for a 

procedure with a 10- or 90-day global period would not also be permitted to bill HCPCS code 

GXXX1 in conjunction with that procedure because any follow-up care management would be 

included in the post-operative portion of the global period. 

 Comment: Many commenters expressed concerns with prohibiting physicians who bill 

services with a global period from billing the TCM code as well. One commenter stated that 
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“permitting a surgeon to receive payment under these circumstances would not result in 

duplicate payment for the same service... [I]f follow-up care management included in the postoperative portion of a global period can be reimbursed separately from the proposed transitional 

care management code when performed by two different physicians, they should remain 

separately reimbursable when these functions are all performed by the same physician.” One 

commenter specifically agreed with our proposal to prohibit the billing of TCM by a physician 

providing the original care within a 010 or 090 day global period code. The AMA CPT TCM 

codes do not allow physicians billing services with global periods of 010 and 090 days to bill for 

TCM services. However, the AMA RUC recommends that specialties work with the CPT 

Editorial Panel to develop a new code for those cases in which comprehensive TCM services are 

furnished along with the services already bundled into the global codes. However, the AMA 

RUC also indicates that it would not be typical for a surgeon to furnish TCM services. 

 Response: We agree with the commenters that the physician who reports a global 

procedure should not be permitted to also report the TCM service, and we are adopting that 

policy in this final rule. The AMA RUC specifically states in its comment letter that it would not 

be typical for surgeons billing global procedures to also provide TCM services. Our goal is that 

the physician billing for TCM services should have an ongoing relationship with the beneficiary. 

We do not believe surgeons typically would be in a position to coordinate all aspects of a 

patient’s care, because their relationship with a beneficiary frequently ends after the end of the 

global period (unless or until additional surgery is required). 

We proposed that the TCM code would be payable only once in the 30 days following a 

discharge, per patient per discharge, to a single community physician or qualified nonphysician 

practitioner (or group practice) who assumes responsibility for the patient’s post-discharge TCM 

. We expressed our belief that, given the elements of the TCM service and the short time period 

during which they must be furnished, it would be unlikely that two or more physicians would 
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meet the requirements for billing the TCM code. 

 Comment: Many commenters requested clarification concerning whether the TCM codes 

could be billed again if another hospital admission and discharge occur within the initial 30 day 

period following a discharge. The commenters recommended that we allow the clock to start 

over with each admission, that is, allow for payment of TCM even when readmission occurs 

within the original 30 day period after a discharge. A few commenters recommended that CMS 

develop a mechanism to monitor readmissions for patients receiving TCM services to determine 

if this effort positively impacts beneficiary outcomes and decreases the burden on the healthcare 

system. The mechanism would require physician reporting at the beginning and end of the care 

period, and may require a “start” and a “stop” modifier to the new G-code. A few commenters 

specifically supported the “only once within 30 days of discharge” policy. The AMA’s C3W 

stipulated that the CPT TCM codes may be reported “...only once per patient within 30 days of 

discharge. Another CPT TCM code may not be reported by the same individual or group for any 

subsequent discharge(s) within the 30 days.” 

 Response: In adopting the CPT TCM codes, we believe it is appropriate to maintain the 

limitation that the codes can be billed only once per patient within 30 days of discharge, which is 

consistent with the policy we proposed for our TCM G-code. Preventing unnecessary hospital 

readmissions in the period shortly after a discharge is an important goal and part of the reason we 

proposed improved recognition and payment of TCM services (as well as other initiatives within 

the Medicare program). We believe that it would be at least inconsistent with this goal, and 

perhaps even counterproductive to it, to allow for another TCM code to be billed when a hospital 

discharge occurs within 30 days after the original discharge for which a TCM code has been 

billed. We appreciate the comments recommending that we monitor readmissions for patients 

receiving TCM services to determine if this effort positively impacts beneficiary outcomes and 

decreases the burden on the healthcare system. We will consider how to incorporate this into our 
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existing initiatives that address these issues. 

 Comment: We proposed that the TCM G-code would be payable to a single community 

physician or nonphysician practitioner (or group practice) who assumes responsibility for the 

patient’s post-discharge TCM. Many commenters recommended allowing more than one 

physician to bill a TCM code during the same 30-day period on the grounds that: “Complex 

patients often have to follow-up with more than one provider after a discharge. Each of these 

providers could be performing care coordination and should be compensated accordingly.” The 

CPT TCM codes allow for only one individual to report these services and only once per patient 

within 30 days of discharge. 

Response: We disagree that more than one physician should be allowed to bill the TCM 

codes during a single 30 day period after a discharge. Coordination of care intrinsically involves 

developing and implementing a single plan of care for a patient. Allowing multiple physicians to 

furnish this service simultaneously would introduce the danger that an individual patient might 

be subjected to inconsistent or even contradictory plans of care. In other words, allowing more 

than one physician to bill TCM codes simultaneously could lead to uncoordinated rather than 

coordinated post-discharge care. We will therefore follow the CPT TCM code rule that these 

services may be billed by only one individual during the 30 day period after discharge. 

 Comment: Other commenters recommended further restricting and/or raising the bar for 

billing TCM codes. Many objected to our proposal to pay the first physician or qualified 

nonphysician practitioner who submitted a claim because, they asserted, it would lead to an 

uncoordinated, sub-optimal “race to bill.” One of these commenters expressed concern that 

practitioners’ offices would have to compete with each other to submit the bill first. In addition, 

this commenter was concerned that practitioners’ offices would not be able to track whether or 

not they are the first to submit a claim and could get paid for the service. MedPAC noted that 

the first physician or nonphysician practitioner to submit a claim may not be providing the bulk 
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of the TCM services, and recommended raising the bar to ensure payment goes to physicians 

actually providing comprehensive primary care to the beneficiary by requiring that the billing 

provider must have billed for an E&M visit (that is, a face-to-face visit) that took place within 

the 30 days prior to admission and within the 14 days following discharge. Another commenter 

recommended that we adopt a multi-stage process of screening claims to identify the 

beneficiary’s primary care physician, who then would be the only physician permitted to bill a 

TCM code. The commenter noted that we referred to the community-based physician as the one 

who would manage and coordinate a beneficiary's care in the post-discharge period, and we 

anticipated that most community physicians will be primary care physicians and practitioners. 

The commenter also stated: “It is thus perplexing that CMS did not propose to restrict the use of 

this code to actual primary care physicians.” Others recommended employing a “plurality of 

services” determination in case more than one physician and/or nonphysician practitioner bills 

TCM after the same discharge. One commenter recommended that we should require 

beneficiaries to prospectively identify their primary care provider. 

 Response Any physician who is appropriately enrolled in Medicare and furnishes the 

service may bill for that service. We continue to expect that most community physicians who 

are furnishing TCM services will be primary care physicians and practitioners. However, we 

also believe that there will be circumstances in which cardiologists, oncologists, or other 

specialists will be in the best position to furnish transitional care coordination after a hospital 

discharge. Furthermore, we believe that the requirements for physicians or qualified 

nonphysician practitioners to furnish multiple specific services for the beneficiary within a 

restricted period of time will limit the circumstances under which more than one practitioner 

might be able to bill the TCM codes. We appreciate MedPAC’s suggestion that we require that 

the billing provider must have billed for an E/M visit (that is, a face-to-face visit) that took place 

within the 30 days prior to admission and within the 14 days following discharge. However we 
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are concerned that adopting such a policy would actually have the unintended consequence of 

prohibiting many physicians with well-established relationships and a history of providing 

comprehensive care for their beneficiaries from reporting the TCM service for these same 

patients, simply because an office visit may not have occurred within 30 days prior to a, possibly 

even unanticipated, hospitalization. After considering all these comments, we continue to 

believe that it is not necessary to develop any further restrictions or complex operational 

mechanisms to identify one and only one physician or nonphysician practitioner who may bill 

the codes for a specific beneficiary. We have used such a “first claim” policy in other areas, 

such as a radiology interpretation and the Annual Wellness Visit. However, we would expect the 

discharging physician to support TCM services by discussing post-discharge services with the 

beneficiary (which is an element in the discharge day management vignette), and to identify a 

community physician for follow-up whenever possible. Specifically, we expect discharging 

physicians and other physicians seeing beneficiaries in a facility to inform the beneficiaries that 

they should receive TCM services from their doctor or other practitioner after their discharge, 

and that Medicare will pay for those services. As a part of this disclosure to patients, we also 

expect that the discharging physician would ask the beneficiary to identify the physician or 

nonphysician practitioner whom he or she wishes to furnish these transitional care management 

services. If the beneficiary does not have a preference for the physician who would furnish these 

services, the discharging physician may suggest a specific physician who might be in the best 

position to furnish the TCM services. The recording of this information could also help in the 

transitional care coordination activities. We believe that it could be helpful for the physician 

providing discharge day management services to record the community physician who would be 

providing TCM services in the discharge medical record and the discharge instructions for 
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patients. We note that recent literature highlights the importance of these patient-centered 

communication activities for effective transitional care management.1

 As we further consider 

how Advanced Primary Care practices can fit with a fee-for-service model, we also will actively 

consider methodologies that could allow Medicare to identify the beneficiary’s 

community/primary care physician.

Comment: Many commenters endorsed our proposal not to restrict billing of this 

proposed TCM code to primary care physicians. Other commenters requested that we confirm 

that specialists can bill the new code if they meet the service requirements of comprehensive 

TCM services. Other commenters similarly requested confirmation that they can bill the TCM 

code if they meet the requirements. Some commenters from health care professions other than 

physicians, NPs, PAs, CNSs, and CNMs similarly requested that they be permitted to bill the 

CPT TCM codes and receive payment for these services. 

Response: We appreciate these comments and take this opportunity to confirm that, while 

we expect the TCM codes to be billed most frequently by primary care physicians, specialists 

who furnish the requisite services in the code descriptions may also bill the new TCM codes. As 

for nonphysician qualified health care professionals, we believe only NPs, PAs, CNSs, and 

certified nurse midwives (CNMs) can furnish the full range of E/M services and complete 

medical management of a patient under their Medicare benefit to the limit of their state scope of 

practice. Other nonphysician practitioners (such as registered dieticians, nutrition professionals 

or clinical social workers) or limited-license practitioners, (such as optometrists, podiatrists, 

doctors of dental surgery or dental medicine), are limited by the scope of their state licensing or 

their statutory Medicare benefit to furnish comprehensive medical evaluation and management 

services, and there is no Medicare benefit category that allows explicit payment to some of the 

 

1

 Hesselink MA, Schoonhoven L, Barach P et al. Improving patient handovers from hospital to 

primary care. Annals of Internal Medicine 2012; 157: 417-428. 
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other health professionals (such as pharmacists and care coordinators) seeking to bill TCM 

services. Accordingly, we will not adopt the requests of other health care professionals to bill 

the CPT TCM codes because these services go beyond the statutory benefit and state scope of 

practice for the requesting practitioners. As already discussed, we consider the separate coding 

and payment for these TCM services to be a short-term initiative as we further consider 

alternatives to ensure that any payment for primary care services would constitute a minimum 

level of care coordination, such as payments in a FFS setting. 

Comment: Several commenters requested that we extend recognition of care coordination 

to RHC physicians and providers as well or at least clarify whether providers practicing in rural 

health clinics may utilize the new HCPCS G-code. 

Response: While we recognize that RHCs have an important role in furnishing care in 

their communities, RHCs are paid an all-inclusive rate per visit. Since RHCs are not paid under 

the PFS, physicians and other RHC providers whose services are paid within the RHC allinclusive rate cannot bill using the CPT TCM codes for services furnished in the RHC. 

However, an RHC physician or other qualified provider who has a separate fee-for-service 

practice when not working at the RHC may bill the CPT TCM codes, subject to the other 

existing requirements for billing under the MPFS. 

Comment: We also proposed that the TCM G-code would be “billable only at 30 days 

post discharge or thereafter.” Although we proposed that the billing for TCM services would 

occur, as it does for most services, after the conclusion of the service that is, only at 30 days post 

discharge or thereafter), we welcomed comment on whether, in this case, there would be merit to 

allowing billing for the code to occur at the time the plan of care is established. Many 

commenters recommended that billing of TCM services should occur (as proposed) at the end of 

the 30-day TCM period. A smaller number of commenters recommended that it should be 

allowed to occur at the time the plan of care is established. One commenter observed that billing 
311 

for the post-transitional service at the time the plan of care is established may help prevent a 

“race to the billing office” by various providers, as the appropriate provider coordinating the 

post-transitional care would be well-established among the various medical providers involved in 

the patient’s care. The CPT TCM code prefatory language provides: "Only one individual may 

report these services and only once per patient within 30 days of discharge.” (Emphasis 

supplied.) 

Response: We continue to believe that the billing for TCM services under the PFS 

should occur, as it does for most fee schedule services, after the conclusion of the service (that is, 

only at 30 days post discharge or thereafter). Allowing for billing at the time the plan of care is 

established, or at any other time prior to the end of the 30 day period, would pose serious 

administrative problems. For example, adopting any policy other than billing at the end of the 30 

day service period would make it difficult to monitor the CPT TCM requirement that the code be 

billed only once in the 30 day period beginning with the discharge. It would also be very 

challenging to monitor our policy that subsequent hospital admissions during that period will not 

begin a new 30 day period and allow reporting of another TCM service. We will provide 

guidance to physicians and qualified NPPs regarding the billing of the CPT TCM codes, which 

will occur at the conclusion of the period for providing TCM services, 30 days post discharge. 

We appreciate the concern about preventing a situation where two physicians may rush to bill for 

TCM services. However, as we have previously discussed, we believe it would be quite unlikely 

that more than one physician or nonphysician practitioner will be able simultaneously to satisfy 

the numerous and complex requirements for billing the CPT TCM codes. 

Comment: Some commenters were concerned about the large number of activities that 

are required to furnish the TCM service. The commenters emphasized that many of the activities 

listed could require a lengthy discussion or actions that need to be undertaken with the patient 

that would far exceed that allowable time. Some commenters stated that the specific requirement 
312 

that the physician communicate with the patient within 2 business days of discharge to begin the 

coordination of care is unrealistic because hospital discharge records are not always available 

that quickly. Other commenters pointed to the requirement for an assessment of the patient’s 

psychosocial needs as potentially an excessively burdensome requirement. One commenter 

asked us to reconsider the requirement that these codes only cover patients of moderate to high 

complexity on the grounds that most admissions are relatively straightforward and patients do 

not require moderate to complex decision making but that these less complex patients still 

require TCM services. On the other hand, some commenters recommended additions to the 

services already listed, such as the addition of communication between the accepting primary 

care/community physician and the discharging inpatient physician.

Response: We agree with the commenters that a large number of activities are required to 

report the TCM codes. However, we believe that these requirements are entirely appropriate. As 

we have noted before, TCM services require management and coordination of all relevant 

aspects of a beneficiary’s health status in the post-discharge period. And as a number of 

commenters maintained, physicians should not undertake TCM services unless they are capable 

and willing to assume comprehensive responsibility for a patient’s care during the period of the 

service. In the light of these considerations, we believe the lengthy list of services required by 

our proposed G-code, and largely paralleled in the AMA’s CPT TCM codes that we are adopting 

in this final rule, is quite appropriate to the nature of the service. With regard to the specific 

requirement for assessment of psychosocial needs, we note again for example that depression in 

older adults occurs in a complex psychosocial and medical context and opportunities are often 

missed to improve behavioral health and general medical outcomes when mental disorders are 

under-recognized and undertreated in primary care settings. We believe that it is therefore 

important to emphasize the equal importance of the beneficiary’s mental health and his or her 

physical condition to successful discharge into the community. We believe that AMA has 
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confirmed our assessment by requiring those reporting the CPT TCM codes to oversee the 

“management and coordination of services, as needed, for all medical conditions, psychosocial 

needs and activity of daily living supports...” The AMA has also confirmed our assessment that 

patients typically require complex and multidisciplinary care modalities in the post-discharge 

period by establishing a requirement of moderate to high complexity for reporting the CPT TCM 

codes. We do not believe that it is necessary to add a formal requirement for communication 

between the accepting primary care/community physician and the discharging inpatient 

physician. The accepting community physician is responsible for reviewing the discharge 

summary, and the community physician can decide whether standard clinical practice indicates 

the need for further communication with the discharging physician. However, as indicated 

above, we note our expectation that the discharging physician will communicate with the 

community physician as necessary as part of billing for discharge day management services. 

 Comment: Some commenters recommended that we create disease specific TCM codes 

for major chronic conditions (for example, Alzheimer’s, diabetes, HIV, cancer survivors 

planning services, etc.) or for special services (for example, comprehensive medication 

management services). The commenters were concerned that, otherwise, many cognitive 

specialists and other practitioners would not be able to bill the proposed TCM G-code. 

 Response: With regard to treatment of the chronic conditions mentioned by commenters, 

both our proposed TCM G-code and the CPT TCM codes we are adopting in this final rule are 

defined broadly enough to incorporate the TCM activities involved in the treatment of patients 

with such diseases in the period after discharge. In addition, as we discuss below, we will be 

considering adoption of the complex care coordination codes developed by the AMA as we 

continue to explore payment for primary care services in future rulemaking. With regard to the 

TCM codes, we indicated in the proposed rule that we proposed the TCM G-code to recognize 

the services related to TCM by a community physician or qualified nonphysician practitioner. 
314 

We used the term community physician and practitioner to refer to the community-based 

physician managing and coordinating a beneficiary’s care in the post-discharge period. We also 

indicated that we anticipated that most community physicians would be primary care physicians 

and practitioners. This is because the nature of the services involved in TCM (for example, 

communication with patient and family education to support self-management, independent 

living, and activities of daily living, assessment and support for treatment regimen adherence and 

medication management, etc.) are characteristic of primary care services as such services are 

usually understood. At the same time, neither the TCM G-code we proposed, nor the CPT TCM 

codes we are adopting in this final rule, preclude cognitive or other specialists from reporting 

these codes when they are appropriately furnishing the required primary care services of TCM. 

We certainly want to encourage cognitive and other specialists to assume responsibility for the 

comprehensive care of patients contemplated in the requirements of the CPT TCM codes when 

they are in the position to do so during the post-discharge period. 

 Comment: A few commenters recommended that there should be special TCM G-codes 

for psychologists and others who are not permitted to bill E/M codes. 

Response: The TCM service includes “the management and/or coordination of services, 

as needed, for all medical conditions, psychosocial needs and activities of daily living.” For 

reasons we have discussed at length above, the services described in the CPT E/M codes are 

intrinsic to furnishing the TCM service. It was for this reason that the AMA decided to include a 

post-discharge, face to face E/M service as a requirement for reporting the CPT TCM codes. We 

have had a longstanding restriction on the use of E/M codes by clinical psychologists. As we 

have explained in previous rulemaking (62 FR 59057), the evaluation and management services 

included in the codes that psychologists cannot bill are services involving medical evaluation and 

management. Psychologists are not licensed to perform these types of services. Therefore, we 

do not believe it would be appropriate to provide a special TCM G-code for these practitioners. 
315 

However, we would expect the community physicians and qualified nonphysician practitioners 

to refer patients to psychologists and other mental health professionals as part of the TCM 

service when doing so is warranted by evaluation of patients’ psychosocial needs in the period 

after discharge. As indicated above, we believe the only nonphysician practitioners who may 

furnish the full range of E/M services and complete medical management of a patient under their 

Medicare benefit are NPs, PAs, CNSs, and CNMs, unless they are otherwise limited by their 

state scope of practice. Other nonphysician practitioners or limited-license practitioners, (such as 

optometrists, podiatrists, doctors of dental surgery or dental medicine), are limited by the scope 

of their state licensing or their Medicare benefit from furnishing comprehensive medical 

evaluation and management services. As already discussed, we consider these TCM services to 

be a short-term initiative as we further consider alternatives to target payment for primary care 

services. 

 Comment: Some commenters cited our statement that the proposed TCM G-code may be 

used “[d]uring transitions in care from hospital (inpatient stay, outpatient observation, and partial 

hospitalization), SNF stay, or CMHC settings to community-based care.” The commenters 

stated that this statement seems to avoid the reality that in many instances the transition from a 

hospital to a facility such as a SNF is, for all intents and purposes, the transition back to the 

community for many patients. 

Response: Individuals in SNFs are considered inpatients, and therefore the TCM codes 

may not be billed when patients are discharged to a SNF. For patients in SNFs there are E/M 

codes for initial, subsequent, discharge care, and the visit for the annual facility assessment, 

specifically CPT codes 99304-99318. These codes may be billed for SNF beneficiaries for the 

care management services they receive in the period after discharge from an acute care hospital. 

And then when SNF patients are discharged from the SNF to the community or to a nursing 

facility (even when the SNF and nursing facility are part of the same entity or located in the same 
316 

building), the physician or practitioner who furnishes transitional care management services can 

use the CPT TCM codes to bill for those services. As such, we believe there will be appropriate 

payment for transitional care management services furnished following each transition of care 

from acute inpatient, to SNF, to the community or nursing facility setting. 

After considering all these comments, and for the reasons stated above we are adopting 

the CPT TCM codes subject to the modifications described in our responses to comments on the 

issues discussed above. In summary, these specific modifications are: our decision not to restrict 

the billing of the CPT TCM codes to established patients, our clarification of the post-discharge 

service period, and our prohibition against billing a discharge day management service on the 

same day that a required E/M visit is furnished under the CPT TCM codes for the same patient. 

We will provide guidance to contractors and revise the relevant manual provisions in order to 

implement these policies. 

Below are the requirements of the CPT TCM codes as modified for Medicare purposes in 

this final rule. 

● 99495 Transitional Care Management Services with the following required elements: 

++ Communication (direct contact, telephone, electronic) with the patient and/or 

caregiver within 2 business days of discharge. 

++ Medical decision making of at least moderate complexity during the service period. 

++ Face-to-face visit, within 14 calendar days of discharge. 

● 99496 Transitional Care Management Services with the following required elements: 

++ Communication (direct contact, telephone, electronic) with the patient and/or 

caregiver within 2 business days of discharge. 

++ Medical decision making of high complexity during the service period. 

++ Face-to-face visit, within 7 calendar days of discharge. 

CPT codes 99495 and 99496 are used to report transitional care management services. 
317 

These services are for a patient whose medical and/or psychosocial problems require moderate or 

high complexity medical decision making during transitions in care from an inpatient hospital 

setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial 

hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the 

patient’s community setting (home, domiciliary, rest home, or assisted living). Transitional care 

management commences upon the date of discharge and continues for the next 29 days. 

 Transitional care management is comprised of one face-to-face visit within the specified 

time frames, in combination with non-face-to-face services that may be performed by the 

physician or other qualified health care professional and/or licensed clinical staff under his or her 

direction. It is our expectation that the services in the two lists of non-face-to-face services 

below will be routinely provided as part of transitional care management service unless the 

practitioner’s reasonable assessment of the patient indicates that a particular service is not 

medically indicated or needed. 

 Non-face-to-face services provided by clinical staff, under the direction of the physician 

or other qualified health care professional, may include: 

● Communication (direct contact, telephone, electronic) with the patient and/or caregiver 

within 2 business days of discharge. 

● Communication with home health agencies and other community services utilized by 

the patient. 

● Patient and/or family/caretaker education to support self-management, independent 

living, and activities of daily living. 

● Assessment and support for treatment regimen adherence and medication 

management. 

● Identification of available community and health resources. 

● Facilitating access to care and services needed by the patient and/or family. 
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Non-face-to-face services provided by the physician or other qualified health care 

provider may include: 

● Obtaining and reviewing the discharge information (for example, discharge summary, 

as available, or continuity of care documents). 

● Reviewing need for or follow-up on pending diagnostic tests and treatments. 

● Interaction with other qualified health care professionals who will assume or reassume 

care of the patient’s system-specific problems. 

● Education of patient, family, guardian, and/or caregiver. 

● Establishment or reestablishment of referrals and arranging for needed community 

resources. 

● Assistance in scheduling any required follow-up with community providers and 

services. 

 Transitional care management requires a face-to-face visit, initial patient contact, and 

medication reconciliation within specified time frames. The first face-to-face visit is part of the 

transitional care management service and not reported separately. Additional E/M services after 

the first face-to-face visit may be reported separately. Transitional care management requires an 

interactive contact with the patient or caregiver, as appropriate, within 2 business days of 

discharge. The contact may be direct (face-to-face), telephonic, or by electronic means. 

telephonic, or by electronic means. Medication reconciliation and management must occur no 

later than the date of the face-to-face visit. 

 Medical decision making and the date of the first face-to-face visit are used to select and 

report the appropriate transitional care management code. For 99496, the face-to-face visit must 

occur within 7 calendar days of the date discharge and medical decision making must be of high 

complexity. For 99495, the face-to-face visit must occur within 14 calendar days of the date of 

discharge and medical decision making must be of at least moderate complexity. 
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 Medical decision making is defined by the E/M Services Guidelines. The medical 

decision making over the service period reported is used to define the medical decision making 

of transitional care management. Documentation includes the timing of the initial post discharge 

communication with the patient or caregivers, date of the face-to-face visit, and the complexity 

of medical decision making. 

 (The E/M Services Guidelines define levels of medical decision making on the basis of 

the following factors: 

● The number of possible diagnoses and/or the number of management options that must 

be considered; 

● The amount and/or complexity of medical records, diagnostic tests, and/or other 

information that must be obtained, reviewed, and analyzed; and 

● The risk of significant complications, morbidity, and/or mortality as well as 

comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), 

and/or the possible management options. 

Medical decision making of moderate complexity requires multiple possible diagnoses and/or the 

management options, moderate complexity of the medical data (tests, etc.) to be reviewed, and 

moderate risk of significant complications, morbidity, and/or mortality as well as comorbidities. 

Medical decision making of high complexity requires an extensive number of possible diagnoses 

and/or the management options, extensive complexity of the medical data (tests, etc.) to be 

reviewed, and a high risk of significant complications, morbidity, and/or mortality as well as 

comorbidities) 

 Only one individual may report these services and only once per patient within 30 days of 

discharge. Another transitional care management service may not be reported by the same 

individual or group for any subsequent discharge(s) within the 30 days. The same individual 

may report hospital or observation discharge services and transitional care management. The 
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same individual should not report transitional care management services provided in the postoperative period for a service with a global period. 

 A physician or other qualified health care professional who reports codes 99495, 99496 

may not report care plan oversight services (99339, 99340, 99374-99380), prolonged services 

without direct patient contact (99358, 99359), anticoagulant management (99363, 99364), 

medical team conferences (99366-99368), education and training (98960-98962, 99071, 99078), 

telephone services (98966-98968, 99441-99443), end stage renal disease services (90951-

90970), online medical evaluation services (98969, 99444), preparation of special reports 

(99080), analysis of data (99090, 99091), complex chronic care coordination services (99481X99483X), medication therapy management services (99605-99607), during the time period 

covered by the transitional care management services codes. 

 It is very important to emphasize that we consider the non-face-to-face services to be 

furnished by physicians, qualified health care professionals, and clinical staff to be intrinsic, 

indeed essential, components of the TCM codes. To support the non-face-to-face services, the 

TCM service requires a face-to-face visit, initial patient contact, and medication reconciliation 

within specified time frames. The first face-to-face visit is part of the TCM service and may not 

be reported separately. Additional reasonable and necessary E/M services required for managing 

the beneficiary’s clinical issues in addition to the face-to-face visit may be reported separately. 

 Despite the importance of the face-to-face service that is a required element of the CPT 

TCM codes, the non-face-to-face services such as communication, referrals, education, 

identification of community resources, and medication management constitute the truly essential 

features that distinguish TCM from those services that are predominantly or exclusively face-toface in nature. 

We are adopting these new CPT TCM codes to provide a separate reporting mechanism 

for the community physician for these services in the context of the broader CMS multi-year 
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strategy to recognize and support primary care and care management. Therefore, we plan to 

monitor the use of the transitional care management billing codes. We wish to emphasize again 

that the policies we are finalizing in this final rule may be short-term payment strategies that may 

be modified and/or revised over time to be consistent with broader primary care and care 

management initiatives. Because CPT TCM codes 99495 and 99496 are new codes, they will be 

valued and designated as interim final in this final rule with comment period and subject to 

public comment. 

We would also note that this proposal coincides with our discussion under section III.J. of 

this final rule with comment period on the Value-based Payment Modifier and Physician 

Feedback Reporting Program which discusses hospital admission measures and a readmission 

measure as outcome measures for the proposed value-based payment modifier adjustment 

beginning in CY 2015. 

c. Proposed Payment for Post-Discharge Transitional Care Management Service 

To establish a physician work relative value unit (RVU) for the proposed post-discharge 

TCM, HCPCS code GXXX1, we compared GXXX1 with CPT code 99238 (Hospital discharge 

day management; 30 minutes or less) (work RVU = 1.28). We recognized that, unlike CPT code 

99238, HCPCS code GXXX1 is not a face-to-face visit. However, we believed that the 

physician time and intensity involved in post-discharge community care management is most 

equivalent to CPT code 99238 which, like the proposed new G code, involves a significant 

number of care management services. Therefore, we proposed a work RVU of 1.28 for HCPCS 

code GXXX1 for CY 2013. We also proposed the following physician times: 8 minutes preevaluation; 20 minutes intra-service; and 10 minutes immediate post-service. In addition, we 

proposed to crosswalk the clinical labor inputs from CPT code 99214 (Level 4 established 

patient office or other outpatient visit) to proposed HCPCS code GXXX1. For malpractice 

expense, we proposed a malpractice crosswalk of CPT code 99214 for HCPCS code GXXX1 for 
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CY 2013. We believe the malpractice risk factor for CPT code 99214 appropriately reflects the 

relative malpractice risk associated with furnishing HCPCS code GXXX1. In our proposal, we 

noted that, as with other services paid under the PFS, the 20 percent beneficiary coinsurance 

would apply to the post-discharge TCM service as would the Part B deductible. 

Comment: Several commenters recommended that we await the recommendations of the 

RUC and accept the RUC RVU values, so that we can fully take into account feedback from 

practicing physicians of all specialties before finalizing values for these non-face-to-face, care 

management services. With regard to the proposed RVU for physician work, a few commenters 

noted that our source code for GXXX1 included only 30 minutes of work for the discharging 

physician for whom most of the information is more readily available and that that time 

understates the effort required of the receiving physician. The commenters urged us to consider 

the significant potential variability in time and effort for the receiving physician. Another 

commenter urged CMS to utilize the work RVUs used for care plan oversight HCPCS codes 

G0181 and G0182 in valuing the new code. 

With regard to PE, another commenter recommended that we assign clinical staff type 

RN/LPN only for the clinical staff work for the TCM codes because those are the only two 

clinical staff types who furnish clinical staff TCM activities. A commenter noted that this 

proposal largely ignores equipment costs (for example, computer, electronic health record, and 

telephone) that are essential to furnishing this service, and urged us to reconsider whether 1.41 is 

an appropriate practice expense RVU amount. Another commenter noted that our source code 

for practice expense, CPT code 99214, is for moderate complexity decision-making and that we 

should consider the greater costs associated with a patient of high complexity. One commenter 

agreed with our proposed malpractice value. 

Response: We agree with commenters that any valuation under the PFS should benefit 

from as much public review and input as possible, including review by the AMA RUC. The 
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AMA RUC conducted a multi-specialty survey of 110 physicians and recommended an RVU for 

each of the new CPT TCM codes. For CPT code 99495, the AMA RUC recommended the 

median survey work RVU of 2.11 with 40 minutes of intra-service time, and for CPT code 

99496, the AMA RUC recommended the median work RVU of 3.05 with 60 minutes of intraservice time. For CPT code 99496, we disagree with the observed median intra-service time of 

60 minutes. We believe that 50 minutes of intra-service time is a more appropriate intra-service 

time for CPT code 99496. We observe that the primary reference code for CPT code 99495, 

CPT code 99214, has 25 minutes of intra-service time. We conclude that the typical physician 

time engaging in additional non-face-to-face activities and overseeing clinical staff care 

management activities is the difference between the intra-service time for CPT code 99214 and 

median intra-service time for CPT code 99495, 15 minutes. We believe that 50 minutes of intraservice time is more appropriate for CPT codes 99496 because it adds the additional non-face-toface care management time of 15 minutes, to the intra-service time for the primary reference 

CPT code 99496, which is CPT code 99215 with an intra-service time of 35 minutes. 

We appreciate comments suggesting that we value our proposed G-code, GXXX1, 

comparable to CPT codes G0180 and G0181. However, because we not finalizing the proposed 

G-codes and instead are adopting the CPT TCM codes on an interim final basis in this final rule 

with comment period, we believe that the AMA RUC recommendation, which reflects the 

services we included in the proposed G-code as well as a face-to-face visit, is a more basis for 

appropriate valuation. In response to comments noting that the discharge day management 

source code, CPT code 99238, for GXXX1, does not contain sufficient time for the receiving 

physician and that the time does not reflect differences in the complexity of decision-making, we 

note that we are adopting AMA RUC recommended times as modified in the preceding 

paragraph on an interim final basis, with refinement, which include a longer time than the 

proposed time of 30 minutes, and those times are specific to the level of complexity. We also 
324 

note that there is a significant amount of clinical labor time incorporated in the practice expense 

calculation for these codes. In summary, we are assigning a work RVU of 2.11 to CPT TCM 

code 99495 with intra-service time of 40 minutes, and a work RVU of 3.05 with intra-service 

time of 50 minutes. The work RVUs included in Addendum B to this final rule with comment 

period reflect these interim final values. The physician time file associated with this PFS final 

rule with comment period is available on the CMS website in the Downloads section for the CY 

2013 PFS final rule with comment period at www.cms.gov/PhysicianFeeSched/. 

Consistent with our policy discussed in section II.C.1. of this final rule with comment 

period for assigning malpractice RVUs, we developed malpractice RVUs for the new CPT TCM 

codes. For CPT code 99495, the AMA RUC recommended a malpractice risk factor crosswalk 

to CPT code 99214, resulting in a malpractice RVU of 0.14 for CPT code 99495. For CPT code 

99496, the AMA RUC recommended a malpractice risk factor crosswalk to CPT code 99215, 

resulting in a malpractice RVU of 0.20 for CPT code 99496. We are accepting the AMA RUC’s 

recommended malpractice crosswalks for CPT codes 99495 and 99496 on an interim final basis. 

We appreciate comments in support of our proposed malpractice value for our non-face-to-face 

G-code, GXXX1, of 0.09. We believe that the interim final malpractice crosswalks 

recommended by the AMA RUC provide appropriate malpractice values for the CPT TCM 

codes, which include a face-to-face visit. 

For practice expense, we are accepting the AMA RUC-recommended practice expense 

inputs for these codes with one refinement to clinical labor time for CPT code 99496. We are 

refining the 60 minutes of recommended clinical labor time for a RN/LPN nurse blend dedicated 

to non-face-to-face care management activities from 60 minutes to 70 minutes. We believe that 

the total clinical labor staff time and physician intra-service work time that the AMA RUCrecommended for non-face-to-face care management activities was accurate, but that the 

proportionality between physician work and clinical staff time should be refined to reflect greater 
325 

clinical staff time. In response to the comment on appropriate clinical staff type for non-face-toface care management services, we note that we are accepting the AMA RUC recommended 

clinical labor staff type of an RN/LPN for conducting non-face-to-face care coordination 

activities. The AMA RUC did not include additional costs for computer, EHR, and telephone in 

their recommendations. We believe accounting for the infrastructure required to furnish 

advanced primary care services is an issue we will consider as we pursue the broader HHS and 

CMS multi-year strategy to recognize and support primary care and care management under the 

MPFS. 

The CY 2013 final rule with comment period direct PE input database reflects these 

inputs and is available on the CMS website under the supporting data files for the CY 2013 PFS 

final rule with comment period at www.cms.gov/PhysicianFeeSched/. The PE RVUs included in 

Addendum B to this final rule with comment period reflect the RVUs that resulted from adopting 

these interim final values. 

For BN calculations, we estimated that physicians or qualified nonphysician practitioners 

would furnish post-discharge TCM services for 10 million discharges in CY 2013. We estimated 

that this number roughly considers the total number of hospital inpatient and SNF discharges, 

hospital outpatient observation services and partial hospitalization patients that may require 

moderate to high complexity decision-making following discharge. 

 Comment: Some commenters indicated that our estimate of the number of claims we 

would receive for the transitional care services was overstated. Using a different set of 

assumptions, the AMA RUC commented that the number of billings would be closer to 2 million 

per year. The AMA RUC provided us with detailed utilization assumptions for the CPT TCM 

codes. These detailed utilization assumptions indicated physicians would bill 2,166,719 claims 

in CY 2013 for the CPT TCM codes, with 60 percent of those claims for CPT TCM code99495 

and 40 percent for CPT TCM code99496. Commenters also indicated that we should offset the 
326 

cost of the TCM codes in our BN calculation with savings from reduced readmissions to 

hospitals and other facilities. 

 Response: The estimate of the number of billings we will receive in CY 2013 for TCM 

services is sensitive to the utilization assumptions used and cannot be easily derived from 

existing codes. The number of discharge day management visits that are billed to Medicare is 

approximately 10 million. As reflected in the RUC recommendations, we agree with 

commenters that this is a reasonable starting point in the development of the estimate for the 

number of billings for the TCM services. 

The next step is to determine how many of these discharges will be readmissions in CY 

2013. Since the patient would only be eligible for one TCM service associated with a hospital 

discharge and the later readmission, we are not counting the readmission in our utilization 

estimate. The AMA RUC used an estimate of 19.6 percent. We disagree with this estimate. 

More recent work by MedPAC indicates that the all cause readmission rate was closer to 15 

percent in CY 2011.2

 Accordingly, we adopted a 15 percent readmission rate. 

The AMA RUC also cited a variety of factors that it believes will reduce the number of 

billings from the universe of discharges, including the number of patients requiring moderate or 

high complexity decision-making based on the percentage of high cost Medicare patients in the 

Medicare population, the number of patients currently seen within 14 days of discharge, 

discharges where the primary care physician didn't know patient was in the hospital, cases where 

the patient couldn't be contacted or seen, cases where the patient died, cases where the patient 

changed doctors or didn't see the primary care doctor, and cases for which physicians will not 

furnish the TCM service as rapidly as we have assumed. The AMA RUC provided assumptions 

 

2

MedPAC September 7, 2012 Public Meeting Transcript, page 94, at 

http://medpac.gov/transcripts/092012_transcript.pdf,, or slide 4 at 

http://www.medpac.gov/transcripts/readmissions%20Sept%2012%20presentation.pdf. 
327 

about the number of discharges it believes will not result in the billing of a TCM service. We 

have posted the AMA RUC calculation on our website at www.cms.gov/PhysicianFeeSched/. 

While we generally agree that some of these factors will impact the billings for the TCM code, 

we believe that the construct of the RUC estimate with assumed exact values for each and every 

one of these factors understates the likely TCM billings. 

In considering this and similar comments, we examined the current distribution of the 

inpatient, observation, and nursing facility evaluation and management codes. Within each of 

these families, we also examined the severity of the presenting problems and the level of 

complexity of the medical decision-making to help differentiate the codes. We found that 85 

percent of Hospital Observation and Initial and Subsequent Hospital Care services (CPT codes 

99218-99233) were at Level 2 or Level 3, generally indicating moderate to high severity and 

complexity. We note that over 90 percent of place of service designations for the discharge 

codes are inpatient or outpatient hospital. We found that 43 percent of Nursing Facility Care 

services (CPT codes 99304-99310) were at Level 2 or Level 3, generally indicating moderate to 

high severity and complexity. Although less relevant for the TCM policy, we also examined the 

Office or Other Outpatient visits (CPT codes 99201-99213) as a point of comparison and found 

that 41 percent of services were at Level 4 or Level 5, generally indicating moderate to high 

severity and complexity. 

In light of the data on the current severity and complexity levels of the evaluation and 

management services, and after consideration of the factors included in the AMA RUC estimate 

and removing 15 percent for readmissions, we believe that two-thirds of the discharges reflected 

in the discharge day management codes, are likely to result in TCM claims. This represents 

approximately 5.7 million claims [=10 million discharges * (1-.15) for readmissions * (2/3) for 

severity and other factors)]. 

We disagree with the RUC that 60 percent of those claims will be for 99495 and 40 
328 

percent for 99496. In looking at the relationship between the moderate and high Hospital 

Observation and Initial and Subsequent Hospital Care services (CPT codes 99218-99233) and 

the relationship between the moderate and high Nursing Facility Care services (99304-99310), 

we believe a more reasonable estimate is that 75 percent of the TCM claims will be for 99495 

and 25 percent for 99496. 

Because the practice expense RVUs for the transitional care codes will vary depending 

on whether or not the service is billed in a facility or non-facility setting, , we also need to further 

refine the estimate to determine the proportion of TCM services that will be paid at the facility 

rate versus the non-facility rate. After examining the facility and non-facility distribution of the 

99214 and 99215 visit codes billed by primary care specialties, we believe that 92 percent of the 

TCM services will be billed in the non-facility setting. 

Lastly, we agree with the RUC that 26 percent of patients had at least one visit within 7 

calendar days of discharge and 44 percent had one within 14 days of discharge. Because these 

are existing visits that will potentially now be billed as part of the TCM service, we partially 

offset the cost of the TCM services with the cost of the existing visits assumed to be billed as 

part of the CPT TCM code. 

For the comments requesting that we also offset the cost of the CPT TCM codes in our 

BN calculation with savings from reduced readmissions, there are currently many efforts 

underway to reduce hospital readmissions. We do not believe that it would be possible to isolate 

the effect of payment for TCM services on the readmission rate. Furthermore, the statute does 

not permit costs or savings from outside of the physician fee schedule to be used in the physician 

fee schedule BN calculation. 

For purposes of the Primary Care Incentive Payment Program (PCIP), we proposed to 

exclude the post discharge TCM services from the total allowed charges used in the denominator 

calculation to determine whether a physician is a primary care practitioner. Under section 
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1833(x) of the Act, the PCIP provides a 10 percent incentive payment for primary care services 

within a specific range of E/M services when furnished by a primary care practitioner. Specific 

physician specialties and qualified nonphysician practitioners can qualify as primary care 

practitioners if 60 percent of their PFS allowed charges are primary care services. As we 

explained in the CY 2011 PFS final rule (75 FR 73435-73436), we do not believe the statute 

authorizes us to add codes (additional services) to the definition of primary care services. 

However, to avoid inadvertently disqualifying community primary care physicians who follow 

their patients into the hospital setting, we finalized a policy to remove allowed charges for 

certain E/M services furnished to hospital inpatients and outpatients from the total allowed 

charges in the PCIP primary care percentage calculation. 

In the proposed rule, we also proposed that the TCM code should be treated in the same 

manner as those services for the purposes of PCIP because post-discharge TCM services are a 

complement in the community setting to the hospital-based discharge day management services 

already excluded from the PCIP denominator. Similar to the codes already excluded from the 

PCIP denominator, we expressed concern that inclusion of the TCM code in the denominator of 

the primary care percentage calculation could produce unwarranted bias against “true primary 

care practitioners” who are involved in furnishing post-discharge care to their patients. 

Therefore, while physicians and qualified nonphysician practitioners who furnish TCM services 

would not receive an additional incentive payment under the PCIP for the service itself (because 

it is not considered a “primary care service” for purposes of the PCIP), the allowed charges for 

TCM services would not be included in the denominator when calculating a physician’s or 

practitioner’s percent of allowed charges that were primary care services for purposes of the 

PCIP. 

 Comment: Some commenters recommended that the proposed TCM G-codes should be 

eligible for the PCIP. The commenters acknowledged that, to add our proposed G-code to the 
330 

codes eligible for PCIP, we would have to revise our previous interpretation concerning the 

extent of the Secretary’s discretion to modify the list of primary care E/M services eligible for 

PCIP. However, the commenters stated that our previous interpretation of the statutory language 

was incorrect, or at least not the only reasonable interpretation of the statutory language. A few 

commenters opposed excluding the allowed charges for TCM services from the denominator of 

the ratio used to determine qualification for the PCIP. 

 Response: We continue to believe that the statute does not permit us to add codes 

(additional services) to the statutory definition of primary care services, which is a range of E/M 

services including office visits. The new CPT TCM codes fall outside the designated range of 

codes that qualify for the PCIP. Therefore, we cannot agree with those commenters who 

contended that it is permissible to add the new TCM codes to the list of codes eligible for PCIP. 

However, to avoid disadvantaging physicians who furnish post-discharge TCM services to their 

patients, we are finalizing our proposal to exclude the allowed charges for TCM services from 

the denominator when calculating a physician’s or practitioner’s percent of allowed charges that 

were primary care services for purposes of the PCIP. 

 Comment: Many commenters urged us not to apply the 20 percent beneficiary 

coinsurance to TCM services. Some commenters stated a belief that we should categorize TCM 

as a preventive service and that we should therefore waive the coinsurance for the service. Other 

commenters expressed concern that beneficiaries will not understand their coinsurance liability 

for this service, since our proposed new post-discharge TCM G-code would not include a faceto-face visit. Some commenters were also concerned that this confusion would lead to increased 

bad debt for physicians and qualified NPPs billing the CPT TCM codes. Others urged us to 

work with the Congress to enact legislation to waive the beneficiary coinsurance for postdischarge care management services. On the other hand, some commenters noted that requiring 

a face-to-face E/M visit when billing the TCM code would reduce potential beneficiary 
331 

confusion about the coinsurance for the TCM service. 

 Response: We appreciate the reasons commenters have offered for waiving the 

beneficiary coinsurance for TCM as a preventive service. However, we do not believe we have 

authority to do so through the rulemaking process. This is because section 1861(ddd)(1)(B) of 

the Act requires, among other criteria, that “additional preventive services” can be added only if 

such services are recommended with a grade of A or B by the United States Preventive Services 

Task Force. We lack such a recommendation regarding the services described by the new CPT 

TCM codes. As we have discussed above, we agree with those commenters who observed that 

requiring a face-to-face E/M visit when billing the TCM code would reduce potential beneficiary 

confusion about the coinsurance for the TCM service. Now that we have modified our proposal 

for a TCM service to include a face-to-face service, beneficiaries will experience a face-to-face 

encounter to which they can relate their copayments for the service. We therefore believe that 

our adoption of the CPT TCM codes that include a required face-to-face visit as a component of 

the service will greatly reduce the potential for beneficiary confusion over the coinsurance for 

the service and the possibility of increased bad debt for physicians. 

2. Primary Care Services Furnished in Advanced Primary Care Practices 

a. Background 

 As we discussed above, we are committed to considering new options and developing 

future proposals for payment of primary care services under the MPFS. Such options would 

promote comprehensive and continuous assessment, care management, and attention to 

preventive services that constitute effective primary care by establishing appropriate payment 

when physicians furnish such services. One potential method for ensuring that any targeted 

payment for primary care services would constitute a minimum level of care coordination and 

continuous assessment under the MPFS would be to pay physicians for services furnished in an 

“advanced primary care practice” that has implemented a medical home model supporting 
332 

patient-specific care. The medical home model has been the subject of extensive study in 

medical literature. Since 2007, the AMA, American Academy of Family Physicians (AAFP), the 

American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the 

American Osteopathic Association (AOA), and many other physician organizations have also 

endorsed “Joint Principles of the Patient-Centered Medical Home.” In February 2011, the 

AAFP, the AAP, the ACP, and AOA also published formal “Guidelines for Patient-Centered 

Medical Home (PCMH) Recognition and Accreditation Programs” to develop and promote the 

concept and practice of the PCMH. (These guidelines are available at 

www.aafp.org/online/etc/medialib/aafp_org/documents/membership/pcmh/pcmhtools/pcmhguid

elines.Par.0001.File.dat/GuidelinesPCMHRecognitionAccreditationPrograms.pdf.) As we have 

discussed above, the Innovation Center has been conducting several initiatives based on the 

medical home concept. 

The medical home concept emphasizes establishing an extensive infrastructure requiring 

both capital investments and new staffing, along with sophisticated processes, to support 

continuous and coordinated care with an emphasis on prevention and early diagnosis and 

treatment. The literature, reports, and guidelines dealing with the medical home concept define 

the requisite elements or functions that constitute this infrastructure and processes in various 

ways. For example, the Innovation Center’s CPC initiative identified a set of five 

“comprehensive primary care functions,” which form the service delivery model being tested and 

the required framework for practice transformation under the CPC initiative. In the proposed 

rule (77 FR 44780), we discussed these five “comprehensive primary care functions” as an 

appropriate starting point for discussing the incorporation of the comprehensive primary care 

services delivered in advanced primary care practices (practices implementing a medical home 

model) into the MPFS. These five functions are: risk-stratified care management, access and 

continuity, planned care for chronic conditions and preventive care, patient and caregiver 
333 

engagement, and coordination of care across the medical neighborhood. (See our detailed 

discussion of these functions at the citation noted above.) 

In the proposed rule, we also discussed the need to establish a set of parameters to 

determine whether or not a clinical practice could be considered an advanced primary care 

practice (medical home) in the event that we were to establish an enhanced payment for primary 

care services furnished to Medicare beneficiaries in an advanced primary care practice 

environment. (77 FR 44781-44782) Specifically, we discussed two possible approaches to 

determining whether a practice has implemented all the necessary functions to be considered an 

advanced primary care practice or medical home. One approach would be to recognize one or 

more of the nationally available accreditation programs currently in use by major organizations 

that provide accreditation for advanced primary care practices, frequently credentialed as 

“PCMHs.” We identified four national models that provide accreditation for organizations 

wishing to become an advanced primary care practice; the Accreditation Association for 

Ambulatory Health, The Joint Commission, the NCQA, and the Utilization Review 

Accreditation Commission (URAC). Alternatively, we could develop our own criteria using, for 

example, the five functions of comprehensive primary care used in the CPC initiative and 

described above, to determine what constitutes advanced primary care for purposes of Medicare 

payment. We would then need to develop a process for determining whether specific physician 

practices meet the criteria for advanced primary care. This could include creating our own 

processes for review or could include using existing accrediting bodies to measure compliance 

against advanced primary care criteria determined by CMS. 

 We also discussed another potential issue surrounding comprehensive primary care 

services delivered in an advanced primary care practice, specifically attribution of a beneficiary 

to an advanced primary care practice. (77 FR 44782) In a fee-for-service environment we 

would need to determine which practice is currently serving as the advanced primary care 
334 

practice for the beneficiary to ensure appropriate payment. One method of attribution could be 

that each beneficiary prospectively chooses an advanced primary care practice. Other attribution 

methodologies might examine the quantity and type of E/M or other designated services 

furnished to that beneficiary by the practice. We welcomed input on the most appropriate 

approach to the issue of how to best determine the practice that is functioning as the advanced 

primary care practice for each beneficiary. We emphasized that we would not consider 

proposals that would restrict a beneficiary’s free choice of practitioners. 

In summary, we stated our belief that targeting primary care management payments to 

advanced primary care practices could have many merits, including ensuring a basic level of care 

coordination and care management. We recognize that the advanced primary care model has 

demonstrated efficacy in improving the value of health care in several contexts, and we are 

exploring whether we can achieve these outcomes for the Medicare population through several 

demonstration projects. Careful analysis of the outcomes of these demonstration projects will 

inform our understanding of how this model of care affects the Medicare population and of 

potential PFS payment mechanisms for these services. At the same time, we also believe that 

there are many policy and operational issues to be considered when nationally implementing 

such a program within the PFS. Therefore, we generally invited broad public comment on the 

accreditation and attribution issues discussed above and any other aspect, including payment, of 

integrating an advanced primary care model into the PFS. 

 We received many helpful and informative comments on the issues we discussed in 

relation to recognizing advanced primary care practices, especially on the criteria and processes 

that should be used to identify such practices. We welcome these comments because we are 

actively considering such an advanced primary care practice model in the near future after a 

complete assessment of the results of ongoing demonstrations and policy and operational 

considerations. 
335 

We also received many comments recommending that we adopt the complex care 

coordination codes developed by the AMA’s C3W for CY 2013. As discussed in section 

III.M.3.a. of this final rule with comment period, on an interim final basis for CY 2013, we are 

assigning CPT codes 99487, 99488, and 99489 a PFS procedure status indicator of B (Payments 

for covered services are always bundled into payment for other services, which are not specified. 

If RVUs are shown, they are not used for Medicare payment. If these services are covered, 

payment for them is subsumed by the payment for the services to which they are bundled (for 

example, a telephone call from a hospital nurse regarding care of a patient). We will consider 

these codes, as well as other payment approaches as we continue our multi-year strategy to 

recognize and support primary care and care management. 

I. Payment for Molecular Pathology Services

The AMA CPT Editorial Panel has created new CPT codes to replace the codes used to 

bill for molecular pathology services that will be deleted at the end of CY 2012. The new codes 

describe distinct molecular pathology tests and test methods. CPT divided these molecular 

pathology codes into Tiers. Tier 1 codes describe common gene-specific and genomic 

procedures. Tier 2 codes capture reporting for less common tests. Each Tier 2 code represents a 

group of tests that the CPT Editorial Panel believes involve similar technical resources and 

interpretive work. The CPT Editorial Panel created 101 new molecular pathology CPT codes for 

CY 2012 and another 14 new molecular pathology codes for CY 2013. 

We stated in our notice for the Clinical Laboratory Fee Schedule (CLFS) Annual Public 

Meeting held on July 16, 2012 (77 FR 31620) that we were following our regular process to 

determine the appropriate basis and payment amounts for new clinical diagnostic laboratory 

tests, including molecular pathology tests, under the CLFS for CY 2013. However, we also 
336 

stated that we understand stakeholders in the molecular pathology community continue to debate 

whether Medicare should pay for molecular pathology tests under the CLFS or the PFS. 

Medicare pays for clinical diagnostic laboratory tests through the CLFS and for services that 

ordinarily require physician work through the PFS. We stated that we believed we would benefit 

from additional public comments on whether these tests are clinical diagnostic laboratory tests 

that should be paid under the CLFS or whether they are physicians’ services that should be paid 

under the PFS. Therefore, we solicited public comment on this issue in the CY 2013 PFS 

proposed rule (77 FR 44782 and 44783), as well as public comment on pricing policies for these 

tests under the CLFS during the CLFS Annual Public Meeting process. 

In the PFS proposed rule, we first discussed and requested public comment on whether 

these molecular pathology CPT codes describe services that ordinarily require physician work, 

and then we discussed our proposal to address payment for these CPT codes on the PFS, pending 

public comment and resolution of the first question. The PFS proposal paralleled the CLFS 

Annual Public Meeting process during which we receive comments and recommendations on the 

appropriate basis for establishing a payment amount for the molecular pathology CPT codes as 

clinical diagnostic laboratory tests under the CLFS. 

As detailed in section II.B.1. of this final rule with comment period, Medicare establishes 

payment under the PFS by setting RVUs for work, practice expense (PE), and malpractice 

expense for services that ordinarily require physician work. To establish RVUs for physician 

work, we conduct a clinical review of the relative physician work (time by intensity) required for 

each PFS service. This clinical review includes the review of RVUs recommended by the 

American Medical Association/Specialty Society Relative Value Scale Update Committee 

(AMA RUC) and others. The AMA RUC-recommended work RVUs for a service typically are 

based in part on results of a survey conducted by the relevant specialty society. CMS establishes 

PE RVUs under a resource-based PE methodology that considers the cost of direct inputs, as 
337 

well as indirect PE costs. The AMA RUC, through the Practice Expense Subcommittee, 

recommends direct PE inputs to CMS, and the relevant specialty societies provide pricing 

information for those direct inputs to CMS. After we determine the appropriate direct PE inputs, 

the PE methodology is used to develop PE RVUs. Physician work and PE RVUs for each CPT 

code are constructed to reflect the typical case; that is, they reflect the service as it is most 

commonly furnished (71 FR 69629). CMS establishes resource-based malpractice expense 

RVUs using weighted specialty-specific malpractice insurance premium data collected from 

commercial and physician-owned insurers, last updated for the CY 2010 final rule (74 FR 

61758). For most services paid under the PFS, beneficiary cost-sharing is 20 percent of the fee 

schedule payment amount. 

CMS establishes a payment rate for new clinical diagnostic laboratory tests under the 

CLFS by either crosswalking or gap-filling. Crosswalking is used when a new test code is 

comparable to an existing test code, multiple existing test codes, or a portion of an existing test 

code on the CLFS. Under this methodology, the new test code is assigned the local fee schedule 

amounts and the national limitation amount (NLA) of the existing test, with payment made at the 

lesser of the local fee schedule amount or the NLA. Gap-filling is used when no comparable test 

exists on the CLFS. In the first year a test is gap-filled, contractor-specific amounts are 

established for the new test code using the following sources of information: charges for the test 

and routine discounts to charges; resources required to perform the test; payment amounts 

determined by other payers; and charges, payment amounts, and resources required for other 

tests that may be comparable or otherwise relevant. For the second year, the NLA is calculated, 

which is the median of the carrier-specific amounts. See §414.508. Services paid under the 

CLFS do not account for any physician work, although tests paid under the CLFS can involve 

assessment by a laboratory technician/technologist, a chemist, molecular biologist, or a geneticist 

– none of which are health care professional occupations that meet the statutory definition of a 
338 

physician. Although payments can vary geographically due to contractor discretion across 

locality areas (which are the same localities used for the GPCIs under the PFS), payments cannot 

exceed a NLA, nor are they adjusted once rates are determined (apart from inflation updates as 

required by statute). In the CY 2008 PFS final rule with comment period, we adopted a 

prospective reconsideration process for new tests paid under the CLFS, allowing a single year for 

Medicare and stakeholders to review pricing for new tests after a payment is initially established 

through crosswalking, and in certain circumstances, up to 2 years for Medicare and stakeholders 

to review pricing for new tests after a payment is initially established through gap-filling (72 FR 

66275 through 66279, 66401 through 66402). Finally, in almost all circumstances, there is no 

beneficiary cost-sharing for clinical laboratory diagnostic tests paid on the CLFS. 

 For a handful of clinical laboratory services paid under the CLFS, we allow an additional 

payment under the PFS for the professional services of a pathologist when they meet the 

requirements for a clinical consultation service as defined in §415.130(c). The PFS pays for 

services that ordinarily require the work of a physician and, with regard to pathology services, 

explicitly pays for both the professional and technical component of the services of a pathologist 

as defined in §415.130(b), including surgical pathology, cytopathology, hematology, certain 

blood banking services, clinical consultations, and interpretive clinical laboratory services. 

Molecular pathology tests are currently billed using combinations of longstanding CPT 

codes that describe each of the various steps required to perform a given test. This billing 

method is called “stacking” because different “stacks” of codes are billed depending on the 

components of the furnished test. Currently, all of the stacking codes are paid through the CLFS; 

and one stacking code, CPT code 83912 (molecular diagnostics; interpretation and report), is 

paid on both the CLFS and the PFS. Payment for the interpretation and report of a molecular 

pathology test when furnished and billed by a physician is made under the PFS using the 

professional component (PC, or modifier 26) of CPT code 83912 (83912-26). Payment for the 
339 

interpretation and report of a molecular pathology test when furnished by nonphysician 

laboratory professional is bundled into payment made under the CLFS using CPT code 83912. 

As we stated in the CY 2013 PFS proposed rule (77 FR 44783), since the creation of new 

molecular pathology CPT codes, there has been significant debate in the stakeholder community 

regarding whether these new molecular pathology CPT codes describe physicians’ services that 

ordinarily require physician work and would be paid under the PFS, or whether they describe 

clinical diagnostic laboratory tests that would be paid on the CLFS. In the CY 2013 PFS 

proposed rule (77 FR 44783), we stated that there is little agreement on whether the technical 

component and/or professional component (interpretation and report) of these services are 

ordinarily furnished by a physician or a nonphysician laboratory professional. Additionally, we 

stated that some stakeholders have suggested that interpretation and report by any health care 

professional is generally not necessary for these services, as the laboratory result reporting is 

becoming more automated. 

In the CY 2012 PFS final rule with comment period (76 FR 73190), we stated that for CY 

2012, Medicare would continue to use the existing stacking codes for the reporting and payment 

of these molecular pathology tests, and that the new molecular pathology CPT codes would not 

be valid for payment for CY 2012. We did this because we were concerned that we did not have 

sufficient information to know whether the new molecular pathology CPT codes describe clinical 

diagnostic laboratory tests or services that ordinarily require physician work. In the PFS 

proposed rule, we stated that, for CY 2013, we continue to have many of the same concerns that 

led us not to recognize the 101 molecular pathology CPT codes for payment for CY 2012. We 

requested comment on whether the new molecular pathology CPT codes describe physicians’ 

services that should be paid under the PFS, or whether they describe clinical diagnostic 

laboratory tests that should be paid under the CLFS. We also requested comment on the 

following more specific questions: 
340 

● Do each of the 101 molecular pathology CPT codes describe services that are 

ordinarily furnished by a physician? 

● Do each of these molecular pathology CPT codes ordinarily require interpretation and 

written report? 

● What is the nature of that interpretation and does it typically require physician work? 

● Who furnishes interpretation services and how frequently? 

In the CY 2013 PFS proposed rule, we also proposed to price all of the new molecular 

pathology CPT codes through a single fee schedule, either the CLFS or the PFS. We stated that 

after meeting with stakeholders and reviewing each CPT code, we believed that there are a 

discrete number of laboratory methods used to generate results across molecular pathology tests. 

For example, two different tests (represented by different CPT codes) may be run using the same 

testing methodologies, but using different genes. However, there are very different processes for 

establishing payment rates under the PFS and the CLFS. As discussed above, Medicare sets 

payment under the CLFS by either crosswalking or gap-filling and, after the prospective 

reconsideration process we do not adjust the payment amount further (apart from inflation 

updates as required by statute). In contrast, Medicare sets payment under the PFS through a set 

of resource-based methodologies for physician work, PE, and malpractice expense, and payment 

can be reviewed and adjusted as the resources required to furnish a service change. We stated 

that we were concerned that establishing different prices for comparable laboratory services 

across two different payment systems would create a financial incentive to choose one test over 

another simply because of its fee schedule placement. We stated that we were also concerned 

that the differences in prices would become more pronounced over time, as we continue to 

review the values for physician work and PE inputs on the PFS relative to established CLFS 

prices. Therefore, largely because of the homogeneity of the laboratory methodologies behind 

these procedure test codes, we stated that we believe that it is appropriate for all new molecular 
341 

pathology CPT codes to be priced on the same fee schedule using the same methodology. We 

invited public comment on that proposal. 

As we considered public comment on whether these molecular pathology CPT codes 

describe services that ordinarily require physician work, we wanted to ensure that there was a 

payment mechanism in place to pay for these CPT codes for CY 2013, either on the PFS or the 

CLFS. We stated that, because we believe that these molecular pathology CPT codes may be 

clinical diagnostic laboratory tests payable on the CLFS, comments and recommendations from 

the public on the appropriate basis for establishing payment amounts on the CLFS would be 

discussed and received through the CY 2013 CLFS Annual Public Meeting process. More 

information on these tests is available on the CMS website at 

www.cms.hhs.gov/ClinicalLabFeeSched. 

As a parallel to determining the appropriate basis and payment amounts for the molecular 

pathology CPT codes as clinical diagnostic laboratory tests through the CLFS Annual Public 

Meeting process, we also proposed payment for these codes under the PFS for CY 2013. In the 

CY 2013 PFS proposed rule, we stated that the AMA RUC and the College of American 

Pathologists (CAP) provided CMS with recommendations for physician work RVUs and PE 

inputs for most of the molecular pathology CPT codes. We did not have recommendations on 

physician work RVUs or direct PE inputs for a small number of codes, which represent tests that 

are patented, and therefore the methodology used to furnish the test is proprietary and was 

unavailable to the AMA RUC or CMS to support developing appropriate work and direct PE 

inputs. As we stated in the PFS proposed rule, the AMA RUC-recommended physician work 

RVUs range from 0.13 to 2.35, with a median work RVU of 0.45. The AMA RUCrecommended physician intra-service times (which, for these codes, equals the total times) range 

from 7 minutes to 80 minutes, with a median intra-service time of 18 minutes. We noted that the 

physician work RVU for CPT code 83912-26 and all but one of the other clinical diagnostic 
342 

laboratory services for which CMS recognizes payment for clinical interpretation is 0.37. Table 

27 lists AMA RUC-recommended physician work RVUs and times, as well as the AMA RUCestimated CY 2013 utilization for these codes. This table contains the AMA RUC’S estimated 

CY 2013 utilization for all 115 molecular pathology codes effective for CY 2013 and 

recommended physician work RVUs and times only for those codes that CAP believes are 

ordinarily performed by a physician. These values are listed for reference only and were not 

used for PFS rate-setting. 

As we stated in the PFS proposed rule, molecular pathology tests can be furnished in 

laboratories of different types and sizes (for example, a large commercial laboratory, academic 

or research laboratory, typically hospital-based, or potentially, a pathology group practice), and 

tests may be furnished in small or large batches. Also, although there are largely homogenous 

methods across the different tests considered here, we recognize that for a specific test, the 

combination of methods may vary across different laboratories. When developing direct PE 

input recommendations for CMS, CAP and the AMA RUC made assumptions about the typical 

laboratory setting and batch size to determine the typical direct PE inputs for each service. 

Given that many of these services are furnished by private laboratories, it was challenging for 

CAP and the AMA RUC to provide recommendations on the typical inputs for many services, 

and not possible for other services. We posted the AMA RUC- and CAP-recommended direct 

PE inputs on the CMS website in the files supporting the CY 2013 PFS proposed rule at 

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-FederalRegulation-Notices.html. We stated in the CY 2013 PFS proposed rule (77 FR 44784) that we 

appreciate all of the effort CAP has made to develop national pricing inputs; however, we agree 

with its view that, in many cases, there is no established approach for the specific number and 

combination of methods involved in executing many of these tests and that the potential 

pathways for a laboratory or pathology group practice to execute these tests can vary 
343 

considerably. 

As we discussed in the CY 2013 PFS proposed rule, in addition to recommendations on 

physician work and direct PE inputs, the AMA RUC provided CMS with recommended 

utilization crosswalks for most of the molecular pathology tests. When there are coding changes, 

the utilization crosswalk tracks Medicare utilization from an existing code to a new code. The 

existing code utilization figures are drawn from Medicare Part B claims data. We use utilization 

crosswalk assumptions to ensure PFS budget neutrality and to create PE RVUs through the PE 

methodology. The AMA RUC’s recommended crosswalk utilization is presented in Table 27 for 

reference, however, we note that because these services are not payable under the PFS, these 

values were not used for rate-setting. In the CY 2013 PFS proposed rule, we stated that we 

believe that the utilization assumptions for the technical component of the new CPT codes 

should be based on the utilization of the corresponding CPT codes currently billed on the CLFS, 

and not on the utilization of CPT code 83912-26. As we discussed in the CY 2013 PFS proposed 

rule, several laboratories provided us with a list of the molecular pathology tests that they 

perform, and identified the stacking codes that are currently used to bill for each test and the new 

CPT code that would be billed for each test. However, because the same molecular pathology 

test may be billed using different stacks, and the same stack may be billed for different tests, it is 

not possible to determine which stacks match which new CPT codes unless the billing entity 

billed both the new molecular pathology CPT code and the stacking codes. Additionally, if a 

beneficiary has more than one test on the same date of service and both stacks are billed on the 

same Medicare claim, it is not possible to determine which stacking codes on the claim relate to 

each test. Furthermore, some tests described by the new CPT codes are currently billed using 

general “not otherwise classified” (NOC) pathology CPT codes that capture a range of services 

and not just the specific molecular pathology tests described by the new CPT codes. We stated 

that, given these factors, it is difficult to estimate the utilization of the new molecular pathology 
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CPT codes based on the Medicare billing of the current stacking and NOC codes. 

We stated that if we were to finalize payment for molecular pathology tests under the 

PFS, we did not believe that we could propose national payment rates, because the following 

questions remained: 

● If these services are furnished by a physician, what are the appropriate physician work 

RVUs and times relative to other similar services? 

● Where and how are each of these services typically furnished—for example, what is 

the typical laboratory setting and batch size? 

● What is the correct projected utilization for each of these services? 

In the CY 2013 PFS proposed rule, we stated that, given these major areas of uncertainty, 

if CMS determined that new molecular pathology CPT codes should be paid under the PFS for 

CY 2013, we would propose to allow the Medicare contractors to price these codes because we 

do not believe that we have sufficient information to engage in accurate national pricing and 

because the price of tests can vary locally. As previously discussed, this proposal was parallel to 

the CLFS Annual Public Meeting process through which we received comments and 

recommendations on the appropriate basis for establishing a payment amount for these molecular 

pathology tests as clinical diagnostic laboratory tests under the CLFS. We stated that if we 

decided to finalize payment for these new codes under the PFS, we would consider modifying 

§415.130 as appropriate to provide for payment to a pathologist for molecular pathology tests. 

Finally, we stated that, after reviewing comments received on the proposals contained 

within the CY 2013 PFS proposed rule (77 FR 44782 through 44787), and after hearing the 

discussion at the CLFS Annual Public Meeting and reviewing comments and recommendations 

during the public meeting process, we would determine the appropriate basis for establishing 

payment amounts for the new molecular pathology CPT codes. We stated that we would publish 

our final decision in the CY 2013 PFS final rule with comment period and, at the same time the 
345 

final rule is published, post final payment determinations for any molecular pathology tests that 

will be paid under the CLFS. 

 A summary of the comments received on the questions and proposals discussed in the CY 

2013 PFS proposed rule, followed by our responses and conclusions are below. 

 We received the following comments in response to our questions on whether these 

molecular pathology CPT codes describe services that are ordinarily furnished by a physician; 

whether the services require interpretation and written report and, if so, who ordinarily furnishes 

that interpretation and how frequently; what is the nature of that interpretation and does it 

typically require physician work; and the broader question of whether these codes describe 

physicians’ services that should be paid under the PFS or if they describe clinical diagnostic 

laboratory tests that should be paid under the CLFS; as well as our proposal to price all 

molecular pathology CPT codes through a single fee schedule: 

Comment: Many commenters stated that these molecular pathology tests are not 

ordinarily furnished by a physician. These commenters stated that the services described by the 

new molecular pathology CPT codes do not require physician involvement, and that the vast 

majority of tests are performed (both the technical component and the interpretation) without a 

physician. The American Clinical Laboratory Association (ACLA) commented that a survey of 

its members showed that in most cases, the tests are performed, supervised, and interpreted by 

nonphysicians, most often doctoral-level scientists with expertise in medical genetics. ACLA 

noted that both Ph.D. geneticists and pathologists can be certified in genetics by an American 

Board of Medical Specialties. Comments indicated that some laboratories performing these tests 

do not employ physicians. 

In contrast, other commenters noted that the molecular pathology CPT codes were 

developed as global services, including both professional (physician work) and technical 

components together, and so the CPT codes inherently include physician work. They noted that 
346 

many of the clinical vignettes developed as a part of the CPT and AMA RUC processes 

demonstrate the incorporation of the technical steps and the professional services by a 

pathologist associated with each code. 

There was little agreement among commenters on whether molecular pathology tests 

require any interpretation and whether that interpretation is ordinarily furnished by a physician. 

Several commenters noted that molecular pathology tests can be divided into three groups based 

on interpretation requirements. The first group includes tests that require interpretation by a 

physician to generate a beneficiary-specific result, which, they stated, includes tests that utilize 

fluorescence in situ hybridization or immunohistochemistry technology. The second group 

includes tests that require interpretation by a nonphysician qualified healthcare professional to 

produce a beneficiary-specific result, which, they stated, includes many of the genetic tests 

assigned to Tier 1 and Tier 2 CPT codes. The third group includes tests that do not require 

interpretation by either a physician or health care professional because the test system produces 

the beneficiary-specific result, which, they stated, includes multi-analyte assays with algorithmic 

analyses (MAAAs) and in vitro diagnostic kits for genetic tests that have been assigned Tier 1 

and Tier 2 CPT codes. 

Other commenters noted that each of the tests represented by the new molecular 

pathology CPT codes ordinarily requires interpretation and report. Several commenters 

explained that even clearly negative results, in most instances, require an expenditure of 

resources for interpretation. One commenter explained that the results of these technical 

procedures require interpretation of the raw data generated, and that a pathologist assumes the 

responsibility for the generation of these results and performs the work associated with 

interpreting them, irrespective of whether the beneficiary has a positive or negative result. 

Additionally, one commenter noted that as molecular pathology tests become more and more 

automated as the field and science evolve, the interpretation and reporting of these tests is 
347 

concurrently becoming more and more complex. 

There was also little agreement among commenters as to whether the interpretation and 

report associated with these molecular pathology tests is ordinarily performed by a physician. 

Many commenters stated that clinical molecular diagnostics is a rapidly evolving diagnostic 

subspecialty that requires both technical and medical knowledge to interpret test results for use in 

beneficiary care. They explained that these molecular pathology tests require review by an 

expert who is well-versed in the interpretation of molecular pathology test results, who has the 

medical knowledge to place the results in a clinical context, and who can guide decisions about 

beneficiary treatment options and care management. They contended that selecting the best 

treatment path for an individual beneficiary’s disease state is a key facet of molecular pathology 

and depends upon the pathologist’s clinical expertise in the disease area. Commenters stated 

that, with molecular pathology, it is medically necessary for the pathologist to provide the 

referring physician with clinical insight about how the result should be interpreted based on the 

technique used and on the beneficiary’s history and medical condition. They contended that this 

differs from other laboratory subspecialties where the ordering physician typically has the 

expertise to interpret test results. These commenters stated that interpretation and report of a 

molecular pathology test is ordinarily furnished by a physician. 

In contrast, other commenters noted that, regardless of the nature of the interpretation for 

a molecular pathology test, doctoral-level geneticists are qualified and credentialed to perform 

the interpretation. The commenters stated that physician interpretation is not typical. They 

stated that in some laboratories, physicians may interpret test results when circumstances require 

a broader clinical review. They went on to note that among 367,370 molecular pathology 

allowed services with interpretation and report paid by Medicare in 2010, approximately 80 

percent of the services did not require a physician interpretation. 

Commenters who stated that molecular pathology tests ordinarily require the 
348 

interpretation of a physician also stated that the molecular pathology tests should be paid under 

the PFS. Generally, these commenters contended that it is medically necessary for a physician to 

interpret the molecular pathology test results, guide the beneficiary’s treatment, assess the 

beneficiary’s progress, and prepare the final report for the beneficiary’s record. As such, the 

commenter stated molecular pathology, as a field, is fundamentally different from laboratory 

medicine. They reasoned that complex tests that require physician interpretation to be clinically 

meaningful belong on the PFS. Additionally, some commenters stated that these services should 

be paid under the PFS because the resources involved in furnishing molecular pathology tests are 

changing rapidly. They pointed out that only the PFS currently allows the valuation of the codes 

to be continuously reviewed and scrutinized, taking into account changing technology and 

increased efficiencies as technology is adopted and becomes more widespread. They noted that 

placing the CPT codes for these molecular pathology tests on the PFS will enable the healthcare 

system to capture those savings. Finally, some commenters who stated that the molecular 

pathology tests should be paid under the PFS also thought that CMS should establish CLFS 

payment for laboratory interpretation and report of a molecular pathology test. 

 Commenters who stated that molecular pathology tests do not ordinarily require the 

interpretation of a physician also stated that the molecular pathology tests should be paid under 

the CLFS. Generally, these commenters contended that if a service is not ordinarily furnished by 

a physician, then CMS is precluded from paying for the service under the PFS. They explained 

that, as stated by the regulation at §415.130(b), allowable physician pathology tests can only be 

paid if they first meet the threshold criteria of §415.102(a)(1) (“The services are personally 

furnished for an individual beneficiary by a physician”) and §415.102(a)(3) (“The services 

ordinarily require performance by a physician.”) Additionally, some commenters stated that the 

tests described by the new molecular pathology CPT codes will continue to be performed exactly 

as they were prior to the coding change and that there is no reason why the tests should not 
349 

continue to be paid under the CLFS. Finally, some commenters who stated that the molecular 

pathology tests should be paid under the CLFS also suggested that CMS should establish PFS 

payment for physician interpretation and report of a molecular pathology test. 

Finally, in response to our proposal to price all molecular pathology CPT codes through a 

single fee schedule, most commenters stated that CMS should assess each CPT code 

independently and include the molecular pathology tests that require physician work on the PFS, 

and the molecular pathology tests that do not require physician work on the CLFS. However, as 

stated above, some commenters stated that all the molecular pathology CPT codes include 

physician work, and should all be placed together on the PFS, while others stated that none of the 

molecular pathology CPT codes require physician work, and all should be placed together on the 

CLFS. Finally, as stated above, some commenters suggested that the tests should be paid under 

the CLFS with a PFS payment for physician interpretation and report of a molecular pathology 

test whereas others stated that the tests should be paid under the PFS with a CLFS payment for 

laboratory interpretation and report of a molecular pathology test. 

Response: We thank the commenters for their thorough responses to our questions and 

proposals. After reviewing the comments, we believe that the molecular pathology CPT codes 

describe clinical diagnostic laboratory tests that should be paid under the CLFS because these 

services do not ordinarily require interpretation by a physician to produce a meaningful result. 

While we recognize that these tests may be furnished by a physician, after reviewing the public 

comments and listening to numerous presentations by stakeholders throughout the comment 

period, we are not convinced that all these tests ordinarily require interpretation by a physician. 

Many commenters stated that geneticists can provide any necessary interpretation for a 

meaningful test result of a molecular pathology test if some interpretation is required. ACLA 

noted that both Ph.D. geneticists and pathologists can be certified in genetics by an American 

Board of Medical Specialties, evidence that the medical community recognizes geneticists as 
350 

qualified to interpret molecular pathology test results. Commenters described automated 

laboratory processes and organizational structures that rely on geneticist interpretation when 

needed, and they presented a claims analysis demonstrating that physician interpretation 

currently is not typical across molecular pathology services in CY 2010. Further, commenters 

stated that these molecular pathology tests are currently payable on the CLFS. 

 We do not agree with some commenters that these codes inherently include physician 

work because they were developed as global services. We have a long-standing policy of 

dividing a global diagnostic service into a professional and technical component to separately 

capture the resources involved in the professional work and technical component of the test. We 

are not convinced that a physician must be involved in performing portions of the technical 

component. We believe that some molecular pathology tests are automated and do not require 

interpretation. Where the laboratory processes are not automated, laboratory personnel, 

including doctoral-level geneticists, can produce accurate molecular pathology test results. 

Although there might be occasions when a physician furnishes some of the technical component 

of a clinical laboratory test paid under the CLFS, we do not believe that performance by a 

physician changes the nature of the work. Rather, we believe it would still be appropriate to 

make payment for the technical work as part of the CLFS payment for the test. One commenter 

provided a claims analysis demonstrating that physicians are the most common entity to bill CPT 

code 89312 in the 2009 claims data; that there are more individual pathologists submitting claims 

for molecular pathology services than there are independent laboratories submitting claims for 

molecular pathology services. We believe this speaks to the different business structures in the 

pathology and laboratory communities. We would expect numerous different pathologists 

working in a hospital-based academic or research laboratory to bill for their professional services 

interpreting and reporting on a molecular pathology test independently under their NPI or group 

NPI using CPT code 83912-26. We would expect commercial laboratories to bill CPT code 
351 

83912 for interpretation and report by a nonphysician laboratory professional, like a doctorallevel geneticist, for a great volume of tests under a single laboratory NPI. We do not believe this 

analysis of the typical provider supports an assessment of whether interpretation is ordinarily 

required for furnishing molecular pathology services. 

 Finally, while we considered the differences in methodology for pricing under the CLFS 

versus the PFS, including the ability to apply a budget neutrality adjustment under the PFS, we 

do not believe that the differences in payment methodologies should be a definitive basis for 

deciding to choose a specific fee schedule. Rather, the statute requires Medicare to pay using 

separate methodologies for physicians’ services and for clinical diagnostic laboratory tests. 

Ultimately, we believe the primary criterion for determining the appropriate payment 

methodology is the identification of a service as one or the other. 

Therefore, for CY 2013, we are assigning a PFS procedure status indicator of X 

(Statutory exclusion. These codes represent an item or service that is not within the statutory 

definition of “physicians’ services” for PFS payment purposes (for example, ambulance 

services). No RVUs are shown for these codes and no payment may be made under the PFS to 

the molecular pathology CPT codes listed in Table 27, because payment will be made for these 

tests under the CLFS. More information on the CLFS determination of the appropriate basis for 

payment (crosswalk or gap-filling) for these tests is available on the CMS website at 

www.cms.hhs.gov/ClinicalLabFeeSched. 

While we do not believe the molecular pathology tests are ordinarily performed by 

physicians, we do believe that, in some cases, a physician interpretation of a molecular pathology 

test may be medically necessary to provide a clinically meaningful, beneficiary-specific result. 

In order to make PFS payment for that physician interpretation, on an interim basis for CY 2013, 

we have created HCPCS G-code G0452 (molecular pathology procedure; physician 

interpretation and report) to describe medically necessary interpretation and written report of a 
352 

molecular pathology test, above and beyond the report of laboratory results. This professional 

component-only HCPCS G-code will be considered a “clinical laboratory interpretation service,” 

which is one of the current categories of PFS pathology services under the definition of 

physician pathology services at §415.130(b)(4). Section §415.130(b)(4) of the regulations and 

section 60 of the Claims Processing Manual (IOM 100-04, Ch. 12, section 60.E.) specify certain 

requirements for billing the professional component of certain clinical laboratory services 

including that the interpretation (1) must be requested by the patient’s attending physician, (2) 

must result in a written narrative report included in the patient’s medical record, and (3) requires 

the exercise of medical judgment by the consultant physician. We note that a hospital’s standing 

order policy can be used as a substitute for the individual request by a patient’s attending 

physician. The current CPT code for interpretation and report, 83912-26, is included on the 

current list of clinical laboratory interpretation services but will be deleted at the end of CY 

2012. 

We will monitor the utilization of this service and collect data on billing patterns to 

ensure that G0452 is only being used when interpretation and report by a physician is medically 

necessary and is not duplicative of laboratory reporting paid under the CLFS. In the near future, 

we intend to reassess whether this HCPCS code is necessary, and if so, in conjunction with 

which molecular pathology tests. A discussion of the work and direct PE inputs for HCPCS Gcode G0452 can be found later in this section. We note that physicians can continue to receive 

payment for the current clinical pathology consultation CPT codes 80500 (Clinical pathology 

consultation; limited, without review of a patient’s history and medical records) and 80502 

(Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review 

of patient’s history and medical records) if the pathology consultation services relating to a 

molecular pathology test meet the definition of those codes. 

 We do not believe it is appropriate to establish a HCPCS G-code on the CLFS for the 
353 

interpretation and report of a molecular pathology test by a doctoral-level scientist or other 

appropriately trained nonphysician health care professional. The new molecular pathology CPT 

codes consolidate the services previously reported using the CLFS stacking codes, including the 

CLFS stacking code for laboratory interpretation and report of a molecular pathology test (CPT 

code 83912). As such, we believe that payment for the interpretation and report service would 

be considered part of the overall CLFS payment for the molecular pathology CPT codes. In 

addition, geneticists and other nonphysician laboratory personnel do not have a Medicare benefit 

category that allows them to bill and be paid for their interpretation services; therefore, they 

cannot bill or receive PFS payment for HCPCS code G0452. 

In response to our questions about the appropriate physician work RVUs and times, 

utilization crosswalks, and direct PE inputs for the molecular pathology services described by the 

CPT codes, as well as our proposal to contractor price the codes for CY 2013 if we determined 

that the codes should be paid under the PFS for CY 2013, we received the following comments: 

Comment: Commenters were not in favor of our proposal to contractor price these CPT 

codes if we determined that the codes should be paid under the PFS. Commenters urged CMS to 

establish national payment rates for the new molecular pathology CPT codes. Several 

commenters recommended that we use the AMA RUC- and CAP-recommended RVUs and 

inputs for these tests. One commenter suggested that contractor pricing is unnecessary to set 

payment rates for the technical component, since CMS has hospital cost data that can be used to 

develop payment rates. This commenter went on to strongly urge CMS to provide clear and 

specific guidance that contractors must work with cost data from constituents in their areas to set 

appropriate rates for physician services. 

Commenters stated that they are concerned that contractor pricing would lack the breadth 

of input, external scrutiny, and relativity utilized in the development of the AMA RUC 

recommendations. Commenters also believe that contractor pricing would add administrative 
354 

complexities and costs, and that variations in contractor pricing would be disruptive. Also, 

commenters stated that contractor pricing could result in movement of sites of testing to the 

highest paying regions in order to maximize Medicare payment for individual services. 

Furthermore, commenters suggested that the variation in the costs of these tests is related to 

differences in laboratory facilities, equipment, and/or test methodologies, and that the variation is 

not geographically based; therefore, contractor pricing is not appropriate. 

Regarding the utilization estimates for the new molecular pathology CPT codes, the 

AMA RUC noted that its utilization projections were based on the utilization of CPT code 83912 

(molecular diagnostics; interpretation and report) , which includes interpretation on both the 

physician fee schedule (83912-26) and the clinical laboratory fee schedule (83912), when 

interpretation by technical laboratory personnel, such as a geneticist, accompanies performance 

of the molecular pathology test represented by other “stacking” codes on a claim. The AMA 

RUC noted that utilization of this service has been growing rapidly and provided updated 

utilization assumptions based on 2011 Medicare allowed charges for CPT code 83912. These 

utilization assumptions, and the AMA RUC-recommended physician work RVUs and times, for 

all 115 codes are included in Table 27 for reference. However, we note that because these 

services are not payable under the PFS, these values were not used for rate-setting. 

Response: We thank the commenters for their detailed responses to our questions and 

proposals. Beginning in CY 2013, the molecular pathology CPT codes will be paid under the 

CLFS, and HCPCS code G0452 (Molecular diagnostics; interpretation and report) will be paid 

under the PFS. Because payment for the molecular pathology CPT codes will be made under the 

CLFS rather than the PFS, it is not necessary to consider further whether contractor pricing 

would be appropriate for the molecular pathology CPT codes under the PFS. We will add a new 

HCPCS code, G0452, to replace the current CPT code that is used to bill under the PFS for 

interpretation and report of a molecular pathology test (CPT code 83912-26), which is being 
355 

deleted at the end of CY 2012. After reviewing the public comments, the AMA RUC and CAP 

recommendations, and the values of the current and similar services, we believe we have enough 

information to nationally price HCPCS code G0452 for CY 2013. We believe it is appropriate to 

directly crosswalk the work RVUs, time, utilization, and malpractice risk factor of CPT code 

83912-26 to HCPCS code G0452, because we do not believe this coding change reflects a 

change in the service or in the resources involved in furnishing the service. The current work 

RVU of 0.37 for CPT code 83912-26 is the same as nearly all the clinical laboratory 

interpretation service codes. This value is also within the range of AMA RUC- recommended 

values for the molecular pathology CPT codes—the utilization-weighted average AMA RUCrecommended work RVU was 0.33, and the median AMA RUC-recommended work RVU was 

0.45 for the molecular pathology CPT codes. Based on this information, we believe a work 

RVU of 0.37 appropriately reflects the work of HCPCS code G0452. Therefore, we are 

assigning a work RVU of 0.37 and 5 minutes of pre-service time, 10 minutes of intra-service 

time, and 5 minutes of post-service time to HCPCS code G0452 on an interim final basis for CY 

2013. We request public comment on the interim final values for HCPCS code G0452. 

TABLE 27: AMA RUC-Recommended Physician Work RVUs, Times, and Estimated CY 

2013 Utilization for Molecular Pathology CPT Codes 

(Please note, these values are displayed for reference only and were not used for PFS ratesetting.) 

CPT 

Code 

Short Descriptor AMA RUC 

Recommended 

Work RVU 

AMA RUC 

Recommended 

Physician Time 

AMA RUC 

Estimated CY 

2013 Utilization 

81200* Aspa gene 450 

81201 Apc gene full sequence 1.40 60 450 

81202 Apc gene known fam variants 0.77 28 90 

81203 Apc gene dup/delet variants 0.80 30 400 

81205* Bckdhb gene 450 

81206 Bcr/abl1 gene major bp 0.37 15 45,729 

81207 Bcr/abl1 gene minor bp 0.15 11 3,500 

81208 Bcr/abl1 gene other bp 0.46 18 1,000 

81209* Blm gene 450 

81210 Braf gene 0.37 15 7,000 

81211* Brca1&2 seq & com dup/del 4,000 
356 

CPT 

Code 

Short Descriptor AMA RUC 

Recommended 

Work RVU 

AMA RUC 

Recommended 

Physician Time 

AMA RUC 

Estimated CY 

2013 Utilization 

81212* Brca1&2 185&5385&6174 var 2,000 

81213* Brca1&2 uncom dup/del var 4,000 

81214* Brca1 full seq & com dup/del 4,000 

81215* Brca1 gene known fam variant 1,000 

81216* Brca2 gene full sequence 4,000 

81217* Brca2 gene known fam variant 600 

81220 Cftr gene com variants 0.15 10 7,000 

81221 Cftr gene known fam variants 0.40 20 1,000 

81222 Cftr gene dup/delet variants 0.22 13 1,300 

81223 Cftr gene full sequence 0.40 20 1,000 

81224 Cftr gene intron poly t 0.15 10 1,300 

81225 Cyp2c19 gene com variants 0.37 13 2,000 

81226 Cyp2d6 gene com variants 0.43 15 2,000 

81227 Cyp2c9 gene com variants 0.38 14 4,000 

81228* Cytogen micrarray copy nmbr 900 

81229* Cytogen m array copy no&snp 900 

81235 Egfr gene com variants 0.51 20 9,000 

81240 F2 gene 0.13 7 31,000 

81241 F5 gene 0.13 8 43,000 

81242* Fancc gene 450 

81243 Fmr1 gene detection 0.37 15 4,000 

81244 Fmr1 gene characterization 0.51 20 100 

81245 Flt3 gene 0.37 15 6,000 

81250* G6pc gene 450 

81251* Gba gene 450 

81252 Gjb2 gene full sequence 0.65 30 400 

81253 Gjb2 gene known fam variants 0.52 28 150 

81254 Gjb6 gene com variants 0.40 15 500 

81255* Hexa gene 450 

81256 Hfe gene 0.13 7 25,000 

81257 Hba1/hba2 gene 0.50 20 4,500 

81260* Ikbkap gene 450 

81261 Igh gene rearrange amp meth 0.52 21 4,500 

81262 Igh gene rearrang dir probe 0.61 20 700 

81263 Igh vari regional mutation 0.52 23 400 

81264 Igk rearrangeabn clonal pop 0.58 22 4,000 

81265 Str markers specimen anal 0.40 17 14,000 

81266 Str markers spec anal addl 0.41 15 300 

81267 Chimerism anal no cell selec 0.45 18 2,000 

81268 Chimerism anal w/cell select 0.51 20 300 

81270 Jak2 gene 0.15 10 19,000 

81275 Kras gene 0.50 20 14,000 

81280* Long qt synd gene full seq 450 

81281* Long qt synd known fam var 450 

81282* Long qt syn gene dup/dlt var 450 

81290* Mcoln1 gene 450 

81291 Mthfr gene 0.15 10 9,000 

81292 Mlh1 gene full seq 1.40 60 1,000 
357 

CPT 

Code 

Short Descriptor AMA RUC 

Recommended 

Work RVU 

AMA RUC 

Recommended 

Physician Time 

AMA RUC 

Estimated CY 

2013 Utilization 

81293 Mlh1 gene known variants 0.52 28 500 

81294 Mlh1 gene dup/delete variant 0.80 30 800 

81295 Msh2 gene full seq 1.40 60 1,000 

81296 Msh2 gene known variants 0.52 28 500 

81297 Msh2 gene dup/delete variant 0.80 30 800 

81298 Msh6 gene full seq 0.80 30 450 

81299 Msh6 gene known variants 0.52 28 600 

81300 Msh6 gene dup/delete variant 0.65 30 500 

81301 Microsatellite instability 0.50 20 1,000 

81302 Mecp2 gene full seq 0.65 30 200 

81303 Mecp2 gene known variant 0.52 28 50 

81304 Mecp2 gene dup/delet variant 0.52 28 150 

81310 Npm1 gene 0.39 19 4,500 

81315 Pml/raralpha com breakpoints 0.37 15 1,000 

81316 Pml/raralpha 1 breakpoint 0.22 12 5,000 

81317 Pms2 gene full seq analysis 1.40 60 600 

81318 Pms2 known familial variants 0.52 28 200 

81319 Pms2 gene dup/delet variants 0.80 30 375 

81321 Pten gene full sequence 0.80 30 950 

81322 Pten gene known fam variant 0.52 28 150 

81323 Pten gene dup/delet variant 0.65 30 200 

81324* Pmp22 gene dup/delet 450 

81325* Pmp22 gene full sequence 450 

81326* Pmp22 gene known fam variant 450 

81330* Smpd1 gene common variants 450 

81331 Snrpn/ube3a gene 0.39 15 250 

81332 Serpina1 gene 0.40 15 1,000 

81340 Trb@ gene rearrange amplify 0.63 25 4,000 

81341 Trb@ gene rearrange dirprobe 0.45 19 1,000 

81342 Trg gene rearrangement anal 0.57 25 5,000 

81350 Ugt1a1 gene 0.37 15 850 

81355 Vkorc1 gene 0.38 15 4,000 

81370 Hla i & ii typing lr 0.54 15 14,000 

81371 Hla i & ii type verify lr 0.60 30 9,000 

81372 Hla i typing complete lr 0.52 15 4,000 

81373 Hla i typing 1 locus lr 0.37 15 4,000 

81374 Hla i typing 1 antigen lr 0.34 13 13,000 

81375 Hla ii typing ag equiv lr 0.60 15 2,000 

81376 Hla ii typing 1 locus lr 0.50 15 2,000 

81377 Hla ii type 1 ag equiv lr 0.43 15 2,000 

81378 Hla i & ii typing hr 0.45 20 2,000 

81379 Hla i typing complete hr 0.45 15 1,000 

81380 Hla i typing 1 locus hr 0.45 15 1,000 

81381 Hla i typing 1 allele hr 0.45 12 1,000 

81382 Hla ii typing 1 loc hr 0.45 15 1,000 

81383 Hla ii typing 1 allele hr 0.45 15 1,000 

81400 Mopath procedure level 1 0.32 10 2,500 

81401 Mopath procedure level 2 0.40 15 2,000 
358 

CPT 

Code 

Short Descriptor AMA RUC 

Recommended 

Work RVU 

AMA RUC 

Recommended 

Physician Time 

AMA RUC 

Estimated CY 

2013 Utilization 

81402 Mopath procedure level 3 0.50 20 2,000 

81403 Mopath procedure level 4 0.52 28 2,000 

81404 Mopath procedure level 5 0.65 30 2,000 

81405 Mopath procedure level 6 0.80 30 1,850 

81406 Mopath procedure level 7 1.40 60 1,000 

81407 Mopath procedure level 8 1.85 60 1,000 

81408 Mopath procedure level 9 2.35 80 1,000 

81479* Unlisted molecular pathology 0 

*The AMA RUC concluded that these services are not typically performed by a physician at this time. 

Therefore, they have not been reviewed for physician work or time by the AMA RUC. 

J. Payment for New Preventive Service HCPCS G-Codes

Under section 1861(ddd) of the Act, as amended by section 4105 of the Affordable Care 

Act, CMS is authorized to add coverage of “additional preventive services” if certain statutory 

criteria are met as determined through the national coverage determination (NCD) process, 

including that the service meets all of the following criteria: (1) they must be reasonable and 

necessary for the prevention or early detection of illness or disability, (2) they must be 

recommended with a grade of A or B by the United States Preventive Services Task Force 

(USPSTF), and (3) they must be appropriate for individuals entitled to benefits under Part A or 

enrolled under Part B. After reviewing the USPSTF recommendations for the preventive 

services, conducting evidence reviews, and considering public comments under the NCD 

process, we determined that the above criteria were met for the services listed in Table 28. 

Medicare now covers each of the following preventive services: 

● Screening and Behavioral Counseling Interventions in Primary Care to Reduce 

Alcohol Misuse, effective October 14, 2011; 

● Screening for Depression in Adults, effective October 14, 2011; 

● Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral 

Counseling (HIBC) to Prevent STIs, effective November 8, 2011; 
359 

● Intensive Behavioral Therapy for Cardiovascular Disease, effective November 8, 

2011; and 

● Intensive Behavioral Therapy for Obesity, effective November 29, 2011. 

Table 28 lists the HCPCS G-codes created for reporting and payment of these services. 

The Medicare PFS payment rates for these services are discussed below. The NCD process 

establishing coverage of these preventive services was not complete at the time of publication of 

the CY 2012 PFS final rule with comment period, so we could not include interim RVUs for 

these preventive services in the addenda to our CY 2012 final rule with comment period. 

However, we were able to include these HCPCS G-codes with national payment amounts for 

these services in the CY 2012 PFS national relative value files, which were effective January 1, 

2012. From the effective date of each service to December 31, 2011, the payment amount for 

these codes was established by the Medicare Administrative Contractors. 

TABLE 28: New Preventive Service HCPCS G-Codes 

HCPCS 

Code 

HCPCS Code Long Descriptor CMS National Coverage 

Determination (NCD) 

CMS 

Change 

Request 

(CR) 

G0442 Annual alcohol misuse screening, 

15 minutes 

Screening and Behavioral 

Counseling Interventions in 

Primary Care to Reduce Alcohol 

Misuse (NCD 210.8) 

CR7633 

G0443 Brief face-to-face behavioral 

counseling for alcohol misuse, 15 

minutes 

Screening Behavioral 

Counseling Interventions in 

Primary Care to Reduce Alcohol 

Misuse (NCD 210.8) 

CR7633 

G0444 Annual Depression Screening, 15 

minutes 

Screening for Depression in 

Adults (NCD 210.9) 

CR7637 

G0445 High-intensity behavioral 

counseling to prevent sexually 

transmitted infections, face-toface, individual, includes: 

education, skills training, and 

guidance on how to change 

sexual behavior; performed semiannually, 30 minutes 

Screening for Sexually 

Transmitted infections(STIs) and 

High- Intensity Behavioral 

Counseling (HIBC) to prevent 

STIs (NCD 210.10) 

CR7610 

G0446 Annual, face-to-face intensive Intensive Behavioral Therapy for CR7636 
360 

behavioral therapy for 

cardiovascular disease, 

individual, 15 minutes 

Cardiovascular Disease (NCD 

210.11) 

G0447 Face-to-face behavioral 

counseling for obesity, 15 

minutes 

Intensive Behavioral Therapy for 

Obesity (NCD 210.12) 

CR7641 

Two new HCPCS codes, G0442 (Annual alcohol misuse screening, 15 minutes), and 

G0443 (Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes), were created 

for the reporting and payment of screening and behavioral counseling interventions in primary 

care to reduce alcohol misuse. 

As we explained in the proposed rule, we believe that the screening service described by 

HCPCS code G0442 requires similar physician work as CPT code 99211 (Level 1 office or other 

outpatient visit, established patient). Accordingly, we proposed a work RVU of 0.18 for HCPCS 

code G0442 for CY 2013, the same work RVU as CPT code 99211. For physician time, we 

proposed 15 minutes, which is the amount of time specified in the HCPCS code descriptor for 

G0442. We proposed a malpractice expense crosswalk to CPT code 99211. The proposed direct 

PE inputs were reflected in the CY 2013 proposed direct PE input database, available on the 

CMS website under the downloads for the CY 2013 PFS proposed rule at 

www.cms.gov/PhysicianFeeSched/. We requested public comment on this CY 2013 proposed 

value for HCPCS code G0442. 

Comment: Commenters supported the proposed payment for HCPCS code GO442 

although a commenter suggested that in the future CMS should use the AMA RUC to assist us in 

valuing new codes. 

Response: In response to the suggestion that we rely upon AMA RUC input in valuing 

new codes, we agree with the commenter that the input of the AMA RUC is extremely useful in 

valuing new codes and in general, we obtain its recommendations in establishing the original 

values for new codes. However, because this new code was added through an NCD effective as 
361 

of October 14, 2011, public commenters, including the AMA RUC, were not able to comment 

for consideration for CY 2012. We note that since this code was valued in CY 2012 based upon 

CPT code 99211 and the AMA RUC had provided a recommendation on this code previously, 

the AMA RUC was involved, albeit indirectly, in setting this rate. In addition, there was 

opportunity for the AMA RUC to provide comment on this code in response to the solicitation 

for comment on the CY 2013 proposed rule. 

After consideration of the public comments we received, we are finalizing our CY 2013 

proposal to establish a work RVU of 0.18 and a time of 15 minutes for HCPCS code G0442. For 

malpractice expense, we are finalizing our proposed crosswalk for HCPCS code G0442 to CPT 

code 99211. We are also finalizing the direct PE inputs as proposed. The direct PE inputs 

associated with this code are included in the CY 2013 direct PE input database, available on the 

CMS website under the downloads for the CY 2013 PFS final rule with comment period at 

www.cms.gov/PhysicianFeeSched/. Additionally, we note that the PE RVUs included in 

Addendum B reflect the values that result from the finalization of this policy. 

As we explained in the proposed rule, we believe that the behavioral counseling service 

described by HCPCS code G0443 requires similar work as CPT code 97803 (Medical nutrition 

therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 

minutes). Accordingly, we proposed a work RVU of 0.45 for HCPCS code G0443 for CY 2013, 

the same work RVU as CPT code 97803. For physician time, we proposed 15 minutes, which is 

the amount of time specified in the HCPCS code descriptor for G0443. For malpractice expense, 

we proposed a malpractice expense crosswalk to CPT code 97803. The proposed direct PE 

inputs are reflected in the CY 2013 proposed direct PE input database, available on the CMS 

website under the downloads for the CY 2013 PFS proposed rule at 

www.cms.gov/PhysicianFeeSched/. We requested public comment on this CY 2013 proposed 

value for HCPCS code G0443. 
362 

Comment: Commenters supported the proposed payment for HCPCS code G0443. A 

commenter inquired why HCPCS code G0443 was crosswalked to CPT code 99212 and CPT 

code 97803 rather than to CPT code 99407 (Smoking and tobacco use cessation counseling visit; 

intensive, greater than 10 minutes). We also received a comment that in the future CMS should 

use the AMA RUC to assist us in valuing new codes. 

Response: The commenter was mistaken in stating that HCPCS code G0443 was 

crosswalked to CPT code 99212; it was crosswalked only to CPT code 97803. In response to the 

comment about crosswalking this code to CPT 99407, we had considered CPT code 99407 when 

we initially set the payment rate for HCPCS code G0443 and after consideration of this comment 

we continue to believe that the value based upon CPT code 97803, which is a 15-minute 

counseling code is appropriate. In response to the suggestion that we rely upon AMA RUC input 

in valuing new codes, we agree with the commenter that the input of the AMA RUC is extremely 

useful in valuing new codes and in general, we obtain its recommendations in establishing the 

original values for new codes. However, because this new code was added through an NCD 

effective as of October 14, 2011, public commenters, including the AMA RUC, were not able to 

comment for consideration for CY 2012. We note that since this code was valued in CY 2012 

based upon CPT code 97803 and the AMA RUC had provided recommendation on this code 

previously, the AMA RUC was involved, albeit indirectly, in setting this rate. In addition, there 

was opportunity for the AMA RUC to provide comment on this code in the solicitation for 

comment on the CY 2013 proposed rule. 

After consideration of the public comments that we received, we are finalizing the 

proposed work RVU of 0.45 and a time of 15 minutes for HCPCS code G0443. For malpractice 

expense, we are finalizing our proposed crosswalk to for HCPCS code G0443 to CPT code 

97803. We are also finalizing the direct PE inputs as proposed. The direct PE inputs associated 

with this code are included in the CY 2013 direct PE input database, available on the CMS 
363 

website under the downloads for the CY 2013 PFS final rule with comment period at 

www.cms.gov/PhysicianFeeSched/. Additionally, we note that the PE RVUs included in 

Addendum B reflect the values that result from the finalization of this policy. HCPCS code 

G0444 (Annual Depression Screening, 15 minutes) was created for the reporting and payment of 

screening for depression in adults. As we explained in the proposed rule, we believe that the 

screening service described by HCPCS code G0444 requires similar physician work as CPT code 

99211. Accordingly, we proposed a work RVU of 0.18 for HCPCS code G0444 for CY 2013, 

the same work RVU as CPT code 99211. For physician time, we proposed 15 minutes, which is 

the amount of time specified in the HCPCS code descriptor for G0444. For malpractice expense, 

we proposed a malpractice expense crosswalk to CPT code 99211. The proposed direct PE 

inputs were reflected in the CY 2013 proposed PE input database, available on the CMS website 

under the downloads for the CY 2013 PFS proposed rule at www.cms.gov/PhysicianFeeSched/. 

We requested public comment on this CY 2013 proposed value for HCPCS code G0444. 

Comment: Commenters supported the proposed payment for HCPCS code GO444 

although a commenter suggested that in the future CMS should use the AMA RUC to assist us in 

valuing new codes. 

Response: In response to the suggestion that we rely upon AMA RUC input in valuing 

new codes, we agree with the commenter that the input of the AMA RUC is extremely useful in 

valuing new codes and in general, we obtain its recommendations in establishing the original 

values for new codes. However, because this new code was added through an NCD effective as 

of October 14, 2011, public commenters, including the AMA RUC, were not able to comment 

for consideration for CY 2012. We note that since this code was valued in 2012 based upon CPT 

code 99211 and the AMA RUC had provided recommendation on this code previously, the 

AMA RUC was involved, albeit indirectly, in setting this rate. In addition, there was opportunity 

for the AMA RUC to provide comment on this code in response to the solicitation for comment 
364 

on the CY 2013 proposed rule. 

After consideration of the public comments we received, we are finalizing the proposed a 

work RVU of 0.18, and a time of 15 minutes for HCPCS G0444 code. For malpractice expense, 

we are finalizing our proposed crosswalk for HCPCS code G0444 to CPT code 99211. We are 

also finalizing the direct PE inputs as proposed. The direct PE inputs associated with this code 

are included in the CY 2013 direct PE input database, available on the CMS website under the 

downloads for the CY 2013 PFS final rule with comment period at 

www.cms.gov/PhysicianFeeSched/. Additionally, we note that the PE RVUs included in 

Addendum B reflect the values that result from the finalization of this policy. HCPCS code 

G0445 (high-intensity behavioral counseling to prevent sexually transmitted infections, face-toface, individual, includes: education, skills training, and guidance on how to change sexual 

behavior, performed semi-annually, 30 minutes) was created for the reporting and payment of 

HIBC to prevent STIs. As we explained in the proposed rule, we believe that the behavioral 

counseling service described by HCPCS code G0445 requires similar physician work as CPT 

code 97803. Accordingly, we proposed a work RVU of 0.45 for HCPCS code G0445 for CY 

2013, the same work RVU as CPT code 97803. For physician time, we proposed 30 minutes, 

which is the amount of time specified in the HCPCS code descriptor for G0445. For malpractice 

expense, we proposed a malpractice expense crosswalk to CPT code 97803. The proposed direct 

PE inputs were reflected in the CY 2013 proposed direct PE input database, available on the 

CMS website under the downloads for the CY 2013 PFS CY 2013 proposed rule at 

www.cms.gov/PhysicianFeeSched/. We requested public comment on this CY 2013 proposed 

value for HCPCS code G0445. 

Comment: Commenters supported the proposed payment for HCPCS code GO445 

although a commenter suggested that in the future we should use the AMA RUC to assist us in 

valuing new codes. 
365 

Response: In response to the suggestion that we rely upon AMA RUC input in valuing 

new codes, we agree with the commenter that the input of the AMA RUC is extremely useful in 

valuing new codes and in general, we obtain its recommendations in establishing the original 

values for new codes. However, because this new code was added through an NCD effective as 

of October 14, 2011, public commenters, including the AMA RUC, were not able to comment 

for consideration for CY 2012.We note that since this code was valued in CY 2012 based upon 

CPT code 97803 and the AMA RUC had provided recommendation on this code previously, the 

AMA RUC was involved, albeit indirectly, in setting this rate. In addition, there was opportunity 

for the AMA RUC to provide comment on this code in response to the solicitation for comment 

on the CY 2013 proposed rule. 

After consideration of the public comments we received, we are finalizing the proposed a 

work RVU of 0.45 and a time of 30 minutes for HCPCS code G0445. For malpractice expense, 

we are finalizing our proposed crosswalk for HCPCS code G0445 to CPT code 97803. We are 

also finalizing the direct PE inputs as proposed. The direct PE inputs associated with this code 

are included in the CY 2013 direct PE input database, available on the CMS website under the 

downloads for the CY 2013 PFS final rule with comment period at 

www.cms.gov/PhysicianFeeSched/. Additionally, we note that the PE RVUs included in 

Addendum B reflect the values that result from the finalization of this policy. HCPCS code 

G0446 (Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 

15 minutes) was created for the reporting and payment of intensive behavioral therapy for 

cardiovascular disease. As we explained in the proposed rule, we believe that the behavioral 

therapy service described by HCPCS code G0446 requires similar physician work as CPT code 

97803. Accordingly, we proposed a work RVU of 0.45 for HCPCS code G0446 for CY 2013, 

the same work RVU as CPT code 97803. For physician time, we proposed 15 minutes, which is 

the amount of time specified in the HCPCS code descriptor for G0446. For malpractice expense, 
366 

we proposed a malpractice expense crosswalk to CPT code 97803. The proposed direct PE 

inputs were reflected in the CY 2013 proposed direct PE input database, available on the CMS 

website under the downloads for the CY 2013 PFS proposed rule at 

www.cms.gov/PhysicianFeeSched/. We requested public comment on this CY 2013 proposed 

value for HCPCS code G0446. 

Comment: Commenters supported the proposed payment for HCPCS code GO446. In 

addition, a commenter urged a change in our policy to allow billing of multiple units of this code 

in one encounter. We also received a comment that in the future CMS should use the AMA 

RUC to assist us in valuing new codes. 

Response: In response to the suggestion regarding billing multiple units of HCPCS code 

G0446, this proposal deals only with the payment rate for this service, not coverage issues. We 

note that the NCD is clear that only one visit annually is covered. In response to the suggestion 

that we rely upon AMA RUC input in valuing new codes, we agree with the commenter that the 

input of the AMA RUC is extremely useful in valuing new codes and in general, we obtain its 

recommendations in establishing the original values for new codes. However, because this new 

code was added through an NCD effective as of October 14, 2011, public commenters, including 

the AMA RUC, were not able to comment for consideration for CY 2012. We note that since 

this code was valued based upon CPT code 97803 and AMA RUC had provided 

recommendation on this code previously, the AMA RUC was involved, albeit indirectly, in 

setting this rate. In addition, there was opportunity for the AMA RUC to provide comment on 

this code in response to the solicitation for comment on the CY 2013 proposed rule. 

Based upon the comments we received, we are finalizing the proposed rate for HCPCS 

code G0446. It will be valued with a work RVU of 0.45, and with a time of 15 minutes. For 

malpractice expense, we are finalizing our proposed crosswalk for HCPCS code G0446 to CPT 

code 97803. We are also finalizing the direct PE inputs as proposed. The direct PE inputs 
367 

associated with this code are included in the CY 2013 direct PE input database, available on the 

CMS website under the downloads for the CY 2013 PFS final rule with comment period at 

www.cms.gov/PhysicianFeeSched/. Additionally, we note that the PE RVUs included in 

Addendum B reflect the values that result from the finalization of this policy. HCPCS G0447 

(Face-to-face behavioral counseling for obesity, 15 minutes) was created for the reporting and 

payment of intensive behavioral therapy for obesity. As we explained in the proposed rule, we 

believe that the behavioral counseling service described by HCPCS code G0447 requires similar 

physician work to CPT code 97803. Accordingly, we proposed a work RVU of 0.45 for HCPCS 

code G0447 for CY 2013, the same work RVU as CPT code 97803. For physician time, we 

proposed 15 minutes, which is the amount of time specified in the HCPCS code descriptor for 

G0447. For malpractice expense, we proposed a malpractice expense crosswalk to CPT code 

97803. The proposed direct PE inputs were reflected in the CY 2013 direct PE input database, 

available on the CMS website under the downloads for the CY 2013 PFS proposed rule at 

www.cms.gov/PhysicianFeeSched/. We requested public comment on this CY 2013 proposed 

value for HCPCS code G0447. 

Comment: Commenters supported the proposed payment for HCPCS code GO447. In 

addition, a commenter urged a change in our policy to allow billing of multiple units of this code 

in one encounter. We also received a comment that in the future CMS should use the AMA 

RUC to assist us in valuing new codes. 

Response: With regard to billing for multiple units of HCPCS code G0447 in the same 

encounter, this proposal addresses only the payment rate for, not the coverage of this code. We 

note that the NCD establishes that coverage is for one visit per day of service. In response to the 

suggestion that we rely upon AMA RUC input in valuing new codes, we agree with the 

commenter that the input of the AMA RUC is extremely useful in valuing new codes and in 

general, we obtain its recommendations in establishing the original values for new codes. 
368 

However, because this new code was added through an NCD effective as of October 14, 2011, 

public commenters, including the AMA RUC, were not able to comment for consideration for 

CY 2012. We note that since this code was valued in CY 2012 based upon CPT code 97803 and 

AMA RUC had provided recommendation on this code previously, the AMA RUC was 

involved, albeit indirectly, in setting this rate. In addition, there was opportunity for the AMA 

RUC to provide comment on this code in the response to the solicitation for comment on the CY 

2013 proposed rule. 

After the consideration of the public comments we received, we are finalizing the 

proposed work RVU of 0.45 and a time of 15 minutes for HCPCS G0447 code. For malpractice 

expense, we are finalizing our proposal to crosswalk HCPCS code G0447 to CPT code 97803. 

We are also finalizing the direct PE inputs as proposed. The direct PE inputs associated with this 

code are included in the CY 2013 direct PE input database, available on the CMS website under 

the downloads for the CY 2013 PFS final rule with comment period at 

http://www.cms.gov/PhysicianFeeSched/. Additionally, we note that the PE RVUs included in 

Addendum B reflect the values that result from the finalization of this policy. 

K. Certified Registered Nurse Anesthetists Scope of Benefit

The benefit category for services furnished by a certified registered nurse anesthetist 

(CRNA) was added in section 1861(s)(11) of the Act by section 9320 of the Omnibus Budget 

Reconciliation Act (OBRA) of 1986. Since this benefit was implemented on January 1, 1989, 

CRNAs have been eligible to bill Medicare directly for services within this benefit category. 

Section 1861(bb)(2) of the Act defines a CRNA as “a certified registered nurse anesthetist 

licensed by the State who meets such education, training, and other requirements relating to 

anesthesia services and related care as the Secretary may prescribe. In prescribing such 

requirements the Secretary may use the same requirements as those established by a national 

organization for the certification of nurse anesthetists.” 
369 

 Section 410.69(b) defines a CRNA as a registered nurse who: (1) is licensed as a 

registered professional nurse by the State in which the nurse practices; (2) meets any licensure 

requirements the State imposes with respect to nonphysician anesthetists; (3) has graduated from 

a nurse anesthesia educational program that meets the standards of the Council on Accreditation 

of Nurse Anesthesia Programs, or such other accreditation organization as may be designated by 

the Secretary; and (4) meets one of the following criteria: (i) has passed a certification 

examination of the Council on Certification of Nurse Anesthetists, the Council on Recertification 

of Nurse Anesthetists, or any other certification organization that may be designated by the 

Secretary; or (ii) is a graduate of a program described in paragraph (3) of this definition and 

within 24 months after that graduation meets the requirements of paragraph (4)(i) of this 

definition. 

Section 1861(bb)(1) of the Act defines services of a CRNA as “anesthesia services and 

related care furnished by a certified registered nurse anesthetist (as defined in paragraph (2)) 

which the nurse anesthetist is legally authorized to perform as such by the State in which the 

services are furnished.” CRNAs are paid at the same rate as physicians for furnishing such 

services to Medicare beneficiaries. Payment for services furnished by CRNAs only differs from 

physicians in that payment to CRNAs is made only on an assignment-related basis (§414.60) and 

supervision requirements apply in certain circumstances. 

At the time that the Medicare benefit for CRNA services was established, anesthesia 

practice, for anesthesiologists and CRNAs, largely occurred in the surgical setting and services 

other than anesthesia (medical and surgical) were furnished in the immediate pre- and postsurgery timeframe. The scope of “anesthesia services and related care” as delineated in section 

1861(bb)(1) of the Act reflected that practice. As anesthesiologists and CRNAs have moved into 

other practice settings, questions have arisen regarding what services are encompassed under the 

benefit category’s characterization of “anesthesia and related care.” As an example, some 
370 

CRNAs now offer chronic pain management services that are separate and distinct from a 

surgical procedure. We recently received additional information about upcoming changes to 

CRNA curricula to include specific training regarding chronic pain management services. Such 

changes in CRNA practice have prompted questions as to whether these services fall within the 

scope of section 1861(bb)(1) of the Act. 

As we noted in the CY 2013 proposed rule (77 FR 44788), Medicare Administrative 

Contractors (MACs) have reached different conclusions as to whether the statutory benefit 

category description of “anesthesia services and related care” encompasses the chronic pain 

management services furnished by CRNAs. The scope of the benefit category determines the 

scope of services for which a physician, practitioner, or supplier may receive Medicare payment. 

In order for the specific services to be paid by Medicare, the services must be reasonable and 

necessary for treatment of the patient’s illness or injury. 

To address what is included in the benefit category for CRNAs in the CY 2013 proposed 

rule, we assessed our current regulations and subregulatory guidance, and determined that the 

existing guidance does not specifically address whether chronic pain management is included in 

the CRNA benefit. In the Internet Only Manual (Pub 100-04, Ch 12, Sec 140.4.3), we discuss 

the medical or surgical services that fall under the “related care” language stating: “These may 

include the insertion of Swan Ganz catheters, central venous pressure lines, pain management, 

emergency intubation, and the pre-anesthetic examination and evaluation of a patient who does 

not undergo surgery.” Some have interpreted the reference to “pain management” in this 

language as authorizing direct payment to CRNAs for chronic pain management services, while 

others have taken the view that the services highlighted in the manual language are services 

furnished in the perioperative setting and refer only to acute pain management associated with 

the surgical procedure. 
371 

After assessing in the proposed rule (see 77 FR 44788) the information available to us, 

we concluded that chronic pain management was an evolving field, and we recognized that 

certain states have determined that the scope of practice for a CRNA should include chronic pain 

management to meet health care needs of their residents and ensure their health and safety. We 

also found that several states, including California, Colorado, Missouri, Nevada, South Carolina, 

and Virginia, were debating whether to include pain management in the CRNA scope of practice. 

After determining that the scope of practice for CRNAs was evolving and that there was not a 

clear answer on pain management specifically, we proposed to revise our regulations at 

§410.69(b) to define the statutory benefit for CRNA services with deference to state scope of 

practice laws. Specifically, we proposed to add the following language: “Anesthesia and related 

care includes medical and surgical services that are related to anesthesia and that a CRNA is 

legally authorized to perform by the state in which the services are furnished.” We explained 

that this proposed definition would set a Medicare standard for the services that can be furnished 

and billed by CRNAs while allowing appropriate flexibility to meet the unique needs of each 

state. The proposal also dovetailed with the language in section 1861(bb)(1) of the Act requiring 

the state’s legal authorization to furnish CRNA services as a key component of the CRNA 

benefit category. Finally, we stated that the proposed benefit category definition was also 

consistent with our policy to recognize state scope of practice as defining the services that can be 

furnished and billed by other NPPs. 

The following is a summary of the comments we received regarding the proposal to 

revise our regulations at §410.69(b) to define the statutory description of CRNA services. We 

received a significant volume of comments from specialty groups, individual physicians, and 

practitioners, including CRNAs and Student Registered Nurse Anesthetists (SRNAs), 

educational program directors, and patients, who strongly supported defining the CRNA benefit 

broadly. There were also many commenters who strongly opposed this proposal, including 
372 

specialty groups, individual physicians and practitioners, patients, educational program directors, 

and a patient advocacy group. 

Comment: Among those supporting the concept of our proposal, we received several 

comments suggesting alternative regulatory definitions of the statutory benefit category phrase, 

“anesthesia and related care.” Many commenters said that CMS should allow CRNAs to 

practice to the full extent of state law. Some commenters provided alternative definitions for 

anesthesia and related care. These included “medical and surgical services that are related to 

anesthesia or that a CRNA is legally authorized to perform by the State in which the services are 

furnished,” “medical and surgical services that are related to anesthesia, including chronic pain 

management services unless specifically prohibited or outside the scope of the CRNA's license to 

practice," “medical services, surgical services, and chronic and acute pain management services 

that a CRNA is legally authorized to perform by the State in which the services are furnished,” 

"medical and surgical services a CRNA is legally authorized to perform by the state in which 

services are furnished and which are done to provide surgical or obstetrical anesthesia or 

alleviate post-operative or chronic pain," and “medical and surgical services that are related to 

anesthesia, including chronic pain management, unless a CRNA is legally prohibited to perform 

by the State in which the services are furnished." One commenter made the point that Medicare 

should use a definition that included coverage of advanced practice registered nurse services that 

are within the scope of practice under applicable state law, just as physicians’ services are now 

covered. 

Other commenters referenced preamble text in our 1992 final rule, which states "we 

describe related care services as... pain management services, and other services not directly 

connected with the anesthesia service or associated with the surgical service" and noted that 

historically, related care services have been recognized as a different class of anesthesia services, 

which may or may not be related to anesthesia. One commenter requested that we define 
373 

“related care” separately from anesthesia, as "medical and surgical services not directly related to 

anesthesia, including but not limited to the insertion of arterial lines, central venous pressure 

lines, and Swan Ganz catheters, acute and chronic pain management and emergency intubation, 

and that a CRNA is legally authorized to perform by the state in which the services are 

furnished." 

Some commenters pointed to Medicare policies allowing other advanced practice nurses 

such as nurse practitioners or clinical nurse specialists to furnish and bill for physicians’ services 

as support for recognizing a similar interpretation of the scope of CRNA practice. Commenters 

stated that CRNAs should be able to practice to the full extent of state law. Commenters cited 

the Institute of Medicine report [The Future of Nursing: Leading Change, Advancing Health, 

11/17/10] that stated that nurses should be able to practice to the full extent of their education 

and training. 

Our proposal to define related care as “related to anesthesia” resulted in various views as 

to whether this would include pain management and other services. Some stated that it restricted 

the benefit category, but others believed that it expanded it. The commenters further stated that 

there are no chronic, long-term, anesthesia related services that occur outside the operating room 

or recovery room where the practice of anesthesia is appropriate. Others stated that chronic pain 

management services are outside the scope of perioperative related care defined in the Act, and 

that chronic pain is not related to anesthesia. 

Response: After reviewing comments regarding our proposed definition of “anesthesia 

and related care,” we believe that the proposed regulation language stating that “Anesthesia and 

related care includes medical and surgical services that are related to anesthesia and that a CRNA 

is legally authorized to perform by the state in which the services are furnished” would not 

accomplish our goals. It would require updating as health care evolves and as CRNA practice 

changes. It also would continue Medicare’s differentiation between CRNAs and other NPPs 
374 

because the Medicare benefit for other NPPs relies more heavily on the NPPs’ authority under 

state law. In addition, we agree with commenters that the primary responsibility for establishing 

the scope of services CRNAs are sufficiently trained and, thus, should be authorized to furnish, 

resides with the states. We agree with commenters that, as CRNA training and practice evolve, 

the state scope of practice laws for CRNAs serve as a reasonable proxy for what constitutes 

“anesthesia and related care.” Therefore, we are revising §410.69(b) to define the statutory 

benefit category for CRNAs, which is specified as “anesthesia and related care,” as “those 

services that a certified registered nurse anesthetist is legally authorized to perform in the state in 

which the services are furnished.” By this action, we are defining the Medicare benefit category 

for CRNAs as including any services the CRNA is permitted to furnish under their state scope of 

practice. In addition, this action results in CRNAs being treated similarly to other advanced 

practice nurses for Medicare purposes. This policy is consistent with the Institute of Medicine’s 

recommendation that Medicare cover services provided by advanced practice nurses to the full 

extent of their state scope of practice. CMS will continue to monitor state scope of practice laws 

for CRNAs to ensure that they do not expand beyond the appropriate bounds of “anesthesia and 

related care” for purposes of the Medicare program. 

Comment: Some commenters suggested that the proposal expands the scope of practice 

of CRNAs into the practice of medicine, and that the proposal undermines medical education, the 

practice of medicine, and the pain medicine specialty by equating nurses with physicians. 

Commenters further stated that such proposals, which lead to privileging and reimbursement for 

nonphysician practitioners that are identical to that of physicians, decrease the incentives to 

complete the rigorous training involved in medical school. Others stated that the proposal would 

interfere with the authority of states to regulate scope of practice. 

Response: We acknowledge the concerns of the physician community; however, the 

intent of the proposal is not to undermine medical education, the practice of medicine, or the pain 
375 

medicine specialty, but to establish parity between the scope of the Medicare benefit category for 

CRNAs and the CRNA authority to practice under state law. This proposal does not address 

payment rates for anesthesiologists or CRNAs. The statutory provisions that establish payment 

rates for CRNAs at the same rate as anesthesiologists are relatively longstanding. Our proposal 

in no way is intended to interfere with the authority of individual states; rather, it largely defers 

to individual states to determine the scope of practice for CRNAs. We believe that using state 

scope of practice law as a proxy for services encompassed in the statutory benefit language 

“anesthesia and related care” is preferable to choosing among individual interpretations of 

whether particular services fall within the scope of “anesthesia and related care.” Moreover, we 

believe states are in an ideal position to gauge the status of, and respond to changes in, CRNA 

training and practice over time that might warrant changes in the definition of the scope of 

“anesthesia services and related care” for purposes of the Medicare program. As such, we 

believe it is appropriate to look to state scope of practice law as a proxy for the scope of the 

CRNA benefit. 

Comment: Many commenters addressed the extent to which the standards for nurse 

anesthesia curricula and the content of nurse anesthesia educational programs do or do not 

prepare CRNAs to practice outside the perioperative setting, and specifically, to furnish chronic 

pain services. We received detailed comments regarding the necessary components of chronic 

pain services and conflicting information about whether CRNAs are trained or licensed to 

furnish such services. We received thorough descriptions of the skills required to furnish chronic 

pain services and the necessity of medical education to prepare one to furnish such services. 

Commenters also provided information about the inherent dangers involved in chronic pain 

services, the manner in which technical skills in chronic pain procedures are obtained, and the 

ways in which chronic pain services are or are not similar to other procedures performed by 

CRNAs in the perioperative setting and for labor epidurals. We received many comments from 
376 

the physician community with concerns about the possibility of the furnishing of procedures that 

are not indicated due to lack of medical knowledge required to screen out patients who are not 

appropriate candidates for procedures. 

Some commenters pointed to the long period of time during which CRNAs have 

furnished chronic pain services with no documented differences in patient outcomes, while 

others expressed concern about negative outcomes observed from inadequately trained providers. 

Descriptions were also provided regarding lawsuits at the state level that have debated whether 

CRNAs are qualified to furnish chronic pain services, the importance of medical regulation in 

protecting patients who may not be able to differentiate between different types of providers, and 

the role of the medical education process in ensuring competency of physicians. Other 

commenters opined that it is the responsibility of the individual provider to assure his or her 

competency for any and all procedures furnished. 

Response: We acknowledge the varying perspectives about the education and training of 

CRNAs to furnish chronic pain management services as well as differences of opinion regarding 

the safety of chronic pain management services furnished by CRNAs. We are unable, at this 

time, to assess the appropriateness of the CRNA training relating to specific procedures. We are 

also unaware of any data regarding the safety of chronic pain management services when 

furnished by different types of professionals. However, we expect that states take into account 

all appropriate practitioner training and certifications, as well as the safety of their citizens, when 

making decisions about the scope of services CRNAs are authorized to furnish and providing 

licenses to individual practitioners in their jurisdictions.

We note that we did not address the services that CRNAs are trained and qualified to 

furnish in our proposal or in this final rule with comment period. Our proposal and this final rule 

merely define what services are included in the scope of the Medicare benefit established in 

section 1861(bb)(1) of the Act. The definition that we are adopting uses the state scope of 
377 

practice as a proxy for what the term “anesthesia and related care” in section 1861(bb)(1) of the 

Act means and thus leaves decisions about what services constitute anesthesia and related care to 

be resolved by the state. This appropriately recognizes the actions of state bodies formed 

specifically to address the issue of what constitutes the scope of practice for a CRNA. We 

believe that determining whether or not CRNAs are adequately trained and can safely furnish 

chronic pain management is an appropriate decision for state bodies. This proposal is consistent 

with the Institute of Medicine’s report on advanced practice nursing, which recommends that 

Medicare should “include coverage of advanced practice registered nurse services that are within 

the scope of practice under applicable state law, just as physicians’ services are now covered." 

We agree with commenters that it also is the responsibility of individual practitioners 

(physicians and CRNAs) to ensure that they are adequately trained and qualified to furnish any 

and all procedures that they furnish. 

Comment: We received comments about the cost of CRNA services relative to those 

furnished by anesthesiologists. Commenters stated that chronic pain management services are 

less costly than surgical interventions, and that the services of CRNAs are more cost-effective 

for the Medicare program. Others stated that allowing CRNAs to furnish these services could 

increase spending due to the provision of inappropriate services and the complications that could 

result from procedures furnished by CRNAs who are not adequately trained. 

Response: We do not have sufficient evidence to determine that chronic pain 

management interventions reduce the need for surgical interventions, or that there would be 

increased provision of inappropriate services and complications under a definition of the 

Medicare benefit category that defines “anesthesia and related care” as services a CRNA is 

authorized to furnish in his or her state. Spending for services under Medicare is not a factor in 

determining whether the statutory benefit encompasses particular services. However, we would 

note that CRNAs are generally paid at the same rate as anesthesiologists so there are no direct 
378 

cost savings when services are furnished by CRNAs. 

Comment: We received comments regarding special concerns about access in rural areas. 

Commenters stated that CRNAs help patients avoid traveling long distances and long waits for 

appointments by having local providers available. Furthermore, commenters noted that as the 

population ages, the demand for chronic pain management services will increase. Commenters 

stated that decreased access to chronic pain management services (which would result if CRNAs 

are not permitted to furnish and bill for these services) would result in more institutionalization, 

reduced quality of life, longer wait times, and increased costs. Others stated that chronic pain 

management services are not emergent care services; that chronic pain management is a specialty 

that should be furnished by those with a high degree of sub-specialty training, and that pain 

physicians can be spread out over large areas since only a small minority of patients need 

procedural care. Some commenters cited a shortage of pain management physicians qualified to 

treat chronic pain, others stated that there is no shortage of such providers, while still others 

stated that the proposal may increase access, but at the expense of having unqualified providers. 

Finally, some commenters stated that procedures furnished improperly pose a greater danger 

than a lack of available services. 

Response: While assuring access for beneficiaries in rural areas is a priority for Medicare, 

we do not have sufficient data to evaluate the presence or degree of problems of access to 

chronic pain management services in rural areas. We also do not have evidence that CRNAs 

have furnished chronic pain management services in quantities sufficient to improve any access 

problems in rural areas. We further lack sufficient data to determine whether beneficiaries who 

lack access to a CRNA care are more likely to suffer the negative outcomes cited by 

commenters. This lack of information does not deter us taking action to define the statutory 

benefit as it is not necessary to conclude that beneficiaries will suffer negative consequences to 

prompt us to act. Rather we are issuing this regulation based upon the factors we described 
379 

above. 

Comment: We received comments regarding those services included in the definition of 

anesthesia and related care, as well as services “related to anesthesia.” Some commenters stated 

that chronic pain management services are not directly “related to anesthesia” but still constitute 

“related care”. Other commenters stated that CMS has already acknowledged in early preamble 

language that CRNAs may furnish services not directly related to anesthesia. Still other 

commenters stated that chronic pain services are not related to anesthesia in any way. One 

commenter suggested that CMS has already differentiated between anesthesia related acute pain 

and interventional chronic pain based on the creation of different specialty codes for anesthesia 

and chronic pain. One commenter requested that CMS make a regulatory change to allow 

CRNAs to order diagnostic tests in order to effectively provide chronic pain management 

services. 

Response: We believe that the statutory intent was to include services not directly related 

to the peri-anesthetic setting in the CRNA benefit category. We believe that relying on state 

scope of practice to define the services encompassed in anesthesia and related care is preferable 

to choosing among conflicting definitions of “anesthesia and related care” or listing the specific 

services that fall within that benefit category. Rather, we believe states are in a better position to 

gauge the status of, and respond to changes in, CRNA training and practice over time that might 

warrant changes in the definition of the scope of “anesthesia services and related care” for 

purposes of the Medicare program. As such, we believe it is appropriate to look to state scope of 

practice law as a proxy for the scope of the CRNA benefit. 

Comment: Several commenters expressed concern with the wording of our proposal; 

specifically, that the term “related to anesthesia” was unclear and subject to interpretation. States 

do not typically define services “related to anesthesia” in their state scope of practice acts. 

Response: We agree with commenters that the wording of the proposal was unclear. In 
380 

response to these and other commenter concerns, we are adopting a modification of our proposal 

to rely on state scope of practice to define the services encompassed in “anesthesia and related 

care” under section 1861(bb)(1) of the Act. 

Comment: One commenter requested that we provide clarification for the payment of 

CRNA services furnished; specifically, which medical and/or surgical CRNA services are 

eligible for cost-based reimbursement (for CRNA pass-through payments or Method II billing 

for Critical Access Hospitals). 

Response: We will be modifying the Internet Only Manual to reflect the change we are 

making in this final rule with comment period. The request for the list of services that are 

eligible for cost-based reimbursement is beyond the scope of this rule, as it pertains to hospital 

billing. We anticipate this matter will be addressed separately in a forthcoming transmittal. 

Comment: Commenters requested that CMS instruct Medicare contractors to review prior 

denials of claims for CRNA services prior to any final rule determination of the scope of the 

CRNA Medicare benefit category. 

Response: This definition of the Medicare benefit for CRNAs will be effective for 

services furnished on or after January 1, 2013. It does not apply to services furnished prior to 

this point so we will not be instructing contractors to review prior denials of claims. 

After consideration of all comments, we are finalizing our proposal with modification to 

revise our regulations at §410.69(b) to define “Anesthesia and related care” under the statutory 

benefit for CRNA services as follows: “Anesthesia and related care means those services that a 

certified registered nurse anesthetist is legally authorized to perform in the state in which the 

services are furnished.” We will continue to monitor the state scope of practice laws for CRNAs 

in order to insure that the use of state scope of practice as a proxy to define “anesthesia services 

and related care” is consistent with the goals and needs of Medicare program. 

L. Ordering of Portable X-Ray Services 
381 

Portable x-ray suppliers furnish diagnostic imaging services at a beneficiary’s location. 

These services are most often furnished in residences, including private homes and alternative 

living facilities (for example, nursing homes) rather than in a traditional clinical setting (for 

example, a doctor’s office or hospital). The supplier transports mobile diagnostic imaging 

equipment to the beneficiary’s location, sets up the equipment, and administers the test onsite. 

The supplier may interpret the results itself or it may furnish the results to an outside physician 

for interpretation. Portable x-ray services may avoid the need for expensive ambulance transport 

of frail beneficiaries to a radiology facility or hospital. 

Our Medicare Conditions for Coverage (CfC) regulations require that “portable x-ray 

examinations are performed only on the order of a doctor of medicine (MD) or doctor of 

osteopathy (DO) licensed to practice in the state...” (§486.106(a)). With the exception of 

portable x-ray services, Medicare payment regulations at §410.32(a) allow physicians, as defined 

in section 1861(r) of the Act, and certain nonphysician practitioners at §410.32(a)(2) to order 

diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests as long as those 

nonphysician practitioners are operating within the scope of their authority under state law and 

within the scope of their Medicare statutory benefit. Physicians other than an MD or DO 

recognized to order diagnostic tests under §410.32(a) include the following limited-license 

practitioners: doctor of optometry, doctor of dental surgery and doctor of dental medicine, and 

doctor of podiatric medicine. Nonphysician practitioners authorized to order diagnostic tests 

under §410.32(a)(2) include nurse practitioners, physician assistants, clinical nurse specialists, 

certified nurse-midwives, clinical psychologists, and clinical social workers. Nonphysician 

practitioners have become an increasingly important component of clinical care, and we believe 

that delivery systems should take full advantage of all members of a healthcare team, including 

nonphysician practitioners.
382 

Although current Medicare regulations limit the ordering of portable x-ray services to a 

MD or a DO, the Office of the Inspector General (OIG) in its December 2011 report entitled 

Questionable Billing Patterns of Portable X-Ray Suppliers (OEI-12-10-00190) found that 

Medicare was paying for portable x-ray services ordered by physicians other than MDs and DOs, 

including podiatrists and chiropractors, and by nonphysician practitioners. We issued a special 

education article on January 20, 2012, through the Medicare Learning Network (MLN) 

“Important Reminder for Providers and Suppliers Who Provide Services and Items Ordered or 

Referred by Other Providers and Suppliers,” reiterating our current policy that portable x-ray 

services can only be ordered by a MD or DO. The article is available at 

http://www.cms.gov/MLNMattersArticles/downloads/SE1201.pdf on the CMS website. Since 

the publication of the above mentioned article, several stakeholders have told us that members of 

the healthcare community fail to distinguish ordering for portable x-ray services from ordering 

for other diagnostic services where our general policy is to allow nonphysician practitioners and 

physicians other than MDs and DOs to order diagnostic tests within the scope of their authority 

under state law and their Medicare statutory benefit. They report finding the different 

requirements confusing. 

 We proposed to revise our current regulations, which limit ordering of portable x-ray 

services to only a MD or DO, to allow other physicians and nonphysician practitioners acting 

within the scope of their Medicare benefit and state law to order portable x-ray services. 

Specifically, we proposed revisions to the CfC at §486.106(a) and §486.106(b) to permit portable 

x-ray services to be ordered by a physician or nonphysician practitioner in accordance with the 

ordering policies for other diagnostic services under §410.32(a). 

This proposed change would allow a MD or DO, as well as a nurse practitioner, clinical 

nurse specialist, physician assistant, certified nurse-midwife, doctor of optometry, doctor of 

dental surgery and doctor of dental medicine, doctor of podiatric medicine, clinical psychologist, 
383 

and clinical social worker to order portable x-ray services within the scope of their authority 

under state law and the scope of their Medicare benefit. Although all of these physicians and 

nonphysician practitioners are authorized to order diagnostic services in accordance with 

§410.32(a), their Medicare benefit and state scope of practice delimits the services that they can 

furnish. For example, the state scope of practice for clinical psychologists typically is limited to 

the diagnosis and treatment of mental health disorders and related services. The scope of the 

Medicare benefit for clinical social workers under 1861(hh) of the Act limits their ability to order 

diagnostic tests to mental health related tests. 

Comment: The majority of commenters supported allowing additional nonphysician and 

limited-license practitioners to order portable x-ray services. The commenters stated that this 

proposal is consistent with the increasing role for practitioners other than MDs or DOs in health 

care delivery today, with nonphysician and limited license practitioner training and practice, with 

staffing decisions for care furnished in nursing homes and other home care settings, and with the 

scope of practice for various practitioners under state law. 

Response: We thank the commenters for their support and agree with these comments. 

As we stated in the CY 2013 PFS proposed rule, we believe nonphysician practitioners have 

become an increasingly important component of clinical care, and we believe that delivery 

systems should take full advantage of all members of a healthcare team, including nonphysician 

practitioners. Allowing limited-license and nonphysician practitioners to order portable x-ray 

services within the scope of their practice will enhance the role of those practitioners. 

Comment: Some commenters either questioned or opposed the ability of certain 

nonphysician or limited-license practitioners to order portable x-ray services. The commenters 

stated that by including clinical psychologists and clinical social workers, our proposal was too 

broad as these nonphysician practitioners do not have the appropriate education or training to 

order portable x-ray services. In addition, they noted that the ordering of portable x-ray services 
384 

is not within clinical psychologists’ and clinical social workers’ state scopes of practice. One 

commenter stated that the ordering authority for portable x-ray services should only be expanded 

to physician assistants, nurse practitioners, and doctors of podiatric medicine, stating that there is 

no convincing or clinically supportable rationale for other practitioners identified in §410.32(a), 

including certified nurse-midwives, doctors of optometry, doctors of dental surgery and doctors 

of dental medicine, clinical social workers, and clinical psychologists, to order portable x-ray 

services. A few commenters stated that some nonphysician and limited-license practitioners 

have not been trained to diagnose an illness, to use x-rays as part of the diagnosis and treatment 

of a beneficiary, to know how to interpret an x-ray, and to plan a course of medically appropriate 

follow-up treatment. Commenters requested the clinical rationale and FY 2011 data on portable 

x-ray ordering by select nonphysician practitioners. One commenter stated that deferring to state 

scope of practice laws for limited- license and nonphysician practitioners did not constitute 

sufficient stewardship by Medicare to ensure payment for appropriate services. 

Response: We disagree. We proposed to modify our rule for ordering portable x-ray 

services to make it consistent with rules for ordering all other diagnostic tests. Our proposed 

policy would eliminate the specific requirements limiting the types of practitioners who can 

order portable x-ray services, and instead place ordering for portable x-ray services under the 

general regulations governing ordering of diagnostic tests in §410.32(a)(2). Under 

§410.32(a)(2), limitations on the ability of various practitioners to order diagnostic tests are 

established by the practitioner’s scope of practice under state law and the scope of the 

practitioner’s Medicare benefit. The current regulation applies to x-rays (other than portable xrays), MRI, CT scans, and a host of other diagnostic tests that are more complex and potentially 

higher risk than portable x-ray services. We do not believe that nonphysician and limitedlicense practitioners who can routinely order and employ the results of reasonable and necessary 

x-rays, MRIs, and CT scans should continue to be precluded from ordering and utilizing portable 
385 

x-ray imaging in the same manner. Further, most of the nonphysician practitioners listed in 

§410.32(a)(2) are authorized by statute to furnish physician services under the scope of their 

Medicare benefit and state scope of practice, including ordering, interpreting, and using test 

results to treat a beneficiary. 

With regard to clinical social workers, under section 1861(hh) of the Act, the scope of 

their Medicare benefit is further limited to services “for the diagnosis and treatment of mental 

illnesses.” Therefore, the proposed change to our regulations to allow clinical social workers to 

order portable x-ray services in the same way that they are permitted to order other diagnostic 

tests under §410.32(a) would not allow clinical social workers to order portable x-ray services. 

Portable x-ray services fall within the scope of the Medicare benefit for the remaining 

nonphysician and limited-license practitioners, including clinical psychologists. As noted above, 

we believe state scope of practice laws might limit ordering of portable x-ray services by clinical 

psychologists or other practitioners. Additionally, certain other practitioners are unlikely to have 

a reason to order portable x-ray services, such as doctors of optometry. We have no evidence to 

suggest that clinical psychologists or other limited license or nonphysician practitioners are 

ordering significant numbers of x-rays, CTs, and MRIs under §410.32(a) authority at this time. 

We do not expect any marked change in ordering patterns following the change in regulation to 

allow for ordering of portable x-ray services. 

With regard to the request for FY 2011 data on portable x-ray ordering by select 

nonphysician practitioners, we do not believe this or any recent data on portable x-ray ordering 

patterns for limited-license or nonphysician practitioners would be meaningful information 

regarding future potential ordering patterns for portable x-ray services because these 

practitioners are not permitted to order portable x-ray services under the current regulation. We 

believe our proposal is consistent with our current regulations that generally allow nonphysician 

practitioners to order diagnostic services, and the agency’s interest in having delivery systems 
386 

take full advantage of all members of a healthcare delivery team. We describe below our 

intention to design monitoring systems that will capture excessive ordering. 

Comment: Several commenters requested that CMS clarify that the proposal for CY 

2013 is actually a clarification of long standing policy that nonphysician practitioners have been 

able to order portable x-ray services since implementation of the their authority to order 

diagnostic tests under §410.32(a)(2) and requested that CMS indicate that this authority is not a 

change in policy effective January 1, 2013. Commenters stated that the regulations at 

§410.32(a), established as a result of the Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33), 

were promulgated long after the 1969 CfC requirement at §486.106 and that the more recent 

regulation trumps older requirements. These commenters stated that it was merely an oversight 

on the part of CMS when the agency failed to update the regulations at §486.106. They also 

stated that some manual language and educational materials have been inconsistent in 

communicating that only MDs or DOs can order portable x-ray services over the years. 

Commenters requested that if CMS does conclude that allowing nonphysician and limitedlicense practitioner ordering of portable x-ray services is a change in policy for CY 2013, then 

CMS should specify in the preamble that no repayments or other actions are required, including 

recoupment efforts as a result of the OIG’s findings in the December 2011 report entitled 

Questionable Billing Patterns of Portable X-ray Suppliers (OEI 12-10-00190) 

Response: There is a longstanding regulation requiring ordering of portable x-ray 

services by an MD or DO at §486.106(a) and §486.106(b). There is a specific section of the 

regulation under §410.32 dedicated to portable x-ray services, §410.32(c), that explicitly crossreferences the requirements under §486.106. As such, we do not believe that, when revising the 

regulation at §410.32 to expand the general rules for ordering diagnostic tests under the BBA, 

the agency simply failed to notice the requirement in the same section relating to portable x-ray 

tests. Further, the specific requirement for MD or DO ordering of portable x-ray services under 
387 

§410.32(c) explicitly excepts portable x-ray services from the general ordering rules under 

§410.32(a). The only means to revise the regulations containing this longstanding CfC is 

through notice and comment rulemaking, which was the purpose of the proposal we made in the 

CY 2013 proposed rule. The change in policy to allow limited-license and nonphysician 

practitioners to order portable x-ray services will be effective beginning in CY 2013. 

The OIG report concluded, and CMS concurred, that CMS should recoup payment for 

portable x-ray services identified under the report as ordered by limited-license physicians and 

nonphysician practitioners, other than a MD or DO in accordance with our regulations at 

§410.32(c) and §486.106 since this was consistent with this recommendation. We will continue 

our recoupment efforts in response to the OIG report. However, we have instructed our payment 

contractors that the ordering of portable x-ray services should not be made a priority for 

additional medical review activity beyond claims identified in the OIG audit. 

After considering the public comments received, we are finalizing our CY 2013 proposal 

to revise the CfC at §486.106(a) and §486.106(b) to permit portable x-ray services to be ordered 

by physicians or nonphysician practitioners in accordance with the general ordering policies for 

other diagnostic services as specified under §410.32(a). Therefore, effective for services 

furnished on or after January 1, 2013, the following practitioners will be permitted to order 

portable x-rays in accordance with Medicare regulations and subject to their scope of practice 

under state law and their applicable Medicare statutory benefit: a physician (including an MD or 

a DO, doctor of optometry, doctor of dental surgery and doctor of dental medicine, and doctor of 

podiatric medicine), or a nurse practitioner, clinical nurse specialist, physician assistant, certified 

nurse-midwife, or clinical psychologist, where the ordering of portable x-ray services is within 

the scope of their practice under state law. As discussed above, although clinical social workers 

are permitted to order diagnostic tests under §410.32(a)(2), the scope of their Medicare benefit is 

limited to services for the diagnosis and treatment of mental illnesses. As such, we do not 
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believe these nonphysician practitioners would need to order portable x-ray services. We also 

are finalizing revisions to the language included under §410.32(c) specific to portable x-ray 

services to recognize the same authority for physicians and nonphysician practitioners to order 

diagnostic tests as is prescribed for other diagnostic services under §410.32(a). 

Finally, we are finalizing two technical corrections that we proposed to make in the CY 2013 

PFS proposed rule. One is to §410.32(d)(2), where we currently cite paragraph (a)(3) for the 

definition of a qualified nonphysician practitioner. The definition of a qualified nonphysician 

practitioner is currently found in paragraph (a)(2),while paragraph (a)(3) does not exist; 

therefore, we are correcting the citation. The second technical correction is in §410.32(b)(2)(iii) 

to better reflect the statutory authority to furnish neuropsychological testing in addition to 

psychological testing. We did not receive any comments on these proposed technical 

corrections. The documentation requirement for this paragraph remains unchanged. 

Although we believe it is appropriate to finalize policy to allow nonphysician 

practitioners and limited-license practitioners to order portable x-ray services within the scope of 

their authority under state law and the scope of their Medicare statutory benefit given overall 

changes in health care delivery practice patterns since the beginning of the Medicare program, 

we remain concerned about the OIG’s recent findings. The OIG observed other questionable 

billing patterns for portable x-ray services in addition to ordering by nonphysician practitioners. 

Of specific note was the observation that some portable x-ray suppliers are furnishing services on 

the same day that the beneficiary also receives services in a clinical setting, such as the physician 

office or hospital. Under current regulations at §486.106(a)(2), the order for portable x-ray 

services must include a statement concerning the condition of the beneficiary which indicates 

why portable x-ray services are necessary. If, on the same day that a portable x-ray service was 

furnished, the patient was able to travel safely to a clinical setting, we believe the statement of 

need for portable x-ray services could be questionable. We also are concerned that the OIG 
389 

observed some portable x-ray suppliers billing for multiple trips to a facility on the same day 

Medicare makes a single payment for each trip the portable x-ray supplier makes to a particular 

location. We make available several modifiers to allow the portable x-ray supplier to indicate 

the number of beneficiaries served on a single trip to a facility. We expect portable x-ray 

suppliers to use those modifiers and not to bill multiple trips to the same facility on a single day 

when only one trip was made. Additionally, we strongly encourage portable x-ray suppliers to 

make efficient use of resources and consolidate trips, to the extent it is clinically appropriate to 

do so, rather than making multiple trips on the same day. 

Comment: Several stakeholders provided scenarios where a portable x-ray service would 

be medically necessary on the same day as a hospital, physician office, or other clinical setting. 

Response: We agree that there may be unusual circumstances when portable x-ray 

services could be appropriate with a same day visit to a hospital, physician office, or other 

clinical setting. Proper documentation of the rationale for such same day occurrences would be 

required to substantiate the necessity for those services. 

 In conjunction with our proposal to expand the scope of physicians and nonphysician 

practitioners who can order portable x-ray services, we intend to develop, as needed, monitoring 

standards predicated by these and other OIG findings. In addition, we will be conducting data 

analysis of ordering patterns for portable x-ray and other diagnostic services to determine if 

additional claims edits, provider audits, or fraud investigations are required to prevent abuse of 

these services and to allow for the collection of any potential overpayments. We encourage 

physicians and practitioners, as with any diagnostic test, to proactively determine and document 

the medical necessity for this testing. 

Comment: One commenter noted that our proposal to expand the scope of ordering for 

portable x-ray services was at odds with our statements indicating our intent to engage in greater 

monitoring of the delivery of portable x-ray services overall. The commenter recommended that 
390 

we target any new program integrity efforts to practitioner groups where there is evidence of 

abuse. 

Response: We disagree. We believe allowing nonphysician and limited-license 

practitioners to order portable x-ray services is consistent with statutory authority and changes in 

health care delivery. Any monitoring effort would target more generally, the utilization and 

delivery of portable x-ray services, of which of the actual x-ray service is only one small 

component. 

In the proposed rule (77 FR 44791), we solicited comments and suggestions for updating 

the current regulations at 42 CFR Part 486, Subpart C—Conditions for Coverage: Portable XRay Services through future rulemaking. Below are our responses to public comments on 

suggestions for future rulemaking at 42 CFR Part 486, Subpart C—Conditions for Coverage: 

Portable X-Ray Services. 

Comment: One commenter suggested CMS clarify the differences between portable xray providers and mobile independent diagnostic testing facilities (IDTFs). The commenter 

specifically recommended that CMS clarify whether portable x-ray suppliers and mobile IDTFs 

can furnish the same services to Medicare beneficiaries or whether there are limitations on the 

types of services that portable x-ray suppliers and IDTFs can furnish. The commenter also 

recommended that CMS establish educational and training requirements for portable x-ray 

suppliers and IDTF technicians. 

Response: We appreciate these comments and will take them into consideration when 

undertaking future rulemaking. 
391 

M. Addressing Interim Final Relative Value Units (RVUs) from CY 2012 and Establishing 

Interim Final RVUs for CY 2013

Section 1848(c)(2)(B) of the Act requires that we review RVUs for physicians’ services 

no less often than every 5 years. Under section 1848(c)(2)(K) of the Act (as added by section 

3134 of the Affordable Care Act), we are required to identify and revise RVUs for services 

identified as potentially misvalued. To facilitate the review and appropriate adjustment of 

potentially misvalued services, section 1848(c)(2)(K)(iii) specifies that the Secretary may use 

existing processes to receive recommendations; conduct surveys, other data collection activities, 

studies, or other analyses as the Secretary determined to be appropriate; and use analytic 

contractors to identify and analyze potentially misvalued services, conduct surveys or collect 

data. In accordance with section 1848(c)(2)(K)(iii) of the Act, we identify potentially misvalued 

codes, and develop and propose appropriate adjustments to the RVUs, taking into account the 

recommendations provided by the AMA RUC, the Medicare Payment Advisory Commission 

(MedPAC), and other public commenters. 

For many years, the AMA RUC has provided CMS with recommendations on the 

appropriate relative values for PFS services. Over the past several years, CMS and the AMA 

RUC have identified and reviewed a number of potentially misvalued codes on an annual basis, 

based on various identification screens for codes at risk for being misvalued. This annual review 

of work RVUs and direct PE inputs for potentially misvalued codes was further bolstered by the 

Affordable Care Act mandate to examine potentially misvalued codes, with an emphasis on the 

following categories specified in section 1848(c)(2)(K)(ii) (as added by section 3134 of the 

Affordable Care Act): 

• Codes and families of codes for which there has been the fastest growth. 
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• Codes or families of codes that have experienced substantial changes in practice 

expenses. 

• Codes that are recently established for new technologies or services. 

• Multiple codes that are frequently billed in conjunction with furnishing a single service. 

• Codes with low relative values, particularly those that are often billed multiple times for 

a single treatment. 

• Codes which have not been subject to review since the implementation of the RBRVS 

(the “Harvard-valued” codes). 

• Other codes determined to be appropriate by the Secretary. 

In addition to providing recommendations to CMS for work RVUs, the AMA RUC's 

Practice Expense Subcommittee reviews, and then the AMA RUC recommends, direct PE inputs 

(clinical labor, medical supplies, and medical equipment) for individual services. To guide the 

establishment of malpractice RVUs for new and revised codes before each Five-Year Review of 

Malpractice, the AMA RUC also provides malpractice crosswalk recommendations, that is, 

“source” codes with a similar specialty mix of practitioners furnishing the source code and the 

new/revised code. 

CMS reviews the AMA RUC recommendations on a code-by-code basis. For AMA 

RUC recommendations regarding physician work RVUs, after conducting a clinical review of 

the codes, we determine whether we agree with the recommended work RVUs for a service (that 

is, whether we agree the AMA RUC-recommended valuation is accurate). If we disagree, we 

determine an alternative value that better reflects our estimate of the physician work for the 

service. 

Because of the timing of the CPT Editorial Panel decisions, the AMA RUC 

recommendations, and our rulemaking cycle, we publish these work RVUs in the PFS final rule 
393 

with comment period as interim final values, subject to public comment. Similarly, we assess 

the AMA RUC's recommendations for direct PE inputs and malpractice crosswalks, and 

establish PE and malpractice interim final values, which are also subject to comment. We note 

that, with respect to interim final PE RVUs, the aspect of our valuation that is open for public 

comment for a new, revised, or potentially misvalued code is the direct PE inputs and not the 

other elements of the PE valuation methodology, such as the indirect cost allocation 

methodology, that also contribute to establishing the PE RVUs for a code. 

If we receive public comments on the interim final work RVUs for a specific code 

indicating that refinement of the interim final work value is warranted based on sufficient and 

new information from the commenters concerning clinical aspects of the physician work 

associated with the service (57 FR 55917) that were not already considered in making the interim 

valuation or the AMA RUC deliberations, we refer the service to a refinement panel, as 

discussed in further detail in section III.M.1.a. of this final rule with comment period. 

 In the interval between closure of the comment period and the subsequent year's PFS 

final rule with comment period, we consider all of the public comments on the interim final 

work, PE, and malpractice RVUs for the new, revised, and potentially misvalued codes and the 

results of the refinement panel, if applicable. Finally, we address the interim final RVUs 

(including the interim final direct PE inputs) by providing a summary of the public comments 

and our responses to those comments, including a discussion of any changes to the interim final 

work or malpractice RVUs or direct PE inputs, in the following year's PFS final rule with 

comment period. We typically finalize the direct PE inputs and the work, PE, and malpractice 

RVUs for the service in that year's PFS final rule with comment period, unless we determine it 

would be more appropriate to continue their interim final status for another year and solicit 

further public comment. 
394 

1. Methodology 

We conducted a clinical review of each code identified in this section and reviewed the 

current and recommended work RVUs, intensity, and time to furnish the pre-service, intraservice, and post-service activities, as well as other components of the service that contribute to 

the value. Our clinical review generally includes, but is not limited to, a review of information 

provided by the AMA RUC and other public commenters, medical literature, and comparative 

databases, as well as a comparison with other codes within the Medicare PFS, consultation with 

other physicians and healthcare professionals within CMS and the Federal Government, and the 

views based on clinical experience of the physicians on the PFS clinical review team. We also 

assessed the methodology and data used to develop the recommendations submitted to us by the 

AMA RUC and other public commenters and the rationale for the recommendations. As we 

noted in the CY 2011 PFS final rule with comment period (75 FR 73328 through 73329), there 

are a variety of methodologies and approaches used to develop work RVUs, including building 

block, survey data, crosswalk to key reference or similar codes, and magnitude estimation. The 

building block methodology is used to construct, or deconstruct, the work RVU for a CPT code 

based on component pieces of the code. Components may include pre-, intra-, or post-service 

time and post-procedure visits, or, when referring to a bundled CPT code, the components could 

be considered to be the CPT codes that make up the bundled code. Magnitude estimation refers 

to a methodology for valuing physician work that determines the appropriate work RVU for a 

service by gauging the total amount of physician work for that service relative to the physician 

work for similar service across the physician fee schedule without explicitly valuing the 

components of that work. The resource-based relative value system (RBRVS) has incorporated 

into it cross-specialty and cross-organ system relativity. This RBRVS requires assessment of 

relative value and takes into account the clinical intensity and time required to perform a service. 
395 

In selecting which methodological approach will best determine the appropriate value for a 

service, we consider the current and recommended physician work and time values, as well as 

the intensity of the service, all relative to other services. 

Several years ago, to aid in the development of pre-service time recommendations for 

new and revised CPT codes, the AMA RUC created standardized pre-service time packages. 

The packages include pre-service evaluation time, pre-service positioning time, and pre-service 

scrub, dress and wait time. Currently there are six pre-service time packages for services 

typically furnished in the facility setting, reflecting the different combinations of straightforward 

or difficult procedure, straightforward or difficult patient, and without or with 

sedation/anesthesia. Currently there are two pre-service time packages for services typically 

furnished in the nonfacility setting, reflecting procedures without and with sedation/anesthesia 

care. 

We have developed several standard building block methodologies to appropriately value 

services when they have very common billing patterns. As we have discussed in past 

rulemaking, most recently in the CY 2012 PFS final rule with comment period (76 FR 73107 

through 73108), in cases where a service is typically furnished to a beneficiary on the same day 

as an evaluation and management (E/M) service, we believe that there is overlap between the 

two services in some of the activities furnished during the pre-service evaluation and postservice time. We believe that at least one-third of the physician time in both the pre-service 

evaluation and post-service period is duplicative of work furnished during the E/M visit. 

Accordingly, in cases where we believe that the AMA RUC has not adequately accounted for the 

overlapping activities in the recommended work RVU and/or times, we adjust the work RVU 

and/or times to account for the overlap. The work RVU for a service is the product of the time 

involved in furnishing the service times the intensity of the work. Pre-service evaluation time 
396 

and post-service time both have a long-established intensity of work per unit of time (IWPUT) of 

.0224, which means that 1 minute of pre-service evaluation or post-service time equates to .0224 

of a work RVU. Therefore, in many cases where we remove 2 minutes of pre-service time and 2 

minutes of post-service time from a procedure to account for the overlap with the same day E/M 

service, we also remove a work RVU of .09 (4 minutes x .0224 IWPUT) if we do not believe the 

overlap in time has already been accounted for in the work RVU. We continue to believe this 

adjustment is appropriate. The AMA RUC has recognized this valuation policy and, in many 

cases, addresses the overlap in time and work when a service is typically provided on the same 

day as an E/M service. 

We appreciate the creation and use of these standardized pre-service time packages. 

However, we believe that services that involve only a local anesthetic agent do not typically 

involve the same amount of pre-service time as procedures involving sedation or non-local 

anesthesia care. We request that the AMA RUC consider assigning services that require only 

local anesthesia without sedation to the “no sedation/anesthesia care” pre-service time package, 

or that the AMA RUC create one or more new pre-service time packages to reflect the preservice time typically involved in furnishing local anesthesia without sedation. 

For many CPT codes that are typically billed on the same day as an E/M service, the 

recommendations from the AMA RUC state that the AMA RUC reviewed the work associated 

with the procedure, and adjusted the pre-service and/or post-service time to account for the work 

that is furnished as a part of the E/M service. For many codes, the AMA RUC made this 

adjustment from the pre-service evaluation time included in the AMA RUC-selected pre-service 

time package. However, as we noted above, we believe that the pre-service time packages for 

procedures with sedation or anesthesia care may overstate the time involved in furnishing 

services that involve only local or topical anesthesia without sedation. As a result, though the 
397 

AMA RUC may have removed some pre-service time from the package to account for the same 

day E/M service, in a few instances, consistent with our established same day E/M reduction 

methodology discussed above, we further reduced the AMA RUC-recommended pre-service 

evaluation time to fully account for the overlapping time with the same day E/M service. 

2. Finalizing CY 2012 Interim and CY 2013 Proposed Values for CY 2013 

In this section, we address the interim final values published in the CY 2012 PFS final 

rule with comment period (76 FR 73026 through 73474), as subsequently corrected in the 

January 4, 2012 (77 FR 227 through 232) correction notice; and the proposed values published in 

the CY 2013 PFS proposed rule (77 FR 44722 through 45061). We discuss the results of the CY 

2012 refinement panels for certain CY 2012 interim final code values, respond to public 

comments received on specific interim final and proposed values (including direct PE inputs), 

and address the other new, revised, or potentially misvalued codes with interim final or proposed 

values. The final CY 2013 direct PE database that lists the direct PE inputs is available on the 

CMS website under the downloads for the CY 2013 PFS final rule with comment period at: 

www.cms.gov/PhysicianFeeSched/. The final CY 2013 work, PE, and malpractice RVUs are 

displayed in Addendum B to this final rule with comment period at: 

www.cms.gov/PhysicianFeeSched/. 

a. Finalizing CY 2012 Interim and Proposed Work RVUs for CY 2013 

i. Refinement Panel 

(1) Refinement Panel Process

 As discussed in the 1993 PFS final rule with comment period (57 FR 55938), we adopted 

a refinement panel process to assist us in reviewing the public comments on CPT codes with 
398 

interim final work RVUs for a year and in developing final work values for the subsequent year. 

We decided the panel would be comprised of a multispecialty group of physicians who would 

review and discuss the work involved in each procedure under review, and then each panel 

member would individually rate the work of the procedure. We believed establishing the panel 

with a multispecialty group would balance the interests of the specialty societies who 

commented on the work RVUs with the budgetary and redistributive effects that could occur if 

we accepted extensive increases in work RVUs across a broad range of services. 

 Depending on the number and range of codes that are subject to refinement in a given 

year, we establish refinement panels with representatives from four 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). Typical panels have included 8 to 10 physicians across the four groups. 

 Following the addition of section 1848(c)(2)(K) to the Act by Section 3134 of the 

Affordable Care Act, which authorized the Secretary to review potentially misvalued codes and 

make appropriate adjustments to the RVUs, we reassessed the refinement panel process. As 

detailed in the CY 2011 PFS final rule with comment period (75 FR 73306), we believed that the 

refinement panel process may provide an opportunity to review and discuss the proposed and 

interim final work RVUs with a clinically diverse group of experts, who then provide informed 

recommendations. Therefore, we indicated that we would continue the refinement process, but 

with administrative modification and clarification. We also noted that we would continue using 

the established composition that includes representatives from the four groups of physicians -- 

clinicians representing the specialty most identified with the procedures in question, physicians 

with practices in related specialties, primary care physicians, and CMDs. 

One change relates to the calculation of the refinement panel results. The basis of the 
399 

process is that following discussion of the information but without an attempt to reach a 

consensus, each member of the panel votes independently. Historically, the refinement panel’s 

recommendation to change a work value or to retain the interim value had hinged solely on the 

outcome of a statistical test on the ratings (an F-test of panel ratings among the groups of 

participants). Over time, we found the statistical test used to evaluate the RVU ratings of 

individual panel members became less reliable as the physicians in each group tended to select a 

previously discussed value, rather than developing a unique value, thereby reducing the observed 

variability needed to conduct a robust statistical test. In addition, reliance on values developed 

using the F-test also occasionally resulted in rank order anomalies among services (that is, a 

more complex procedure is assigned lower RVUs than a less complex procedure). As a result, 

we eliminated the use of the statistical F-test and instead indicated that we would use the median 

work value of the individual panel members’ ratings. We said that this approach would simplify 

the refinement process administratively, while providing a result 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. At the same time, we clarified that we have the final 

authority to set the RVUs, including making adjustments to the work RVUs resulting from the 

refinement process, and that we will make such adjustments if warranted by policy concerns 

(75 FR 73307). 

 As we continue to strive to make the refinement panel process as effective an efficient as 

possible, we would like to remind readers that the refinement panels are not intended to review 

every code for which we did not propose to accept the AMA RUC-recommended RVUs. Rather 

the refinement panels are designed for situations where there is new information available that 

might provide a reason for a change in work values and for which a multi-specialty panel of 

physicians might provide input that would assist us in making work RVU decisions. To facilitate 
400 

the selection of services for the refinement panels, we would like to remind specialty societies 

seeking reconsideration of proposed or interim final work RVUs, including consideration by a 

refinement panel, to specifically state they are requesting refinement panel review in their public 

comment letters. 

Furthermore we have asked commenters requesting refinement panel review to submit 

sufficient new information concerning the clinical aspects of the work assigned for a service to 

indicate that referral to the refinement panel is warranted (57 FR 55917). We note that the 

majority of the information presented during the CY 2012 refinement panel discussions was 

duplicative of the information provided to the AMA RUC during its development of 

recommendations. As detailed in section III.B. of this final rule with comment period, we 

consider information and recommendations from the AMA RUC when assigning proposed and 

interim final RVUs to services. Thus, if the only information that a commenter has to present is 

information already considered by the AMA RUC, referral to a refinement panel is not 

appropriate. To facilitate selection of codes for refinement, we request that commenters seeking 

refinement panel review of work RVUs submit supporting information that has not already been 

considered the AMA RUC in creating recommended work RVUs or by CMS in assigning 

proposed and interim final work RVUs. We can make best use of our resources as well as those 

of the specialties involved and physician volunteers, by avoiding duplicative consideration of 

information by the AMA RUC, CMS, and a refinement panel. To achieve this goal, CMS will 

continue to critically evaluate the need to refer codes to refinement panels in future years, 

specifically considering any new information provided by commenters. 

(2) Interim Final Work RVUs Referred to the Refinement Panel in CY 2012 

We referred to the CY 2012 refinement panel 17 CPT codes with interim final work 

values for which we received a request for refinement that met the process described above. For 
401 

these 17 CPT codes, all commenters requested increased work RVUs. For ease of discussion, we 

will be referring to these services as “refinement codes.’’ Consistent with the process described 

above, we convened a multi-specialty panel of physicians to assist us in the review of the 

comments. The panel was moderated by our physician advisors, and consisted of the following 

voting members: 

• One to two clinicians representing the commenting organization; 

• One to two primary care clinicians nominated by the American Academy of Family 

Physicians and the American College of Physicians; 

• Four contractor medical directors (CMDs); and 

• One to two clinicians with practices in related specialties who were expected to have 

knowledge of the services under review. 

 The panel process was designed to capture each participant's independent judgment and 

his or her clinical experience which informed and drove the discussion of the refinement code 

during the refinement panel proceedings. Following the discussion, each voting participant 

rated the physician work of the refinement code and submitted those ratings to CMS 

individually and confidentially, with no attempt to achieve consensus among the panel members. 

As finalized in the CY 2011 PFS final rule with comment period (75 FR 73307), we reviewed 

the ratings from each panel member and determined the median value for each service that was 

reviewed by the refinement panel. 

 We note that the individual codes reviewed by the CY 2012 refinement panel, and their 

final work RVUs are discussed in section III.B.1.b. of this final rule with comment period. Also, 

see Table 29 for the refinement panel ratings and the final work RVUs for the codes reviewed by 

the CY 2012 refinement panel. 

TABLE 29: Codes Reviewed under the CY 2012 Refinement Panel Process
402 

CPT 

Code Short Descriptor 

CY 2012 

Interim 

Final 

WRVU 

AMA RUC/ 

HCPAC 

Recommend

ed Work 

RVU 

2012 

Refinement 

Median 

Panel 

Rating 

CY 2013 

Final 

WRVU 

26341 Manipulat palm cord post inj 0.91 1.66 1.30 0.91 

29581 Apply multlay comprs lwr leg 0.25 0.60 0.50 30.25 

32096 Open wedge/bx lung infiltr 13.75 17.00 17.00 13.75 

32097 Open wedge/bx lung nodule 13.75 17.00 17.00 13.75 

32098 Open biopsy of lung pleura 12.91 14.99 14.99 12.91 

32100 Exploration of chest 13.75 17.00 17.00 13.75 

32505 Wedge resect of lung initial 15.75 18.79 18.79 15.75 

38230 Bone marrow harvest allogen 3.09 4.00 4.00 3.50 

38232 Bone marrow harvest autolog 3.09 3.50 3.50 3.50 

62370 Anl sp inf pmp /mdreprg&fil 0.90 1.10 1.10 0.90 

92587 Evoked auditory test limited 0.35 0.45 0.45 0.35 

92588 Evoked auditory tst complete 0.55 0.60 0.60 0.55 

94060 Evaluation of wheezing 0.26 0.31 0.27 0.27 

94726 Pulm funct tst plethysmograp 0.26 0.31 0.26 0.26 

94727 Pulm function test by gas 0.26 0.31 0.26 0.26 

94728 Pulm funct test oscillometry 0.26 0.31 0.26 0.26 

94729 C02/membane diffuse capacity 0.17 0.19 0.19 0.19 

ii. Code-specific Issues 

In this section, we discuss all code families for which we received a comment on an 

interim final physician work value in CY 2012 PFS final rule with comment period or on a 

proposed value in the CY 2013 PFS proposed rule. Refer to Addendum B for a comprehensive 

list of all final values. 

(1) Integumentary System: Skin, Subcutaneous, and Accessory Structures (CPT Code 11056) 

For discussion on CY 2013 interim final work values for CPT code 11056 refer to section 

III.M.3. of this final rule with comment period. 

(2) Integumentary System: Nails (CPT code 11719) 

For discussion on CY 2013 interim final work values for CPT code 11719 refer to section 

III.M.3. of this final rule with comment period. 

 

3

This value is interim final for CY 2013. 
403 

(3) Integumentary System: Repair (Closure) (CPT Codes 12035-12057) 

For discussion on CY 2013 interim final work values for CPT codes 12035 through12057 

refer to section III.M.3. of this final rule with comment period. 

(4) Integumentary System: Repair (Closure) (CPT Codes 15272 and 15276) 

As detailed in the CY 2012 final rule with comment period (76 FR 73112), for CY 2012, 

the CPT Editorial Panel deleted 24 skin substitute codes and established a 2-tier structure with 8 

new codes (CPT codes 15271 through 15278) to report the application of skin substitute grafts, 

which are distinguished according to the anatomic location and surface area rather than by 

product description. 

We assigned a work RVU of 0.33 to CPT code 15272 (Application of skin substitute 

graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm 

wound surface area, or part thereof (List separately in addition to code for primary procedure)) 

on an interim final basis for CY 2012. After clinical review of CPT code 15272, we believed 

that a work RVU of 0.33 accurately reflected the work associated with this service. The AMA 

RUC reviewed the survey results for CPT code 15272 and recommended the survey 25th 

percentile work RVU of 0.59 for this service. However, we believed this value overstated the 

work of this procedure when compared to the base CPT code 15271 (Application of skin 

substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or 

less wound surface area). We believed that CPT code 15272 is similar in intensity to 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 that the primary factor distinguishing 

the work of these two services is the intra-service physician time. CPT code 15341 has a work 

RVU of 0.50, 15 minutes of intra-service time, and an IWPUT of 0.0333. CPT code 15272 has 

10 minutes of intra-service time. Ten minutes of intra-service work at the same intensity as CPT 
404 

code 15341 is equal to a work RVU of 0.33 (10 minutes x 0.0333 IWPUT). Therefore, we 

assigned a work RVU of 0.33 to CPT code 15272 on an interim final basis for CY 2012. 

Comment: Commenters opposed the CMS-recommended interim final work RVU of 0.33 

assigned to CPT code 15272. Commenters disagreed with our rationale to crosswalk CPT code 

15272 to CPT code 15341 and stated that CPT code 15003 (Surgical preparation or creation of 

recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), 

or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq. cm, or part 

thereof, or each additional 1% of body area of infants and children (List separately in addition to 

code for primary procedure), which has a work RVU of 0.80, is a more suitable comparison 

code. Commenters noted that although CPT code 15003 requires 15 minutes of intra-service 

time whereas CPT code 15272 requires 10 minutes, it is a more appropriate comparison for 

valuation of the services under this code. Commenters stated that the AMA RUC-recommended 

work RVU places this service in the proper rank order with the base code, CPT code 15271. 

Furthermore, commenters noted that if all the AMA RUC recommendations for the family of 

CPT codes 15271 through15278 were accepted, the result would be financial savings for 

Medicare. Therefore, commenters recommended that we accept the AMA RUC-recommended 

work RVU of 0.59 for CPT code 15272. 

Response: Based on the comments received, we re-reviewed CPT code 15272 and 

continue to believe that CPT code 15272 is similar in intensity to CPT code 15341. The primary 

distinguishing factor between the two services is that CPT code 15272 has 10 minutes of intraservice time and CPT code 15341 has 15 minutes. We continue to believe that the AMA RUCrecommended work RVU overstates the intensity of this procedure compared to the base 

procedure CPT code 15271. We maintain that valuing the 10 minutes of intra-service work at 

the same intensity as CPT code 15341, which equates to a work RVU of 0.33, is appropriate. 
405 

We believe that this resulting work RVU maintains appropriate relativity with the base code and 

the entire family of CPT codes (15271 through15278). Therefore, we are finalizing a work RVU 

of 0.33 for CPT code 15272. 

We assigned a work RVU of 0.50 to CPT code 15276 (Application of skin substitute 

graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple 

digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or 

part thereof (List separately in addition to code for primary procedure)) on an interim final basis 

for CY 2012 based on our clinical review of the work associated with this service. The AMA 

RUC reviewed the survey results for CPT code 15276 and recommended a work RVU of 0.59, 

which corresponds to the AMA RUC's recommended work RVU for CPT code 15272. We 

disagreed with the AMA RUC that these two CPT codes should be valued the same. We 

assigned an interim final work RVU of 0.33 to CPT code 15272 but believed that the work 

associated with CPT code 15276, which describes work on the face, scalp, eyelids, mouth, neck, 

ears, orbits, genitalia, hands, feet, and/or multiple digits, is more intense than the work associated 

with CPT code 15272, which describes work on the trunk, arms, and legs. Accordingly, we 

noted that our interim final work RVU for CPT code 15276 accurately captured the work 

associated with this service and established the appropriate relativity between the services. 

Therefore, we assigned a work RVU of 0.50 to CPT code 15276 on an interim final basis for CY 

2012. 

Comment: Commenters disagreed with the CMS-recommended interim final work RVU 

for CPT code 15276. Commenters suggested that CPT code 15276 is analogous to CPT code 

15272, for which the AMA RUC originally recommended a work RVU of 0.59, both in 

physician work and time and recommended that CPT code 15276 should be directly crosswalked 

to CPT code 15272. Further, the commenters agreed with the AMA RUC key reference to CPT 
406 

code 15003 (Surgical preparation or creation of recipient site by excision of open wounds, burn 

eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, 

arms, legs; each additional 100 sq. cm, or part thereof, or each additional 1% of body area of 

infants and children), which has a work RVU of 0.80, and stated that CPT code 15276 requires 5 

minutes less intra-service time, 10 minutes versus 15 minutes, and requires less physician work 

to perform. Commenters recommended that we value CPT code 15276 based upon the AMA 

RUC-recommended work RVU of 0.59 for CPT code 15276. 

Response: Based on the comments received, we re-evaluated whether CPT code 15003 

was an appropriate comparison code for CPT code 15276. However, we concluded that the 

services of CPT code 15276 are more intense than those of CPT code 15272 accordingly; CPT 

code 15276 should be valued to reflect the difference in intensity. We believe a work RVU of 

0.50 establishes the appropriate difference in intensity between these two services. Additionally, 

we believe this work RVU value maintains appropriate relativity with the base code, CPT code 

15271, and maintains relatively within the entire family of CPT codes (15271 through15278). 

Therefore, we are finalizing a work RVU of 0.50 for CPT code 15276. 

(5) Musculoskeletal: Hand and fingers (CPT Code 26341) 

CPT code 26341 (Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection 

(eg, collagenase), single cord) was created by the CPT Editorial Panel along with CPT code 20517 to 

describe a technique for treating Dupuytren's contracture by injecting an enzyme into the Dupuytren's 

cord for full finger extension and manipulation, effective January 1, 2012. 

As detailed in the CY 2012 final rule with comment period, we assigned an interim final work 

RVU of 0.91 to CPT code 26341 (76 FR 73192). After reviewing survey results for CPT code 26341, the 

AMA RUC recommended a work RVU of 1.66, which corresponds to the survey 25th percentile value. 

After clinical review of CPT code 26341, we believed the service described by CPT code 26341 is 

analogous to that of CPT code 97140 (Manual therapy techniques (eg, mobilization/ manipulation, 
407 

manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes), which has a work 

RVU of 0.43. However, since CPT code 97140 has no post-service visits (global period=XXX), while 

CPT code 26341 includes 1 CPT code 99212 (level 2 office or outpatient visit) (global period= 010), we 

added the work RVU of 0.48 for CPT code 99212, to the work RVU of 0.43 for CPT code 97140 to 

obtain the work RVU of 0.91 for CPT code 26341. 

Comment: Commenters disagreed with our decision to crosswalk the work RVU of CPT code 

26341 to that of CPT code 97140, stating that the codes do not have comparable work because CPT code 

97140 is performed by physical therapists while surgeons perform CPT code 26341. Commenters also 

stated that the work associated with CPT code 26341 includes local or regional anesthesia and the 

procedure may result in skin rupture, requiring physician attention to manipulation. In addition, 

commenters noted that the post-procedure neurovascular assessment involved in CPT code 26341 is 

added physician work that is distinctly different from the manual therapy techniques furnished in CPT 

code 97140. Commenters asserted that the difference in physician work, intensity, and complexity 

distinguishes the two codes. Commenters also disagreed with our use of a reverse building block 

methodology to value the additional work and complexity and said that we arbitrarily reduced the value of 

the surgeon's work involved. Commenters recommended we instead value the code based upon the AMA 

RUC-recommended work RVU of 1.66 for CPT code 26341 and requested refinement panel review of the 

code. 

Response: Based on comments received, we referred CPT code 26341 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median work RVU for CPT code 

26341 was 1.30. We believe that the refinement panel median work RVU would create a rank order 

anomaly between this code and similar codes. Although CPT code 97140 is typically furnished by a 

physical therapist, we do not believe that the difference in the provider specialty typically furnishing the 

service results in a difference in intensity of the service. Commenters stated that the post-procedure 

assessment involved in CPT code 26341 added physician work that is distinctly different from the manual 

therapy techniques furnished in CPT code 97140. We disagree; both services require an assessment 

following manipulation appropriate to the provided service to determine the adequacy and outcome, both 
408 

positive and negative, of the intervention and attention to an atypical response to treatment. We continue 

to believe that the crosswalk and reverse building block methodologies that we used in assigning the 

interim final work value are appropriate and the resulting work RVU accurately reflects the work 

associated with this service. After consideration of the public comments, refinement panel median, and 

our clinical review, we are finalizing a work RVU of 0.91 for CPT code 26341. 

(6) Musculoskeletal: Application of Casts and Strapping (CPT Codes 29581-29584) 

For discussion on interim final work values for CPT codes 29581, 29582, 29583, and 

29584 refer to section III.M.3. of this final rule with comment period. 

 (7) Respiratory: Lungs and Pleura (CPT Codes 32096-32100, 32505) 

In the CY 2012 final rule with comment period, we assigned an interim final work RVU 

of 13.75 for CPT code 32096 (Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, 

wedge, incisional), unilateral) (76 FR 73193). As we noted, the CPT Editorial Panel reviewed 

the lung resection family of codes and deleted eight, revised five, and created 18 new codes to 

describe thoracoscopic procedures effective January 1, 2013. For the wedge resection 

procedures, the revisions were based on three tiers; first, the approach, thoracotomy or 

thoracoscopy; second, the target to remove nodules or infiltrates; and lastly the intent, diagnostic 

or therapeutic (for nodules only, all infiltrates will be removed for diagnostic purposes). 

As we noted in the CY 2012 final rule with comment period, after clinical review of CPT 

code 32096, we believed a work RVU of 13.75 accurately reflected the work associated with this 

service compared to other related services. The AMA RUC reviewed the survey results, 

compared the code to other services, and concluded that the survey 25th percentile work RVU of 

17.00 appropriately accounted for the work and physician time required to perform this 

procedure. We determined that the work associated with CPT code 32096 was similar in terms 

of physician time and intensity to CPT code 44300 (Placement, enterostomy or cecostomy, tube 

open (eg, for feeding or decompression) (separate procedure)). Therefore, we assigned the same 
409 

work RVU to CPT code 32096 as that of CPT code 44300 on an interim final basis for CY 2012. 

 Comment: Commenters stated that CPT code 44300 is an arbitrary crosswalk, noting that 

CPT code 32096 describes an open thoracic procedure whereas CPT code 44300 is the 

placement of a feeding tube. A commenter shared a regression analysis of physician time and 

physician work of all thoracic surgery codes, which showed that the interim final work RVU 

value falls below the regression line and stated that this indicated an inappropriate work value. 

Commenters stated our work values are lower for equivalent physician time than virtually all our 

prior decisions for the specialty. Additionally, commenters noted that the values result in 

IWPUT values that are approximately half of those ordinarily associated with major surgical 

procedures. Therefore, commenters stated that the interim final work RVU of 13.75 for CPT 

code 32096 would result in rank order anomalies with other codes in the physician fee schedule. 

Commenters recommended we use the AMA RUC-recommended work RVU of 17.00 and 

requested refinement panel review of the code. 

Response: Based on comments received, we referred CPT code 32096 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median work RVU for CPT code 

32096 was 17.00. Following the refinement panel, we again conducted a clinical review and continue to 

believe a work RVU of 13.75 accurately reflected the work associated with this service. For CY 2012, 

the CPT Editorial Panel deleted CPT code 32095 which had a work RVU of 10.14 and created CPT codes 

32096, 32097, and 32100 to replace CPT code 32095. Upon our clinical review, we do not believe that 

there is a significant difference in intensity between deleted CPT code 32095 and replacement CPT code 

32096. We believe that the appropriate work RVU for CPT code 32096 should be close to a work RVU 

of 10.14, but should account for the increase in 15 minutes of total time between deleted CPT code 32095 

and new CPT code 32096. We believe that the refinement panel median work RVU of 17.00 far 

overstates this difference. Additionally, we continue to believe that the work associated with 32096 is 

similar in terms of physician time and intensity to CPT code 44300. Therefore, we still believe the work 
410 

RVU of 13.75 appropriately values this service. After consideration of the public comments, refinement 

panel results, and our clinical review, we are assigning a work RVU of 13.75 as the final value for CPT 

code 32096. 

As detailed in the CY 2012 final rule with comment period, we assigned an interim final 

work RVU of 13.75 for CPT code 32097 (Thoracotomy, with diagnostic biopsy(ies) of lung 

nodule(s) or mass(es) (eg, wedge, incisional), unilateral) (76 FR 73194). We noted that after 

clinical review of CPT code 32097, we believed a work RVU of 13.75 accurately reflected the 

work associated with this service compared to other related services. We also noted that the 

AMA RUC had reviewed the specialty society survey results, compared the code to other 

services, and recommended the survey 25th percentile work RVU of 17.00. We stated that we 

determined that the work associated with CPT code 32097 was similar to CPT code 32096, to 

which we assigned a work RVU of 13.75 on an interim final basis for CY 2012. Therefore, we 

assigned a work RVU of 13.75 for CPT code 32097 on an interim final basis for CY 2012. 

Comment: Commenters stated that CPT code 44300 is an arbitrary crosswalk for CPT 

code 32097 because it describes an open thoracic procedure whereas CPT code 44300 is the 

placement of a feeding tube. Commenters shared a regression analysis of physician work and 

time for all thoracic surgery codes, which shows that the interim final work RVU value falls 

below the regression line and noted that this indicates inappropriately low work intensity. 

Commenters stated our interim final work RVU values are lower for equivalent physician time 

than virtually all prior work RVU decisions for this specialty. Commenters noted that the 

interim final work RVU values result in IWPUT values that are approximately half of those 

ordinarily associated with major surgical procedures. Commenters added that the interim final 

work RVU of 13.75 for CPT code 32097 result in rank order anomalies with other codes. 

Commenters recommended we instead use the AMA RUC-recommended work RVU of 17.00 

for CPT code 32097 and requested refinement panel review of the code. 
411 

Response: Based on comments received, we referred CPT code 32097 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median work RVU for CPT code 

32097 was 17.00. CPT codes 32096, 32097, and 32100 were created to replace CPT code 32095, which 

was deleted, effective January 1, 2012. We believe these three services involve the same amount of 

physician work and should have the same work RVU. Thus, the same rationale that we used to value 

CPT code 32096 applies to CPT code 32097. We continue to believe that the work associated with CPT 

code 32097 is similar in terms of physician time and intensity to CPT code 44300 and thus, still believe 

the work RVU of 13.75 is appropriate. Additionally, we continue to believe that a work RVU of 17.00 

overstates the increase in work between deleted CPT code 32095 and its replacement CPT codes. After 

consideration of the public comments, refinement panel results, and our clinical review, we are assigning 

a work RVU of 13.75 as the final value for CPT code 32097. 

As detailed in the CY 2012 final rule with comment period, we assigned an interim final work 

RVU of 12.91 to CPT code 32098 (Thoracotomy, with biopsy(ies) of pleura) (76 FR 73194). We noted 

that after clinical review, we believed a work RVU of 12.91 accurately reflected the work associated with 

this service as compared to other related services. After reviewing survey results and comparing the code 

to other services, the AMA RUC recommended the survey 25th percentile work RVU of 14.99. We noted 

that the work associated with CPT code 32098 was similar in terms of physician time and intensity to 

CPT code 47100 (Biopsy of liver, wedge) and therefore we believed that crosswalking to the work RVU 

of CPT code 47100 appropriately accounted for the work associated with CPT code 32098. Therefore, 

we assigned a work RVU of 12.91 to CPT code 32098 on an interim final basis for CY 2012. 

Comment: Commenters shared a regression analysis of physician time and physician 

work of all thoracic surgery codes, and indicated that our interim final work RVU value falls 

below the regression line, which commenters noted indicated inappropriately low work intensity. 

Commenters stated that a work RVU of 12.91 results in an IWPUT of 0.0741, which is 

insufficient intensity compared to other similar procedures. Commenters stated that our interim 

final work RVU of 12.91 for CPT code 32098 placed this service out of relativity with the CPT 
412 

codes in this family for which we accepted the AMA RUC recommendations and requested 

refinement panel review of the code. 

Response: Based on comments received, we referred CPT code 32098 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median was a work RVU of 14.99. 

This service would be out of rank order with the other services in the family described by CPT codes 

32096, 32097, 32100, and 32505 if we adopted a work RVU of 14.99. As noted above, we continue to 

believe a work RVU of 13.75 is appropriate for CPT code 32096. Since CPT code 32098 describes a 

more limited procedure that takes less time than the other codes in the family (CPT codes 32096, 32097, 

32100, and 32505) it should have a lower work RVU. After consideration of the public comments, 

refinement panel results, and our clinical review, we believe that that the work associated with 32098 is 

similar in terms of physician time and intensity to CPT code 47100 and therefore we are assigning a work 

RVU of 12.91 as the final value for CY 2013 for CPT code 32098. 

We assigned a work RVU of 13.75 for CPT code 32100 (Thoracotomy; with exploration) 

on an interim final basis in the CY 2012 final rule with comment period (76 FR 73194). After 

clinical review of CPT code 32100, we believed a work RVU of 13.75 accurately reflected the 

work associated with this service as compared to other related services. The AMA RUC 

reviewed the specialty society survey results, compared the code to other services, and 

recommended a work RVU of 17.00. We noted that the affected specialty society and AMA 

RUC asserted that CPT code 32100 should be valued the same as CPT codes 32096 and 32097 

because they believe that the work is similar for these three services. We noted that we assigned 

a work RVU of 13.75 to CPT codes 32096 and 32097, and therefore a work RVU of 13.75 to 

CPT code 32100 as well. 

Comment: Commenters stated that CPT code 44300 is an inappropriate crosswalk for 

CPT code 32100 because it describes an open thoracic procedure whereas CPT code 44300 is the 

placement of a feeding tube. Commenters shared a regression analysis of physician work and 
413 

time all thoracic surgery codes that shows the interim final work RVU value falls below the 

regression line and stated that this indicates inappropriately low work intensity. Commenters 

stated the interim final work RVU value is lower for equivalent physician time than virtually all 

prior work RVU assignments for this specialty. Commenters noted that the interim final work 

RVU value results in IWPUT values that are approximately half of those ordinarily associated 

with major surgical procedures. Therefore, commenters stated that the interim final work RVU 

of 13.75 for CPT code 32100 would result in rank order anomalies with other codes in the fee 

schedule. Commenters recommended we value the work based upon the AMA RUCrecommended work RVU of 17.00 for CPT code 32100 and requested refinement panel review 

of the code. 

Response: Based on comments received, we referred CPT code 32100 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median work RVU for CPT code 

32100 was 17.00. CPT codes 32096, 32097, and 32100 were created to replace CPT code 32095, which 

was deleted, effective January 1, 2012. We believe these three services involve the same amount of 

physician work and should have the same work RVU. Thus, the same rationale that we used to value 

CPT codes 32096 and 32097 applies to CPT code 32100. We continue to believe that the work associated 

with 32100 is similar in terms of physician time and intensity to CPT code 44300. In addition, we agree 

with the specialty society and AMA RUC’s assertion that CPT code 32100 should be valued the same as 

CPT codes 32096 and 32097. Furthermore, we continue to believe that a work RVU of 17.00 overstates 

the increase in work between deleted CPT code 32095 and its replacement CPT codes. Thus, we 

maintain that the interim final work RVU of 13.75 is still appropriate. After consideration of the public 

comments, refinement panel results, and our clinical review, we are assigning a work RVU of 13.75 as 

the final value for CY 2013 for CPT code 32100. 

We assigned a work RVU of 15.75 for CPT code 32505 (Thoracotomy; with therapeutic 

wedge resection (eg, mass, nodule), initial) on an interim final basis in the CY 2012 final rule 
414 

with comment period (76 FR 73194). We noted that after clinical review of CPT code 32505, 

we believed a work RVU of 15.75 accurately reflected the work associated with this service 

compared to other related services. After reviewing the survey results, comparing the code to 

other services, the AMA RUC recommended the survey 25th percentile work RVU of 18.79. 

We explained that we assigned the interim final work RVU of 15.75 in recognition of the greater 

physician work and intensity involved in CPT 32505 as compared to CPT code 32096. We 

valued the additional 30 minutes of intra-service work associated with CPT code 32505 at 2.00 

work RVUs. Accordingly, we assigned a work RVU of 15.75 for CPT code 32505 on an interim 

final basis for CY 2012. 

Comment: Commenters stated that they entirely disagreed with the methods used to value 

CPT code 32096 and therefore, disagreed with the value assigned to 32505 that was based upon 

the value assigned to CPT code 32096. Commenters said that the methods used for valuing CPT 

code 32505 have never been employed to determine a code’s work value. Further, commenters 

explained that our value results in an IWPUT of 0.06, which is lower than the AMA RUC 

recommendation. Commenters recommended we value CPT code 32505 based upon the AMA 

RUC-recommended work RVU of 18.79 for this code and requested refinement panel review. 

Response: Based on comments received, we referred CPT code 32505 to the CY 2012 

multi-specialty refinement panel for further review. We determined that the refinement panel 

median work RVU of 18.79 was relatively high in relation to the other codes in the family. We 

maintain that the incremental difference between CPT code 32096 and CPT code 32505 is 2.00 

RVUs and, therefore continue to believe that a work RVU value of 15.75 accurately reflects the 

value of the service. As a result of the refinement panel results, the public comments, and our 

clinical review, we are assigning a work RVU of 15.75 as the final value for CPT code 32505. 

(8) Respiratory: Lungs and Pleura (CPT Codes 32663, 32668-32673) 
415 

For discussion on interim final work values for CPT codes 32663, 32668 through 32673 

refer to section III.M.3. of this final rule with comment period. 

(9) Cardiovascular: Heart and Pericardium (CPT Code 36247) 

In the Fourth Five-Year Review of Work (76 FR 32445), we discussed CPT code 36247 

(Selective catheter placement, arterial system; initial third order or more selective abdominal, 

pelvic, or lower extremity artery branch, within a vascular family) and proposed a CY 2012 work 

RVU of 6.29 and a global period change from 90 days (Major surgery with a 1-day pre-operative 

period and a 90-day postoperative period included in the fee schedule amount) to XXX (the 

global concept does not apply). In the CY 2012 PFS final rule with comment period (76 FR 

73132), we agreed with commenters to the Fourth Five-Year Review of Work that our discussion 

of the global period was incorrect and should have indicated a change in global period from 

XXX to 000 (Minor procedure-includes RVUs for pre- and post-operative procedures on the 

same day). We stated that, based on comments received, we referred CPT code 36247 to the CY 

2011 multi-speciality refinement panel for further review. The refinement panel median value 

was a work RVU of 7.00, the AMA RUC-recommended value. We went on to state that upon 

clinical review, we believed that our proposed work RVU of 6.29 was more appropriate. We 

stated that we observed a significant decrease in the physician times reported for this service that 

argue for a lower work RVU, notwithstanding that the survey was conducted for a 0-day global 

period, which includes an E/M service on the same day. Therefore, we assigned work RVUs of 

6.29 and a global period of 000 to CPT code 36247 on an interim basis for CY 2012 and invited 

additional public comment on this code in the CY 2012 final rule with comment period. 

Comment: A commenter appreciated that we acknowledged that we made an inadvertent error 

when we referred to the original global period of the code as 90 global days rather than XXX global days. 

However, this commenter stated that the new 0-day global period, which includes an E/M service on the 

same day, justified the refinement panel’s median value of a work RVU of 7.00. Additionally, 
416 

commenters stated that the change from a global period of XXX (global concept does not apply) to a 

global period of 000 (Minor procedure-includes RVUs for pre- and post-operative procedures on the same 

day) added additional pre-service work. Other commenters stated that with the removal of the lower 

extremity intervention patients from the code, the procedures now coded with this procedure are more 

complex and warrant an increased value. Commenters also pointed out that the CY 2011 refinement 

panel median for the code was 7.00 work RVUs. Commenters requested that we accept the AMA RUC 

recommendation of 7.00 work RVUs for CPT code 36247. 

Response: Based on comments received, we re-reviewed CPT code 36247. We continue 

to believe that our proposed work RVU of 6.29 accurately reflects the work associated with this 

service. Based on the significant reduction in the physician intra-service time assigned to this 

service from 86 minutes to 60 minutes, if this CPT code had maintained a global period of XXX, 

we believe it would have been appropriate to reduce the work RVU below the current value of 

6.29 to reflect the reduction in time. We do not believe that the potential increase in intensity 

due to the complexity of the patient mix counter balances the decrease in intra-service time. We 

understand that this service now includes the work of a same day E/M visit, and we believe this 

additional work is accounted for by maintaining the current work RVU of 6.29 rather than 

reducing the work RVU, as would have been appropriate if the service had maintained global 

period of XXX. Therefore, we are finalizing a work RVU of 6.29 and a 000 global period for 

CPT code 36247. 

(10) Renal Angiography codes (CPT code 36251) 

As detailed in the CY 2012 final rule with comment period (76 FR 73196), the CPT 

Editorial Panel created four bundled renal angiography services (CPT codes 36251, 36252, 

36253, and 36254), effective January 1, 2012. 

We assigned a work RVU of 5.35 to CPT code 36251 (Selective catheter placement 

(first-order), main renal artery and any accessory renal artery(s) for renal angiography, including 
417 

arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image 

postprocessing, permanent recording of images, and radiologic supervision and interpretation, 

including pressure gradient measurements when performed, and flush aortogram when 

performed; unilateral) on an interim final basis for CY 2012 based upon our clinical review of 

the code. The AMA RUC reviewed the survey results, compared the code to other services, and 

concluded that the work value for CPT code 36251 should be directly crosswalked to CPT code 

31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from 

maxillary sinus) endoscopy, surgical, with maxillary antrostomy; with removal of tissue from 

maxillary sinus), which has a work RVU of 5.45, and recommended a work RVU of 5.45 for 

CPT code 36251. We determined that the work associated with CPT code 36251 is closely 

aligned in terms of physician time and intensity with that of CPT code 52341 

(Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, 

electrocautery, and incision), which has a work RVU of 5.35. We believed crosswalking to the 

work RVU of CPT code 52341 appropriately accounted for the work associated with CPT code 

36251. Therefore, we assigned a work RVU of 5.35 to CPT code 36251 on an interim final basis 

for CY 2012. 

Comment: Commenters disagreed with the interim final work RVU of 5.35 for CPT code 

36251, stating that the family of CPT codes (36251, 36252, 36253, and 36254) was carefully 

reviewed by the AMA RUC and the rank order was appropriately established by the AMA RUC 

recommendations. Commenters recommended CPT code 36251 should be directly crosswalked 

to CPT code 31267 as the AMA had recommended and requested that we use 5.45 work RVUs 

for CPT code 36251. 

Response: Based on the comments received, we re-reviewed CPT code 36251 and 

considered the commenters’ recommendation that it be directly crosswalked to CPT code 31267. 
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After re-considering the crosswalk, we continue to believe that the work associated with CPT 

code 36251 is closely aligned in terms of physician time and intensity with CPT code 52341 and 

that crosswalking to CPT code 52341 appropriately results in a work RVU of 5.35. Therefore, 

we are finalizing a work RVU of 5.35 for CPT code 36251 for CY 2013. 

We assigned an interim final work RVU of 6.99 to CPT code 36252 (Selective catheter 

placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, 

including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image 

postprocessing, permanent recording of images, and radiologic supervision and interpretation, 

including pressure gradient measurements when performed, and flush aortogram when 

performed; bilateral), for CY 2012 after clinical review. The AMA RUC reviewed the survey 

results, compared the code to other services, and concluded that the work value for CPT code 

36252 should be directly crosswalked to CPT code 43272 (Endoscopic retrograde 

cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s) not 

amenable to removal by hot biopsy forceps, bipolar cautery or snare technique), which has a 

work RVU of 7.38. Although the AMA RUC recommended a work RVU of 7.38 for CPT code 

36252, we found that the intensity of this service is more similar to CPT code 58560 

(Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)), which 

has a work RVU of 6.99. Accordingly, we assigned an interim final work RVU of 6.99 to CPT 

code 36252 for CY 2012. 

Comment: Commenters stated that this family of CPT codes 36251, 36252, 36253, and 

36254 were carefully reviewed by the AMA RUC, that the rank order was appropriately 

established based on the AMA RUC recommendations, and that CPT code 36252 should be 

crosswalked to CPT code 43272 (Endoscopic retrograde cholangiopancreatography (ERCP); 

with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy 
419 

forceps, bipolar cautery or snare technique), which has a work RVU of 7.38, as the AMA 

recommended. 

Response: Based on the comments received, we re-reviewed CPT code 36252. Although 

commenters recommended a direct crosswalk to CPT code 43272, we continue to believe that 

the work of the services is similar to the reference CPT code 58560. Accordingly, we find that 

the resulting work RVUs of 6.99 is still appropriate and accounts for the work associated with 

this service and we are finalizing a work RVU value of 6.99 for CPT code 36252. 

(11) IVC Transcatheter Procedures (CPT codes 37192 and 37193) 

As discussed in the CY 2012 final rule with comment period (76 FR 73197), for CPT 

code 37192 (Repositioning of intravascular vena cava filter, endovascular approach inclusive of 

vascular access, vessel selection, and all radiological supervision and interpretation, 

intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy)), we assigned 

a work RVU of 7.35 to CPT code 37192, with a refinement to 45 minutes of intra-service time, 

on an interim final basis for CY 2012. 

After clinical review of CPT code 37192, we believed a work RVU of 7.35 accurately 

reflected the work associated with this service. The AMA RUC reviewed the survey results, 

compared the code to other services, and concluded that the survey 75th percentile intra-service 

time of 60 minutes and the 25th percentile of work RVU of 8.00 accurately described the 

physician work involved in the service. We determined that the work associated with CPT code 

37192 is similar to CPT code 93460 (Catheter placement in coronary artery(s) for coronary 

angiography, including intraprocedural injection(s) for coronary angiography, imaging 

supervision and interpretation; with right and left heart catheterization including intraprocedural 

injection(s) for left ventriculography, when performed), which has a work RVU of 7.35, 48 

minutes pre-service time, 50 minutes intra-service time, and 30 minutes post-service time. By 
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comparing the times assigned to those of CPT code 93460, we determined that the survey 

median intra-service time of 45 minutes appropriately accounted for the time required to furnish 

the intra-service work of CPT code 37192. Therefore, we assigned it a work RVU of 7.35, with 

a refinement to 45 minutes of intra-service time on an interim final basis for CY 2012. A 

complete listing of the times associated with this code is available on the CMS website at: 

www.cms.gov/PhysicianFeeSched/. 

Comment: A commenter disagreed with our valuation for CPT code 37192, but did not 

provide information as to why the valuation was inappropriate. The commenter urged that we 

accept the AMA RUC-recommended work RVU and times. 

Response: After clinical re-review of CPT code 37192, we maintain that the work 

associated with CPT code 37192 is similar to CPT code 93460, which has the following times: 

48 minutes pre-service, 50 minutes intra-service, and 30 minutes post-service. As a result, we 

continue to believe that the survey median intra-service time of 45 minutes appropriately 

accounts for the time involved in furnishing the intra-service work of this procedure. We believe 

that the crosswalk work RVU of 7.35 more appropriately values the services furnished in this 

code than the AMA RUC recommended value of 8.00 RVUs. We are finalizing a work RVU of 

7.35 to CPT code 37192, with a refinement to 45 minutes of intra-service time. A complete 

listing of the times associated with this code is available on the CMS website at 

www.cms.gov/PhysicianFeeSched/. 

As discussed in the CY 2012 final rule with comment period (76 FR 73197), for CPT 

code 37193 (Retrieval (removal) of intravascular vena cava filter, endovascular approach 

inclusive of vascular access, vessel selection, and all radiological supervision and interpretation, 

intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy)), we assigned 

a work RVU of 7.35 to CPT code 37193, with a refinement to 45 minutes of intra-service time, 
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on an interim final basis for CY 2012. After clinical review of CPT code 37193, we believed a 

work RVU of 7.35 accurately reflected the work associated with this service. The AMA RUC 

reviewed the survey results, compared the code to other services, and concluded that the survey 

75th percentile intra-service time of 60 minutes and the 25th percentile of work RVU of 8.00 

accurately described the physician work involved in the service. We believed that the work 

associated with CPT code 37193 is similar to CPT code 93460 (Catheter placement in coronary 

artery(s) for coronary angiography, including intraprocedural injection(s) for coronary 

angiography, imaging supervision and interpretation; with right and left heart catheterization 

including intraprocedural injection(s) for left ventriculography, when performed), which has a 

work RVU of 7.35, 48 minutes pre-service time, 50 minutes intra-service time, and 30 minutes 

post-service time. Based upon these times, we believed that the survey median intra-service time 

of 45 minutes appropriately accounted for the time required to furnish the intra-service work 

associated with CPT code 37193. Therefore, we assigned a work RVU of 7.35 to CPT code 

37193, with a refinement to 45 minutes of intra-service time, on an interim final basis for CY 

2012. A complete listing of the times associated with this code is available on the CMS website 

at: www.cms.gov/PhysicianFeeSched/. 

Comment: Without providing more information, a commenter disagreed with the work RVUs 

assigned and refinement to time for CPT code 37193 and urged that we accept the AMA RUCrecommended work RVU of 8.00, and recommended time. 

Response: After clinical re-review of CPT code 37193, we maintain that the work associated with 

CPT code 37193 is similar to CPT code 93460, which has the following times: 48 minutes pre-service, 50 

minutes intra-service, and 30 minutes post-service. We continue to believe that the survey median intraservice time of 45 minutes appropriately accounted for the time required to furnish the intra-service work 

of this CPT code 37193 rather than the AMA RUC-recommended intra-service time of 60 minutes. We 

also continue to believe that the work RVU of 7.35 more appropriately values the services furnished in 
422 

this code than the AMA-recommended work RVU of 8.00. Therefore, we are finalizing a work RVU of 

7.35 to CPT code 37132, with a refinement to 45 minutes of intra-service time. A complete listing of the 

times associated with this code is available on the CMS website at: www.cms.gov/PhysicianFeeSched/. 

(12) Hemic and Lymphatic Systems: General, Bone Marrow or Stem Cell Services/Procedures 

(CPT codes 38230 and 38232) 

On an interim final basis, we assigned a work RVU of 3.09 to CPT codes 38230 (Bone 

marrow harvesting for transplantation; allogeneic) and 38232 (Bone marrow harvesting for 

transplantation; autologous) for CY 2012 (76 FR 73197). In the CY 2012 final rule with 

comment period we noted that for CY 2012, the CPT Editorial Panel split CPT code 38230 into 

two separate CPT codes: 38230 and 38232 to more accurately reflect current medical practice. 

We noted that we changed the global period from 010 to 000 for CPT code 38230, and assigned 

a global period of 000 to CPT code 38232, as these services rarely required overnight 

hospitalization and physician follow-up in the days following the procedure. 

We noted that after clinical review of CPT codes 38230 and 38232, we believed that a work RVU 

of 3.09 appropriately accounted for the work associated with these services. The AMA RUC reviewed 

the survey results and, after comparison to similar CPT codes, the AMA RUC recommended the survey 

median work RVU of 4.00 for CPT code 38230, and the survey median work RVU of 3.50 for CPT code 

38232. Notwithstanding the AMA-RUC recommendation, we noted that the work for these services is 

very similar and should be valued the same. In CY 2011, CPT code 38230 had a work RVU of 4.85 with 

a ten-day global period that included a CPT code 99213 (Level 3 office or outpatient visit, established 

patient), and a CPT code 99238 (discharge day management service). We explained that we considered 

converting the value of CPT code 38230 from a 10-day global period to a 0-day global period by 

subtracting the work RVUs for CPT code 99213 (work RVU=0.97) and CPT code 99238 (work 

RVU=1.28), but believed that the resulting work RVU of 2.60 would result in this code being valued too 

low compared to other similar services. Instead, we found that the CPT code 38230 survey 25th 

percentile work RVU of 3.09 accurately captured the intensity of this service with the revised global 
423 

period. Therefore, we assigned a work RVU of 3.09 to CPT code 38230 on an interim final basis for CY 

2012. Since, as explained above, we believed that CPT code 38232 should have the same work RVU as 

CPT code 38230, we also assigned a work RVU of 3.09 to CPT code 38230 on an interim final basis for 

CY 2012. 

Comment: Commenters acknowledged that the intra-service times of CPT codes 38230 

and 38232 are similar; however, they stated that the service described by CPT code 38230 is 

typically more intense and stressful since it is being performed on a donor, who does not directly 

benefit from the procedure. Commenters also noted that collecting donor cells is typically 

prolonged to ensure that enough cells have been collected. Commenters stated that although the 

survey did not reflect the intra-service time for CPT code 38230, the AMA RUC-recommended 

values appropriately accounted for the lower time reported in the survey with a higher work 

RVU value. Additionally, commenters stated that the reverse building block methodology was 

an inappropriate policy to apply to any services with changing global day periods and in this 

case, particularly inappropriate because the post-operative visits built into the code were initially 

valued by the Harvard study several years ago. Given these arguments, commenters requested 

the AMA RUC recommended work RVUs of 4.00 for CPT code 38230 and 3.50 for CPT code 

38232 be used to value these codes and requested refinement panel review of these codes. 

Response: Based on comments received, we referred CPT codes 38230 and 32832 to the CY 

2012 multi-specialty refinement panel for further review. The refinement panel median work RVU for 

CPT code 38230 was 4.00, and the median work RVU for CPT code 38232 was 3.50. We continue to 

believe that CPT codes 38232 and 38230 require the same amount of physician work and should be 

valued the same. After reviewing the public comments and the refinement panel ratings, we agree that 

the refinement panel median work RVU of 3.50 for CPT code 38232 more appropriately reflects the work 

of CPT codes 38230 and 38232 than the interim final work RVU of 3.09. We believe the refinement 

panel median work RVU of 4.00 for CPT code 38230 overstates the work associated with these services, 
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especially considering that for CPT code 38230 the survey 25th percentile work RVU was 3.09 and a 

building block methodology based on the CY 2011 work RVU and global period yielded work RVU of 

2.60 for this service. As a result of the refinement panel ratings, the public comments, and our clinical 

review, we are finalizing a work RVU of 3.50 for CPT codes 32830 and 32832. 

(13) Digestive: Abdomen, Peritoneum, and Omentum (CPT code 49084) 

As detailed in the CY 2012 final rule with comment period (76 FR 73198), the CPT 

Editorial Panel deleted CPT codes 49080 and 49081and created three new CPT codes, 49082, 

49083, and 49084, effective January 1, 2012, to more accurately describe the current medical 

practice. 

After clinical review, we assigned a work RVU of 2.00 to CPT codes 49083 (Abdominal 

paracentesis (diagnostic or therapeutic); with imaging guidance) and 49084 (Peritoneal lavage, including 

imaging guidance, when performed) on an interim final basis for CY 2012. The AMA RUC 

recommended a work RVU of 2.00 for CPT code 49083 and a work RVU of 2.50 for CPT code 49084. 

We agreed with the AMA RUC-recommended work RVU of 2.00 for CPT code 49083, but disagreed that 

CPT 49084 should be valued more. Instead, we believed that CPT code 49084 requires similar work to 

code 49083 and should be valued the same. Therefore, we assigned a work RVU of 2.00 to CPT codes 

49083 and 49084 on an interim final basis for CY 2012. 

Comment: One commenter disagreed with our valuation of CPT code 49084 and the resulting 

work RVU recommendation but did not describe why. 

Response: After clinical re-review of CPT code 49084, we continue to believe that CPT code 

49084 requires similar work as CPT code 49083 and should be valued the same. Accordingly, we are 

finalizing a work RVU of 2.00 for CPT codes 49083 and 49084. 

(14) Nervous: Spine and Spinal Cord (CPT Codes 62370) 

CPT code 62370 (Electronic analysis of programmable, implanted pump for intrathecal 

or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription 

status)); with reprogramming and refill (requiring physician's skill)) newly created by the CPT 
425 

Editorial Panel for CY 2012, was assigned an interim final work RVU of 0.90 for CY 2012 as 

discussed in the CY 2012 final rule with comment period (76 FR 73199). 

As we noted in the CY 2012 final rule with comment period, after clinical review of CPT 

code 62370, we believed that a work RVU of 0.90 accurately accounted for the work associated 

with this service. We noted that after a comparison to similar services, the AMA RUC 

recommended a work RVU of 1.10 for CPT code 62370 based on a crosswalk to CPT code 

56605 (Biopsy of vulva or perineum (separate procedure); 1 lesion) however, we believed that a 

work RVU of 1.10 for CPT code 62370 was too high compared to similar services in this family. 

Instead, we found CPT code 62370 to be similar in intensity and complexity to CPT code 93281 

(Programming device evaluation (in person) with iterative adjustment of the implantable device 

to test the function of the device and select optimal permanent programmed values with 

physician analysis, review and report; multiple lead pacemaker system), which has a work RVU 

of 0.90. We noted that this value, which is between the specialty society survey 25th percentile 

and median work RVU, appropriately reflected the work of CPT code 62370. Therefore, we 

assigned a work RVU of 0.90 to CPT code 62370 on an interim final basis for CY 2012. 

 Comment: Commenters disagreed with the value, explaining that CPT code 93281 was 

not an appropriate crosswalk because it was a programming only code while CPT code 62370, is 

a procedure and programming code. Commenters noted that the interim final work RVU of 0.90 

does not account for the work in refilling the pump, which requires a sterile puncture in a patient 

whose complexities preclude provision of these services by a nonphysician. Therefore, 

commenters requested that CPT code 62370 be valued based upon the AMA RUC recommended 

value of 1.10 work RVUs and requested refinement panel review of this code. 

 Response: Based on comments received, we referred CPT code 62370 to the CY 2012 

multi-specialty refinement panel for further review. The refinement panel median work RVU for 
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CPT code 62370 was 1.10. In subsequent review, we determined that valuing this code at the 

refinement panel median work RVU value would result in too high a value as compared to the 

other codes in the family. CPT code 62369 (Electronic analysis of programmable, implanted 

pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm 

status, drug prescription status); with reprogramming and refill) has a work RVU of 0.67. CPT 

code 62369 describes the same procedure as CPT code 62370, except in CPT code 62369 the 

reprogramming and refill does not require physician skill and in CPT code 62370 the 

reprogramming and refill does require physician skill. We believe a work RVU of 0.90 for CPT 

code 62370 reflects the appropriate incremental increase in physician work for reprogramming 

and refill by a physician, versus a nonphysician. We also continue to believe that CPT code 

93281, which was recently reviewed, has similar intensity and complexity to CPT code 62370, 

and that CPT codes 93281 and 62370 include the same amount of intra-service physician time. 

We believe that CPT codes 93281 and 62370 involve the same amount of physician work and 

maintain that a work RVU of 0.90 appropriately captures the physician work of these procedures. 

After reviewing the public comments, the refinement panel ratings, and our clinical review, we 

are finalizing a work RVU of 0.90 as for CPT code 62370. 

(15) Diagnostic Radiology: Abdomen (CPT Codes 74174) 

For discussion on CY 2013 interim final work values for CPT code 74174 refer to section 

III.M.3. of this final rule with comment period. 

(16) Pathology and Laboratory: Urinalysis (CPT Codes 88120 and 88121) 

For discussion on CY 2013 interim work values for CPT codes 88120-88121, refer to 

section III.M.3. of this final rule with comment period. 

(17) Psychiatry: Psychiatric Therapeutic Procedures (CPT codes 90845 and 90869) 

For discussion on interim work values for CPT codes 90845 and 90869, refer to section 
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III.M.3. of this final rule with comment period. 

(18) Ophthalmology: Special Ophthalmological Services (CPT codes 92071) 

As detailed in the CY 2012 final rule with comment period (76 FR 73202), for the Fourth 

Five-Year Review, we identified CPT code 92070 through the Harvard-Valued--Utilization over 

30,000 screen as a potentially misvalued code. Upon review of this service, the CPT Editorial 

Panel deleted CPT code 92070 and created two new CPT codes (92071 and 92072) to distinguish 

reporting of fitting of contact lens for treatment of ocular surface disease and fitting of contact 

lens for management of keratoconus. 

We assigned an interim final work RVU of 0.61, with refinement to time as noted above 

to CPT code 92071 (Fitting of contact lens for treatment of ocular surface disease) for CY 2012. 

We determined that CPT code 92071 is expected to capture the utilization of the deleted code 

CPT code 92070 (Fitting of contact lens for treatment of disease, including supply of lens). 

Since CPT code 92070 was typically billed with an E/M service on the same day, we believed 

that CPT code 92071 would also typically be billed with an E/M service on the same day. We 

concluded that some of the activities conducted during the pre- and post-service times of the 

procedure code and the E/M visit overlapped and, therefore, should not be counted twice in 

developing the procedure's work value. To account for this overlap, we reduced the pre-service 

evaluation time and post-service time by one-third each. Specifically, we reduced each the preservice evaluation time and the post-service time from 5 minutes to 3 minutes. To determine the 

appropriate work RVU for CPT code 92071, we calculated the value of the extracted time and 

subtracted it from the AMA RUC-recommended work RVU of 0.70, which equals the CY 2011 

work RVU for the deleted code, CPT 92070. In valuing CPT code 92071, we removed a total of 

4 minutes (as described above) at an intensity of 0.0224 per minute, which amounted to the 

removal of 0.09 work RVUs. Therefore, we assigned an interim final work RVU of 0.61, with 
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refinement to time as noted above to CPT code 92071 for CY 2012. A complete listing of the 

times associated with this code is available on the CMS website at: 

www.cms.gov/PhysicianFeeSched/. 

Comment: Commenters disagreed with the rationale used to lower the value for CPT 

code 92071 and further disagreed with the reverse building block methodology used. 

Commenters stated that the AMA RUC and the affected specialty society had reviewed and 

valued CPT code 92071 with the assumption that an E/M service would be billed in conjunction 

with the service and cited the AMA summary of recommendations as evidence. Therefore, none 

of the pre- and post-time allocated to this code overlapped with the E/M service. They pointed 

out that the AMA RUC-recommended work RVU of 0.70 was lower than the survey median 

work RVU of 1.11. Commenters preferred the AMA RUC comparison of CPT code 92071 to 

CPT code 65205 (Removal of foreign body, external eye; conjunctival superficial) with a work 

RVU of 0.71 and noted that both services have identical physician time components and should 

be valued similarly. Therefore, commenters requested the AMA RUC recommended work RVU 

of 0.70 and the AMA RUC recommended pre-service and immediate post-service physician time 

of 5 minutes, each. 

Response: After clinical re-review, we continue to believe that the reverse building block 

methodology is an appropriate way to value the services described by CPT code 92071. We maintain that 

some of the activities conducted during the pre- and post-service times of the procedure code and the E/M 

visit overlap and, therefore, should not be counted twice in developing the procedure's work value. To 

account for the overlap in work between CPT code 92071 and the same day E/M service, the AMA RUC 

removed 2 minutes pre-service time from the pre-service package time of 7 minutes. We believe that the 

pre-service package overstates the time involved in this procedure and that a more appropriate starting 

point for the same day E/M reduction for this procedure is the survey median pre-service time. We 

believe that removing 2 minutes of pre-service time from the survey median pre-service time of 5 
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minutes, as well as 2 minutes from the post-service time of 5 minutes better reflects the time involved in 

furnishing the work of this procedure alongside an E/M service. We continue to believe that a work RVU 

of 0.61 accurately reflects the work of the service relative to similar services. Therefore, we are finalizing 

a refinement to time and a work RVU of 0.61 for CPT code 92071. The times assigned to this CPT code 

are available on the CMS website at: www.cms.gov/PhysicianFeeSched/. 

(19) Special Otorhinolaryngologic Services: Audiologic Function Tests (CPT codes 92587 and 

92588) 

On an interim final basis for CY 2012, we assigned a work RVU of 0.35 to CPT code 

92587 (Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the 

presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic 

emissions, with interpretation and report) as detailed in the CY 2012 final rule with comment 

period (76 FR 73202). We identified CPT code 92587 as a potentially misvalued code through 

the Fastest Growing screen. The specialty society surveyed this service to create a new 

recommendation for CY 2011. However, after reviewing the survey data, it concluded that more 

than one service is represented by this code and requested the service be referred back to the 

CPT Editorial Panel for further clarification. As a result, the CPT Editorial Panel created CPT 

code 92558 (Distortion product evoked otoacoustic emissions; comprehensive diagnostic 

evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 

frequencies), with interpretation and report) to describe evoked otoacoustic emissions screening, 

and revised CPT codes 92587 and 92588 clarify the otoaucoustic emissions evaluations, 

effective January 1, 2012. After clinical review of CPT code 92587, we believed that the survey 

25th percentile work RVU of 0.35 accurately described the work associated with this service. 

The HCPAC reviewed the survey results, and after a comparison to similar CPT codes, 

recommended a work RVU of 0.45 for CPT code 92587, which was between the survey 25th 

percentile and median values. We believed that CPT code 92587 was similar in time and 
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intensity to CPT code 97124 (Therapeutic procedure, 1 or more areas, each 15 minutes; massage, 

including effleurage, petrissage and/or tapotement (stroking, compression, percussion)), which 

has a work RVU of 0.35, and that the survey 25th percentile value appropriately reflected the 

relativity of this service. Therefore, we assigned a work RVU of 0.35 to CPT code 92587 on an 

interim final basis for CY 2012. 

Comment: Commenters disagreed with the interim final work RVU of 0.35 and urged CMS to 

use the HCPAC recommendation of 0.45 since it is between the survey 25th percentile and median 

values. Commenters stated that although 25th percentile might be reasonable in situations where the 

accuracy of the survey data is in doubt, in this case the overall distribution of the data, the size of the 

sample, and response rate made the median a better guide. Commenters noted the importance of cross 

specialty comparisons, but stated that a crosswalk to CPT code 97124 was not appropriate. Commenters 

stated that CPT code 92587 is a cognitive diagnostic service that requires the audiologist to review and 

interpret data resulting from numerous tonal pair samples administered to a patient’s inner ear whereas 

CPT code 97124 is a therapeutic service involving hands-on manipulation of tissue and muscles. As a 

result, a more appropriate comparison code listed within the physical therapy section is the cognitive 

diagnostic work required to perform CPT code 97001 (Physical Therapy Evaluation), which has a work 

RVU of 1.20 and an intra-service time of 30 minutes. Commenters stated that it was, therefore, 

comparable to the requested 0.45 for 12 minutes of intra-service work for CPT code 92587. Commenters 

requested that we accept the HCPAC-recommended work RVU of 0.45 for CPT code 92587 and 

requested refinement panel review of the code. 

Response: Based on comments received, we referred CPT code 92587 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median value for CPT code 92587 

was a work RVU of 0.45. We note that prior to our assignment of interim final work RVUs for CY 2012, 

CPT code 92587 had a work RVU of 0.13 because the work of this service was captured in the practice 

expense RVU as clinical labor, rather than in the work RVU as professional work. For CY 2012, the 

work of this service was moved from the PE RVU to the work RVU. In re-valuing the service to reflect 
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this shift, we believe the survey 25th percentile work RVU of 0.35 captured the intensity of the 

professional work. While CPT codes 97124 and 92587 describe different services, we believe they 

involve the same time and have a very similar level of intensity and complexity and therefore should be 

valued the same. After consideration of the public comments, refinement panel results, and our clinical 

review, we are finalizing a work RVU of 0.35 for CPT code 92587. 

On an interim final basis for CY 2012, we assigned a work RVU of 0.55 to CPT code 

92588 (Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation 

(quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 

frequencies), with interpretation and report) (76 FR 73202). After clinical review of CPT code 

92588, we believed that the survey 25th percentile work RVU of 0.55 accurately described the 

work associated with this service. The HCPAC reviewed the survey results, and after a 

comparison to similar CPT codes, recommended the survey median work RVU of 0.62 for CPT 

code 92588. We believed that CPT code 92588 is similar in work to CPT code 92570 (Acoustic 

immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, 

and acoustic reflex decay testing) , which has a work RVU of 0.55, and that the survey 25th 

percentile work RVU of 0.55 appropriately reflected the relativity of this service. Therefore, we 

assigned a work RVU of 0.55 to CPT code 92588 on an interim final basis for CY 2012. 

Comment: Commenters agreed with us that CPT code 92588 involves a higher level of 

professional work and should be valued incrementally higher than CPT code 92587. However, 

commenters disagreed with the interim final work RVU values and believe the services furnished under 

the code involve a greater degree of professional work. Commenters stated that CPT code 92570 is not 

an appropriate comparison code because it is a bundled code that includes three different audiology tests, 

acoustic reflex threshold testing and acoustic reflex decay, as currently represented individually by CPT 

codes 92567 and 92568. As a bundled service, the work RVU for 92570 was reduced below the level of 

the combined services to account for efficiencies involved in conducting the three tests together. 
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Commenters noted it is not appropriate to compare a bundled service, for which the work RVU has been 

reduced, with a test intended to evaluate overall outer hair cell function, using a minimum of 12 

frequencies. Therefore, commenters requested the code be reviewed by the refinement panel. 

Response: Based on comments received, we referred CPT code 92588 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median value for CPT code 92588 

was a work RVU of 0.60. We note that prior to our assignment of interim final work RVUs for CY 2012, 

CPT code 92588 had a work RVU of 0.36 because the work of this service was captured in the practice 

expense RVU as clinical labor, rather than in the work RVU as professional work. For CY 2012, the 

work of this service was moved from the PE RVU to the work RVU. In re-valuing the service to reflect 

this shift, we believe the survey 25th percentile work RVU of 0.55 captured the intensity of the 

professional work. While CPT codes 92570 is a bundled service, we believe CPT codes 92570 and 92588 

involve very similar time and intensity and should be valued the same. Furthermore, we believe a work 

RVU of 0.55 for CPT code 92588 reflects the appropriate incremental difference over the work RVU of 

0.35 for CPT code 92587. After consideration of the public comments, refinement panel results, and our 

clinical review, we are finalizing a work RVU of 0.55 for CPT code 92588. 

 (20) Cardiovascular: Cardiac Catheterization (CPT codes 93451-93568) 

For CY 2012, we assigned the following interim final work RVUs for the following CPT 

codes: 2.72 for CPT code 93451 (Right heart catheterization including measurement(s) of 

oxygen saturation and cardiac output, when performed), 4.75 for CPT code 93452 (Left heart 

catheterization including intraprocedural injection(s) for left ventriculography, imaging 

supervision and interpretation, when performed), 6.24 for CPT code 93453 (Combined right and 

left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging 

supervision and interpretation, when performed), 4.79 for CPT code 93454 (Catheter placement 

in coronary artery(s) including intraprocedural injection(s) for coronary angiography, imaging 

supervision and interpretation), 5.54 for CPT code 93455 (with catheter placement(s) in bypass 

graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for 
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bypass graft angiography with catheter placement(s) in bypass graft(s) (internal mammary, free 

arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography), 6.15 

for CPT code 93456 (Catheter placement in coronary artery(s) including intraprocedural 

injection(s) for coronary angiography, imaging supervision and interpretation with right heart 

catheterization), 6.89 for CPT code 93457 (Catheter placement in coronary artery(s) including 

intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation 

with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) 

including intraprocedural injection(s) for bypass graft angiography and right heart 

catheterization), 5.85 for CPT code 93458 (Catheter placement in coronary artery(s) including 

intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation 

with left heart catheterization including intraprocedural injection(s) for left ventriculography, 

when performed), 6.60 for CPT code 93459 (Catheter placement in coronary artery(s) including 

intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation 

with left heart catheterization including intraprocedural injection(s) for left ventriculography, 

when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, 

venous grafts) with bypass graft angiography), 7.35 for CPT code 93460 (Catheter placement in 

coronary artery(s) including intraprocedural injection(s) for coronary angiography, imaging 

supervision and interpretation with right and left heart catheterization including intraprocedural 

injection(s) for left ventriculography, when performed), 8.10 for CPT code 93461 (Catheter 

placement in coronary artery(s) including intraprocedural injection(s) for coronary angiography, 

imaging supervision and interpretation with right and left heart catheterization including 

intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in 

bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography), 

1.11 for CPT code 93563 (Injection procedure during cardiac catheterization including image 
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supervision, interpretation, and report; for selective coronary angiography during congenital 

heart catheterization), 1.13 for CPT code 93564 (Injection procedure during cardiac 

catheterization including image supervision, interpretation, and report; for selective coronary 

angiography during congenital heart catheterization for selective opacification of aortocoronary 

venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free 

mammary artery graft) to one or more coronary arteries and in situ arterial conduits (eg, internal 

mammary), whether native or used for bypass to one or more coronary arteries during congenital 

heart catheterization, when performed), 0.86 for CPT code 93565 (Injection procedure during 

cardiac catheterization including image supervision, interpretation, and report; for selective 

coronary angiography during congenital heart catheterization for selective left ventricular or left 

arterial angiography), 0.86 for CPT code 93566 (Injection procedure during cardiac 

catheterization including image supervision, interpretation, and report; for selective coronary 

angiography during congenital heart catheterization for selective right ventricular or right atrial 

angiography), 0.97 for CPT code 93567 (Injection procedure during cardiac catheterization 

including image supervision, interpretation, and report; for selective coronary angiography 

during congenital heart catheterization for supravalvular aortography), and 0.88 for CPT code 

93568 (Injection procedure during cardiac catheterization including image supervision, 

interpretation, and report; for selective coronary angiography during congenital heart 

catheterization for pulmonary angiography). As discussed in the CY 2011 final rule with 

comment period, the AMA RUC provided CMS with recommendations for several categories of 

new diagnostic cardiac catheterization services codes that previously were reported under 

multiple component codes. These AMA RUC-recommended values for the comprehensive 

diagnostic cardiac catheterization codes did not appear to reflect the efficiencies in work and/or 

PE that occur when component services are furnished together. The AMA RUC generally 
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recommended the lower of either the sum of the current RVUs for the component services or the 

specialty society survey 25th percentile value for the comprehensive cardiac catheterization. In 

most cases, the AMA RUC's recommendation for the comprehensive service was actually the 

sum of the current work RVUs for the component services, and we stated in the CY 2011 final 

rule with comment period that we were unsure how this approach is resource-based with respect 

to physician work. As we noted in the CY 2011 final rule with comment period, in valuing these 

comprehensive services, we used a conservative estimate of 10 percent for the work efficiencies 

we would expect to occur when multiple component cardiac catheterization services are bundled 

together. In the CY 2011 final rule with comment period, we requested that the AMA RUC 

reexamine the cardiac catheterization codes. 

As discussed in the CY 2012 final rule with comment period (76 FR 73202), the AMA 

RUC reviewed these codes again for CY 2012 and reiterated its previous recommendations, 

maintaining that there are negligible work efficiencies gained in the bundling of these services. 

However, we continued to believe that there would be efficiencies when these services are 

performed together that should be reflected in the values assigned. In lieu of a more specific 

estimate from the AMA RUC, and using the best information available to us at the time, we 

noted that we believed it was appropriate to assign as interim final for CY 2012 the AMA RUC 

CY 2011 recommendation with a 10 percent reduction in work to reflect the efficiencies 

described above. 

Comment: Commenters noted that at CMS’s second request, the AMA RUC workgroup 

reviewed significant documentation of the valuation and coding history of the codes and after 

this extensive review, still found the original work value recommendations for these codes to be 

appropriate. Commenters stated that maintaining the diagnostic catheterization codes at their CY 

2011 work RVU levels is arbitrary and that instead we should accept the AMA RUC 
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recommendation for these new set of codes for diagnostic cardiac catheterization. 

Response: Based on the comments we received, we re-reviewed the cardiac catheterization codes 

(CPT codes 93451 through 93568). We appreciate that the AMA RUC reviewed the code set again; 

however, we still maintain that there are work efficiencies gained in the bundling of these services, and all 

services. The AMA RUC used a variety of methodologies in developing RVUs for the comprehensive 

services reviewed for CY 2012. The AMA RUC-recommended RVUs for the comprehensive codes for 

diagnostic cardiac catheterization were an average of only one percent lower than the original component 

codes. Given that the AMA RUC recommendations for the bundling of endovascular revascularization 

and CT codes resulted in average reductions in the RVUs of 27 percent and 25 percent, respectively, we 

continue to believe an approximation of work efficiencies garnered through the bundling of the 

component codes could be as high as 27 percent. Thus, in the absence of more precise information, we 

believe that a 10 percent reduction in the AMA RUC-recommended work RVUs is an appropriate and 

conservative approximation of these efficiencies. Therefore, we are finalizing the CY 2012 interim final 

values for the cardiac catheterization codes as the final work RVU values for CY 2013. Specifically, we 

are finalizing the following work RVUs for the following CPT codes: a work RVU of 2.72 for CPT code 

93451; a work RVU of 4.75 for CPT code 93452; a work RVU of 6.24 for CPT code 93453; a work RVU 

of 4.79 for CPT code 93454; a work RVU of 5.54 for CPT code 93455; a work RVU of 6.15 for CPT 

code 93456; a work RVU of 6.89 for CPT code 93457; a work RVU of 5.85 for CPT code 93458; a work 

RVU of 6.60 for CPT code 93459; a work RVU of 7.35 for CPT code 93460; a work RVU of 8.10 for 

CPT code 93461; a work RVU of 1.11 for CPT code 93563; a work RVU of 1.13 for CPT code 93564; a 

work RVU of 0.86 for CPT code 93565; a work RVU of 0.86 for CPT code 93566; a work RVU of 0.97 

for CPT code 93567; and a work RVU of 0.88 for CPT code 93568. 

(21) Pulmonary: Other Procedures (CPT Codes 94060, 94726-94729) 

CPT code 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and postbronchodilator administration) was assigned an interim final work RVU of 0.26 in the CY 2012 

final rule with comment period (76 FR 73206). After CPT code 94060 was identified for review 
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because it was on the Multispecialty Points of Comparison List, and also was identified as 

potentially misvalued through Codes Reported Together 75 percent or More screen, the CPT 

Editorial Panel reviewed the code and created CPT codes 94060, 94726 (Plethysmography for 

determination of lung volumes and, when performed, airway resistance), 94727 (Gas dilution or 

washout for determination of lung volumes and, when performed, distribution of ventilation and 

closing volumes), 94728 (Airway resistance by impulse oscillometry), and 94729 (Diffusing 

capacity (eg, carbon monoxide, membrane) (List separately in addition to code for primary 

procedure)). For CY 2012, the CPT Editorial Panel also created CPT codes 94780 and 94781 to 

report car seat testing administered to the patient in the private physician's office. 

For CY 2012, we assigned a work RVU of 0.26 to CPT codes 94060, 94726, 94727, and 

94728 on an interim final basis (76 FR 73206). After clinical review, we determined that CPT 

codes 94060, 94726, 94727, and 94728, involve similar work and should have the same work 

RVUs. We noted that CPT code 94240 (Functional residual capacity or residual volume: helium 

method, nitrogen open circuit method, or other method) (work RVU=0.26) was deleted and the 

utilization associated with that service would be captured under the CPT codes 94726 and 92727. 

We also noted that we believed that a work RVU of 0.26 appropriately reflected the work 

associated with CPT codes 94060, 94726, 94727, and 94728 and that the AMA RUC had 

recommended the same work RVU (0.31) for all four codes, based upon each survey’s 25th 

percentile work RVU. We explained that this value was further supported by CPT code 97012 

(Application of a modality to 1 or more areas; traction, mechanical), which has a work RVU of 

0.25) and which had similar time and intensity. Therefore, we assigned a work RVU of 0.26 to 

CPT codes 94060, 94726, 94727, and 94728 on an interim final basis for CY 2012. 

Comment: Commenters disagreed with the work RVU assignments for these codes and 

stated that CPT code 94375 (Respiratory flow volume loop), which has a work RVU of 0.31, is 
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the appropriate reference code, as the AMA RUC recommended. Although CPT code 94375 has 

more intra-service time (7 minutes compared to 5 minutes), the survey respondents rated the 

surveyed codes as more intense and complex than the reference code. Commenters stated that 

the appropriate value for the level of physician work involved in CPT codes 94060, 94726, 

94727, and 94728 is 0.31 work RVUs. Therefore, commenters urged that we value CPT codes 

94060, 94726, 94727, and 94728 based upon the AMA RUC-recommended work RVU of 0.31 

and requested these codes be reviewed by the refinement panel. 

Response: Based on comments received, we referred CPT codes 94060, 94726, 94727, 

and 94728 to the CY 2012 multi-specialty refinement panel for further review. The refinement 

panel median work RVUs for the CPT codes were 0.27, 0.26, 0.26, and 0.26, respectively. As a 

result of the refinement panel ratings and our clinical review, we are assigning a work RVU of 

0.27 as the final value for CPT code 94060 and 0.26 work RVUs as the final value for CPT code 

94726, 94727, and 94728. 

After clinical review of CPT code 94729 (Diffusing capacity (eg, carbon monoxide, 

membrane) (List separately in addition to code for primary procedure)), we believed that a work 

RVU of 0.17 accurately reflected the work associated with this service. Based on a comparison 

to similar services, the AMA RUC recommended a work RVU of 0.19. We believed that CPT 

code 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow 

rate measurement(s), with or without maximal voluntary ventilation), which has a work RVU of 

0.17, was similar in time and intensity to CPT code 94729, and that the codes should have the 

same work RVUs. Therefore, we assigned a work RVU of 0.17 to CPT code 94729 on an 

interim final basis for CY 2012. 

Comment: Commenters disagreed that CPT code 94010 was similar in time and intensity 

to CPT code 94729, explaining that the service furnished under CPT code 94010, simple 
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spirometry, is considered the foundation of pulmonary function testing and does not involve the 

same physician work as services furnished under CPT code 94729 a diffusing capacity including 

the membrane. Commenters suggested that the AMA RUC-recommended crosswalk code 93352 

(Use of echocardiographic contrast agent during stress echocardiography), which has a work 

RVU of 0.19 has identical physician time of 5 minutes and comparable physician work and 

intensity to CPT code 94729. Commenters requested that we value the code based upon the 

AMA RUC-recommended work RVU of 0.19 for CPT code 94729 and requested this code be 

reviewed by the refinement panel. 

Response: Based on comments received, we referred CPT code 94729 to the CY 2012 

multi-specialty refinement panel for further review. The refinement panel median work RVU for 

CPT code 94729 was 0.19. As a result of the refinement panel ratings and our clinical review, 

we are finalizing a work RVU of 0.19 for CPT code 94729. 

Furthermore, for CY 2013, we received no public comments on the CY 2012 interim 

final work RVUs for CPT codes 94780 and 94781. We believe these values continue to be 

appropriate and are finalizing them without modification. 

(22) Neurology and Neuromuscular Procedures: Autonomic Function Tests (CPT Codes 95938-

95939) 

For discussion on interim work values for CPT codes 95938 and 95939, refer to section 

III.M.3. of this final rule with comment period. 

(23) Central Nervous System Assessments/Tests (CPT codes 96110, HCPCS code G0451) 

For CY 2012, the CPT Editorial Panel revised CPT code 96110 (Developmental 

screening, with interpretation and report, per standardized instrument form) to reflect current 

practice and avoid use of inaccurate terms associated with this code. For CY 2012 we created 

HCPCS code G0451 (Development testing, with interpretation and report, per standardized 
440 

instrument form) to replace CPT code 96110, which is discussed in the CY 2012 final rule with 

comment period (76 FR 73265). In the CY 2012 final rule correction notice (77 FR 227), we 

noted that the discussion of CPT codes 96110 and G0451 was omitted from the CY final rule 

with comment period due to an inadvertent error, and we included our intended discussion in 

subsequent the correction notice. Additionally, we corrected the PFS status indicator in 

Addendum B for CPT code 96110 to N (Non-covered service. These codes are noncovered 

services. Medicare payment is not made for these codes. If RVUs are shown, they are not used 

for Medicare payment.), from X (Statutory exclusion. These codes represent an item or service 

that is not within the statutory definition of “physicians' services” for PFS payment purposes (for 

example, ambulance services). No RVUs are shown for these codes and no payment may be 

made under the PFS.). The discussion and information in this section reflects the changes made 

in CY 2012 final rule correction notice. 

The CPT Editorial Panel revised the long descriptor for CPT code 96110 from (Developmental 

testing; limited (for example, Developmental Screening Test II, Early Language Milestone Screen), with 

interpretation and report) to (Developmental screening, with interpretation and report, per standardized 

instrument form),effective January 1, 2012. With this change, we believed that the services described by 

CPT code 96110 consisted of screening services, and thus was not within the scope of benefits of the 

Medicare program, as defined by the Act. Therefore, we assigned CPT code 96110 a PFS procedure 

status indicator of N. To continue to make payment under the PFS for the testing services described 

under CPT code 96110 prior to revision of the long descriptor, we created HCPCS code G0451 

(Developmental testing, with interpretation and report, per standardized instrument form). To calculate 

resource-based RVUs for HCPCS code G0451, we crosswalked the utilization, direct practice expense 

inputs, and malpractice risk factor from CPT code 96110 to HCPCS code G0451. We noted in the CY 

2012 final rule with comment period that CPT code 96110 did not have physician work RVUs, therefore 
441 

no physician work RVUs had been assigned to HCPCS code G0451. The CY 2012 interim final RVUs 

assigned to G0451 were included in Addendum B of the CY 2012 final rule correction notice. 

 Comment: We received notice from many commenters that they did not believe a procedure 

status of X was appropriate for CPT code 96110. Commenters stated that the change in the code 

description from “developmental testing; limited" to "developmental screening" should not preclude 

payment for this service. Additionally, other commenters raised concerns that this code is used for early 

developmental screening in pediatric offices and worried that our decision not to cover this code under the 

Medicare program would influence Medicaid coverage. Commenters recommended that this testing 

service should continue to be paid under the Medicare PFS. 

Response: We thank commenters for bringing the error in the status indicator for CPT 

code 96110 to our attention. As noted above, we corrected the PFS status indicator in a 

correction notice (77 FR 227) to 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) is more appropriate for this code. Regarding commenters concern that the 

testing services previously reported under CPT code 96110 continue to be payable, we point out 

that while these service are no longer payable using CPT code 96110, they continue to be 

payable using HCPCS code G0451, effective January 1, 2012. We understand that our lack of 

discussion of these services in the CY 2012 PFS final rule with comment period may have 

furthered this concern. We received no public comments on the CY 2012 interim final work 

RVUs for HCPCS code G0451. We believe these values continue to be appropriate and are 

finalizing them without modification. 

b. Finalizing CY 2012 Interim Direct PE Inputs 

i. Background and Methodology 

In this section, we address interim final direct PE inputs as presented in the CY 2012 PFS 
442 

final rule with comment period and displayed in the final CY 2012 direct PE database available 

on the CMS Web site under the downloads at 

http://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage. 

 On an annual basis, the AMA RUC provides CMS with recommendations regarding 

direct PE inputs, including clinical labor, supplies, and equipment, for new, revised, and 

potentially misvalued codes. We review the AMA RUC-recommended direct PE inputs on a 

code-by-code basis, including the recommended facility PE inputs and/or nonfacility PE inputs, 

as clinically appropriate for the code. We determine whether we agree with the AMA RUC’s 

recommended direct PE inputs for a service or, if we disagree, we refine the PE inputs to 

represent inputs that better reflect our estimate of the PE resources required for the service in the 

facility and/or nonfacility settings. We also confirm that CPT codes should have facility and/or 

nonfacility direct PE inputs, and make changes based on our clinical judgment and any PFS 

payment policies that would apply to the code. 

As we explained in the CY 2012 PFS final rule (76 FR 73212), we generally only 

establish interim final direct PE inputs for services when we receive direct PE input 

recommendations in the context of new, revised or potentially misvalued codes. However, for 

CY 2012, we established interim final direct PE inputs for several codes for which we did not 

receive direct PE recommendations. In the case of these codes, we believed it was necessary to 

establish new interim final direct PE inputs in order to maintain appropriate relativity among 

those codes and other related codes or between the PE, work and malpractice components of the 

PFS payment for the codes. 

Comment: Several commenters stated that they understood CMS’ rationale for refining 

the direct PE inputs on an interim final basis as we explained above, but urged CMS to bring the 
443 

AMA RUC’s attention to these codes during the AMA RUC process so that these interim final 

refinements by CMS could be avoided. 

Response: We appreciate the commenters’ suggestion. We also encourage the AMA 

RUC and other public commenters to consider issues related to maintaining appropriate relativity 

among related codes or between the PE, work, and malpractice components of the PFS payment 

for individual codes in the development of the recommendations that they provide to us. We 

believe that the AMA RUC and medical specialty societies, in light of CPT code descriptors and 

other language, as well as the guiding principles established through PFS rulemaking, are in a 

good position to identify, review, and develop direct PE input recommendations for coherent sets 

of codes, including component and combined codes, that ought to be developed or updated 

concurrently. 

In the CY 2012 PFS final rule with comment period (76 FR 73213), we addressed the 

general nature of some of our common refinements to the AMA RUC-recommended direct PE 

inputs as well as the reasons for refinements to particular inputs. In the following subsections, 

we respond broadly to comments we received regarding common refinements we made based on 

established principles or policies. Following those discussions, we summarize and respond to 

comments received regarding other refinements to particular codes. 

We note that the interim final direct PE inputs for CY 2012 that are being finalized for 

CY 2013 are displayed in the final CY 2013 direct PE input database, available on the CMS 

website under the downloads for the CY 2013 PFS final rule at www.cms.gov/PhysicianFeeSched/. The 

inputs displayed there have also been used in developing the CY 2013 PE RVUs as displayed in 

Addendum B of this final rule. 

We also note that for several codes for which we established interim final direct PE 

inputs for CY 2012, we either made proposals in the CY 2013 PFS proposed rule with comment 
444 

period as a result of those comments or we are establishing CY 2013 interim final direct PE 

inputs for the services based on new recommendations from the AMA RUC. We acknowledge 

receipt of those comments here and we note that those comments were taken into consideration 

in the development of CY 2013 PFS proposals and our consideration of the CY 2013 AMA RUC 

direct PE input recommendations. 

ii Common Refinements 

(1) Equipment Time 

Prior to CY 2010, the AMA RUC did not generally provide CMS with recommendations 

regarding equipment time inputs. In CY 2010, in the interest of ensuring the greatest possible 

degree of accuracy in allocating equipment minutes, we requested that the AMA RUC provide 

equipment times along with the other direct PE recommendations, and we provided the AMA 

RUC with general guidelines regarding appropriate equipment time inputs. We continue to 

appreciate the AMA RUC’s willingness to provide us with these additional inputs as part of its 

direct PE recommendations.

In general, the equipment time inputs correspond to the intra-service portion of the 

clinical labor times. We have clarified that assumption to consider equipment time as the sum of 

the times within the intra-service period when a clinician is using the piece of equipment, plus 

any additional time the piece of equipment is not available for use for another patient due to its 

use during the designated procedure. In addition, when a piece of equipment is typically used 

during additional visits included in a service’s global period, the equipment time should also 

reflect that use. 

We believe that certain highly technical pieces of equipment and equipment rooms are 

less likely to be used during all of the pre-service or post-service tasks performed by clinical 

labor on the day of the procedure (the clinical labor service period) and are typically available for 
445 

other patients even when one member of clinical staff may be occupied with a pre-service or 

post-service task related to the procedure. 

Some commenters have repeatedly objected to CMS’ rationale for refinement of 

equipment minutes on this basis. We acknowledge the comments we received that reiterate 

those objections to this rationale and refer readers to our extensive discussion regarding those 

objections in the CY 2012 PFS final rule with commenter period (76 FR 73182). In following 

paragraphs we address new comments on this policy. 

Comment: One commenter suggested that “CMS allows only a single staff type” for 

certain services, so that when pre-service and post-service clinical labor tasks are assigned only 

to one type of clinical labor (a CT technologist, for example), the equipment otherwise used by 

that technologist (the CT room) is necessarily unavailable to another patient. Therefore, the 

commenter argued that in those cases CMS should also allocate the total number of minutes for 

all the clinical labor tasks on the day of the service to the CT room regardless of whether or not it 

is typical for the pre-service or post-service activities to actually take place in the room. 

Response: We understand the commenter’s argument, but we do not agree with the 

conclusion for several reasons. First, we do not agree that allocating a number of minutes to a 

particular type of clinical staff in the direct PE input database can be appropriately viewed as 

CMS “allowing only a single staff type” being used to furnish services to Medicare beneficiaries. 

We believe that the direct PE input database should reflect the resources typically required in 

furnishing particular services, but we have no reason to believe that the inputs included in the 

database are prescriptive as to what actually happens in a medical practice. Therefore, we do not 

think the direct PE database staff type is likely to be a determining factor for the division of labor 

in physician offices and other nonfacility settings. Furthermore, we do not believe that most 

free-standing centers that furnish highly technical services to Medicare beneficiaries typically 
446 

only employ one clinical staff member at a time. Therefore, it would not be reasonable to 

assume that all capital equipment in a typical practice is unavailable for use whenever pre- or 

post-service tasks are being undertaken by any individual technologist. 

We also note that there are hundreds of services in the direct PE input database that 

include more than one type of staff in the clinical labor inputs. For many services, for example, 

minutes are allocated for a standard nurse blend staff type for pre-service and post-service tasks, 

while technologists are only allocated intra-service period minutes. There is no standing CMS 

policy that would prevent consideration of dividing clinical labor tasks among different types of 

clinical labor in the direct PE input database. 

Comment: One commenter expressed a concern regarding the relationship between the 

CMS refinement of recommended equipment minutes and the 75% equipment utilization rate 

assumption mandated by section 1848(b)(4)(C) of the Act. The commenter also stated that these 

refinements are arbitrary and will further widen the gap between Medicare payments determined 

by the Medicare hospital outpatient prospective payment system (OPPS) and the technical 

component of PFS services. 

Response: As we have previously stated, we believe that many of the pre-service and 

post-service clinical labor tasks typically take place outside of resource-intensive equipment 

rooms to maximize use of capital-intensive resources. Monopolizing the room for fewer minutes 

per patient maximizes the availability of the machines. In turn, the assumed rate of use for the 

machine should be greater, and the resource cost of the machine is reduced through these 

efficiencies. Since the direct PE input database should reflect the typical resource costs of 

medical equipment, we believe that the reduced minutes and increased utilization rate are 

complementary, not contradictory. 
447 

In response to the commenter’s second assertion, these refinements are far from arbitrary. 

We have consistently applied these principles in refining the direct PE inputs for services as we 

review equipment inputs through the potentially misvalued code initiative and our review of new 

and revised codes since the AMA RUC started providing equipment minute recommendations to 

CMS in 2010. We believe that imprecise allocation of equipment minutes may be a significant 

factor in certain potentially misvalued codes. We understand the importance of relativity within 

the equipment category of direct practice expenses and seek public comment on whether it might 

be necessary to consider making corresponding refinements to equipment minutes for services 

across the fee schedule for the sake of maintaining relativity. 

Finally, as a general statement, differences in payment rates between different payment 

systems do not necessarily indicate a lack of appropriate relativity within each system. There 

can be legitimate reasons why a payment rate should vary in different payment systems (for 

example, higher indirect costs, different payment bundles). Nevertheless, excessive differences 

in payment rates between payment systems can be one indication of the need to examine the relativity 

between services in one or both systems. While we continue to examine this issue, we do not 

believe that it would be appropriate to establish or maintain inaccurate direct PE inputs for these 

services based on comparisons between the PFS and OPPS payment rates. 

We will continue to work to improve the accuracy of the equipment minutes as reflected 

in the direct PE input database and will address any further improvements in future rulemaking. 

After consideration of these comments, we are finalizing the current interim final direct 

PE inputs as refined based on this policy. The direct PE inputs are displayed in the final CY 

2013 direct PE input database, available on the CMS website under the downloads for the CY 

2013 PFS final rule at www.cms.gov/PhysicianFeeSched/. 

(2) Changes in Physician Time 
448 

Some direct PE inputs are directly affected by revisions in physician time. Specifically, 

changes in the intra-service portions of the physician time and changes in the number or level of 

postoperative visits associated with the global periods result in corresponding changes to direct 

PE inputs. While the direct PE input recommendations generally correspond to the physician 

time values associated with services, we believe that in some cases inadvertent discrepancies 

between physician time values and direct PE inputs should be refined in the establishment of 

interim final direct PE inputs. In other cases, CMS refinement of recommended interim final 

physician times prompts necessary adjustments in the direct PE inputs. In the context of our 

establishment of interim final direct PE inputs for CY 2013, we explain those refinements in 

section III.M.3.b of this final rule with comment period. 

 Comment: One commenter requested an explanation regarding why CMS assumes that 

the clinical time allocated for assisting the physician performing the procedure should conform 

to the physician intra-service time. 

Response: As we have explained in previous rulemaking (76 FR 73213), for 

most codes valued in the nonfacility setting, a portion of the clinical labor time allocated to the 

intra-service period reflects minutes assigned for assisting the physician with the procedure. 

This time is usually allocated at some proportion of the physician time for a procedure. 

Frequently, the allocation is for the full physician intraservice time; this reflects the assumption 

that the clinical staff is assisting the physician during the entire procedure. For other services, 

the allocation is two-thirds or one-half of the physician time; this reflects the assumption that 

clinical staff is assisting the physician for a portion of the procedure time. In establishing interim 

final direct PE inputs, we note a change in clinical labor time (or corresponding change in 

equipment minutes) that results from a change in physician time as “conforming to physician 

time.” This note is not used to reflect a refinement to the recommended proportion for which the 
449 

staff is assisting the physician performing the procedure. Instead, these refinements reflect a 

change in the base procedure time assumption for the service. After consideration of this 

comment, we are finalizing the current interim final direct PE inputs as refined based on this 

policy. The direct PE inputs are displayed in the final CY 2013 direct PE input database, 

available on the CMS website under the downloads for the CY 2013 PFS final rule at 

www.cms.gov/PhysicianFeeSched/. 

(3) Proxy Inputs for Digital Imaging 

Comment: In the context of several codes, several commenters objected to CMS’ not 

accepting certain recommended items as direct PE inputs since these items, though atypical, may 

be considered surrogate items for digital imaging technology. 

Response: A variety of imaging services across the PFS include direct PE inputs that 

reflect film-based technology instead of digital technology. We have accepted the film-based 

technology inputs in the RUC recommendations as proxy inputs until a more comprehensive 

migration of such inputs from film to digital imaging can be executed. We anticipate updating 

all of the associated inputs in future rulemaking. 

 After consideration of these comments, we are finalizing the current interim final direct 

PE inputs as refined based on this policy. The direct PE inputs are displayed in the final CY 

2013 direct PE input database, available on the CMS website under the downloads for the CY 

2013 PFS final rule at www.cms.gov/PhysicianFeeSched/. 

iii Code-specific direct PE inputs 

(1) Integumentary System: Repair (Closure) (CPT Codes 15271, 15273, 15275, 15277) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendation for CPT codes 15271 (Application of skin substitute graft to trunk, arms, legs, 

total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area), 15273 
450 

(Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or 

equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and 

children), 15275 (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, 

orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; 

first 25 sq cm or less wound surface area), and 15277 (Application of skin substitute graft to 

face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total 

wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 

1% of body area of infants and children) to allocate the full service period minutes to the basic 

instrument pack (EQ137) by reducing the equipment allocation by 3 minutes to account for the 

overlapping time for cleaning the room and the pack. 

Comment: One commenter disagreed with CMS’ reduction of the recommended minutes 

and stated that since the pack is unavailable for other patients while the room is being cleaned, 

the pack should be allocated the full number of service period clinical labor minutes, including 

the time for cleaning both the room and the pack. The commenter also stated that cleaning of the 

instruments is discrete work, most often done after the patient's departure. 

 Response: Since clinical labor is allocated a specific number of minutes for cleaning 

surgical instrument packs, we do not believe that we should also allocate the clinical labor 

minutes for cleaning the other equipment associated with the services. Because we agree with 

the commenter that the task is discrete from the cleaning associated with the other equipment and 

the room itself, we do not think that the instrument pack is unavailable when the room is being 

cleaned. 

 CMS also refined the recommended direct PE inputs for CPT codes 15273 and 15275 by 

not including the post-op incision care (suture) pack (SA054) in each code because the code 

itself does not describe post-op care. 
451 

Comment: One commenter disagreed with the refinement and pointed out that CPT 

guidelines state: "Skin replacement surgery consists of surgical preparation and topical 

placement of an autograft (including tissue cultured autograft) or skin substitute graft (ie, 

homograft, allograft, xenograft). The graft is anchored using the provider’s choice of fixation. 

When services are performed in the office, routine dressing supplies are not reported separately. 

Removal of current graft and/or simple cleansing of the wound is included, when performed." 

The commenter also noted that CPT codes 15273 and 15277 typically involve large grafts that 

will be anchored by sutures, and although these codes have a 0-day global period, removal of the 

graft is included in the work and therefore a suture removal kit is appropriate as a supply item. 

Response: Based on the rationale presented by the commenters, CMS agrees that one 

pack should be included as a supply item for CPT codes 15273 and 15277. 

After consideration of the comments received, we are finalizing the direct PE inputs for CPT 

codes 15271, 15273, 15275, and 15277 as established as interim final with the additional 

refinement of incorporating the supply item discussed above for CPT codes 15273 and 15277. 

(2) Musculoskeletal: General: Introduction or Removal (CPT Code 20527) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendation for CPT code 20527 (Injection, enzyme (eg, collagenase), palmar fascial cord 

(ie, dupuytren's contracture)) by including a minimum multi-specialty visit pack (SA048) as a 

direct PE input for the service. 

 Comment: A commenter presented information indicating that the multi-specialty pack is 

not typically used in furnishing the service. 

 Response: We agree with the information presented by the commenter. 

After consideration of this comment, we are finalizing the direct PE inputs for CPT code 20527 

as established as interim final with the additional refinement of removing the supply item 
452 

discussed above. The direct PE inputs are displayed in the final CY 2013 direct PE input 

database, available on the CMS website under the downloads for the CY 2013 PFS final rule at 

www.cms.gov/PhysicianFeeSched/. 

(3) Musculoskeletal: Spine (Vetebral Column) (CPT Code 22525) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendation for CPT code 22525 (Percutaneous vertebral augmentation, including cavity 

creation (fracture reduction and bone biopsy included when performed) using mechanical device, 

1 vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); each additional thoracic or 

lumbar vertebral body (list separately in addition to code for primary procedure))by not 

including additional clinical labor and equipment time for preparing the room, equipment, and 

supplies since the CPT code 22525 is an add-on code and time for those tasks is already included 

in the base code. 

 Comment: A commenter disagreed with the removal of 2 minutes for preparing the room, 

equipment, and supplies and stated that since the add-on code requires more equipment than the 

base code the direct PE inputs should include additional minutes for preparing that equipment. 

 Response: Based on our clinical review, we believe that the standard number of minutes 

allocated for the clinical labor to prepare the room, equipment, and supplies in the base code 

approximates the typical number of minutes for such tasks including the cases where the add-on 

code is necessary. Were the minutes accounted for separately in the add-on code, the number of 

minutes included in the base code would need to be re-examined. At this time, we believe that it 

would be more appropriate to maintain the standard number of minutes in the base code and not 

allocate additional time in the add-on code. 

Comment: A commenter informed CMS that the clinical labor codes associated with CPT 

Code 22525 were transposed in the direct PE input database. 
453 

Response: We appreciate being informed of the inadvertent assignment of labor codes. 

After consideration of these comments, we are finalizing the direct PE inputs for CPT 

code 22525 as established as interim final with the additional refinement of assigning the 

appropriate labor codes. 

(4) Musculoskeletal: Hand and Fingers (CPT Code 26341) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendation for CPT code 26341 (Manipulation, palmar fascial cord (ie, dupuytren's cord), 

post enzyme injection (eg, collagenase), single cord) by including a minimum multi-specialty 

visit pack (SA048) as a direct PE input for the service period in the nonfacility and the same 

pack in both settings to account for the post-service office visit included in the global period. 

 Comment: A commenter stated that while the pack was typically used in the nonfacility 

setting during the service period, it is not typically used for the post-service office visit. 

 Response: The allocation of the supply pack minutes in the facility setting reflects the 

standard allocation of direct PE inputs based on the office visits included in the global period for 

the service. We discuss the specifics related to these standard allocations in section III.M.3.b of 

this final rule with comment period. At this time, we do not believe it would be appropriate to 

deviate from these standards. We direct readers interested in the appropriate valuation of 

services with global periods to section III.B.2.d of this final rule with comment period. 

 After consideration of this comment, we are finalizing the direct PE inputs for CPT code 

26341 as established as interim final. The direct PE inputs are displayed in the final CY 2013 

direct PE input database, available on the CMS website under the downloads for the CY 2013 

PFS final rule at www.cms.gov/PhysicianFeeSched/. 

(5) Respiratory: Lungs and Pleura (CPT Code 32405) and Digestive: Liver (CPT Code 47000) 
454 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT codes 32405 (Biopsy, lung or mediastinum, percutaneous needle) and 

47000 (Biopsy of liver, needle; percutaneous) by removing minutes allocated to the CT room 

(EL007) since these services are typically billed with radiological supervision and interpretation 

(S&I) services. 

Comment: A commenter pointed out that the CT room time included with the S&I code 

77012 is only 9 minutes, which reflects a convention for some S&I codes. On this basis, the 

commenter suggested that for these codes, the CT room should be allocated the standard number 

of minutes minus the 9 minutes that overlap with the S&I code. 

 Response: We appreciate the commenter pointing out this allocation of equipment 

minutes. We note that this convention does not apply consistently to all S&I codes and related 

procedure codes. We may address such inconsistencies in future rulemaking. 

 After consideration of this comment, we are finalizing the direct PE inputs for CPT codes 

32405 and 47000 as established as interim final with the additional refinement of including the 

CT room as a direct PE input for the services, with the reduction of 9 minutes to account for the 

overlapping number of minutes allocated in the S&I code. 

(6) Cardiovascular: Arteries and Veins (CPT Codes 36200, 36246, 36247) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT codes 36200 (Introduction of catheter, aorta), 36246 (Selective 

catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity 

artery branch, within a vascular family), and 36247 (Selective catheter placement, arterial 

system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, 

within a vascular family) by reducing the number of clinical labor minutes allocated for 
455 

preparing the room, equipment, and supplies used in the service to the standard number of 

minutes allocated to clinical labor for those tasks. 

 Comment: One commenter stated that since vascular procedures have more variable 

supplies than typical procedures, more minutes for preparing supplies should be allocated for the 

clinical labor direct PE inputs. 

Response: Upon clinical review of these procedures, we believe that the standard number 

of minutes allocated for such tasks in similar services across the direct PE input database 

adequately accounts for the variability of supplies in these procedures. 

 After consideration of this comment, we are finalizing the direct PE inputs for CPT codes 

36200, 36246, and 36247 as established as interim final. The direct PE inputs are displayed in 

the final CY 2013 direct PE input database, available on the CMS website under the downloads 

for the CY 2013 PFS final rule at www.cms.gov/PhysicianFeeSched/. 

(7) Digestive: Abdomen, Peritoneum, and Omentum (CPT Code 49083) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT code 49083 (Abdominal paracentesis (diagnostic or therapeutic); with 

imaging guidance) by reducing the number of clinical labor minutes recommended for a series of 

tasks to correspond with the standard minutes as allocated across PFS services. Additionally, 

CMS refined the minutes allocated to the equipment associated with the service based on the 

standard allocation of minutes for highly technical and resource-intensive equipment. 

 Comment: A commenter suggested that 42 minutes should be allocated to the equipment 

using CMS’ methodologies and including the 25 minutes corresponding to the assist physician 

time. 

 Response: We agree with the commenter that the 25 minutes is the appropriate time 

allocated for assisting the physician. However, we do not agree with the final number of minutes 
456 

that should be allocated for the equipment. Based on our standard review for such equipment, 

we believe that the equipment should be allocated the minutes assumed for preparing the room, 

equipment, and supplies, preparing and positioning the patient, the procedure time itself, and the 

time allocated to clean the room and the equipment. Based on the procedure-specific assist 

physician time and the standard number of minutes allocated for the additional pre-service and 

post-service tasks, we have calculated the appropriate equipment minutes to sum to 32. 

 After consideration of this comment, we are finalizing the direct PE inputs for CPT code 

49083 as established as interim final, with the additional refinement of allocating 32 minutes for 

the equipment used in the service. The direct PE inputs are displayed in the final CY 2013 direct 

PE input database, available on the CMS website under the downloads for the CY 2013 PFS 

final rule at www.cms.gov/PhysicianFeeSched/. 

(8) Urinary: Bladder (CPT Code 51736) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT code 51736 (Simple uroflowmetry (ufr) (eg, stop-watch flow rate, 

mechanical uroflowmeter)) by adding the following supplies to the direct PE inputs for the 

service based on CMS clinical review: paper towel (SK082), disinfectant spray (SM012), and 

sanitizing cloth wipe (SM022). 

Comment: A commenter disagreed with this refinement and suggested instead that these 

supplies, as well as the digital uroflowmeter (EQ259), should instead only be included as direct 

PE inputs for CPT code 51741 (Complex uroflowmetry (eg, calibrated electronic equipment)). 

 Response: Upon further clinical review, and on the basis of the commenter’s 

recommendation, we agree that the items should be removed from the service. 

 After consideration of this comment, we are finalizing the direct PE inputs for CPT code 

51741 as established as interim final, with the additional refinement of removing the three supply 
457 

items and one equipment item identified above. The direct PE inputs are displayed in the final 

CY 2013 direct PE input database, available on the CMS website under the downloads for the 

CY 2013 PFS final rule at www.cms.gov/PhysicianFeeSched/. 

(9) Nervous: Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System (CPT 

Codes 64633, 64635) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT code 64633 (Destruction by neurolytic agent, paravertebral facet joint 

nerve(s), with imaging guidance (fluoroscopy or ct); cervical or thoracic, single facet joint) and 

64635 (Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 

(fluoroscopy or ct); lumbar or sacral, single facet joint) by not including the recommended 

radiofrequency probe kit (SA100) as a supply item. As we explained in the CY 2012 PFS final 

rule (76 FR 73214), the very expensive disposable item had not previously been included as a 

direct PE input for predecessor codes that described the same services, and the recommendation 

did not include any information suggesting that such a significant resource cost had become 

typical in furnishing the services. At that time, we noted that the direct PE inputs for these codes 

were considered interim for CY 2012, and we would consider any submitted information 

regarding the use of this supply in furnishing these services prior to finalizing the direct PE 

inputs for CY 2013. 

 Comment: One commenter responded to this refinement by explaining that furnishing 

the service requires a radiofrequency kit, but that the kit is reusable and typically has a useful life 

of several months. 

 Response: We appreciate the information from the commenter, though we generally 

prefer additional information, including paid invoices, in order to price supply or equipment 

items accurately. For CY 2013, we believe it would be appropriate to finalize the direct PE 
458 

inputs for these services with a new equipment item based on the disposable item included in the 

original recommendation and the information supplied by the commenter. We encourage 

stakeholders to submit additional information through the public process for updating prices for 

supplies and equipment we established in the CY 2011 PFS final rule (75 FR 73205-73207). We 

believe that that process will allow us to describe the item and assign its price and useful life 

more accurately. 

 CMS also refined the recommended direct PE inputs for CPT codes 64633 and 64635 

by allocating equipment minutes in the facility setting for the exam table (EF023) and the exam 

light (EQ168) based on the post-service office visits included in the global periods. 

 Comment: One commenter suggested that allocating this time was not appropriate. 

 Response: The allocation of equipment minutes in the facility setting reflects the standard 

allocation of direct PE inputs based on the office visits included in the global period for the 

service. We discuss the specifics related to these standard allocations in section III.M.3.b of this 

final rule with comment period. At this time, we do not believe it would be appropriate to 

deviate from these standards. We direct readers interested in the appropriate valuation of 

services with global periods to section III.B.2.d of this final rule with comment period. 

 After consideration of these comments, we are finalizing the direct PE inputs for CPT 

code 64633 and 64635 as established as interim final, with the additional refinement of 

establishing this equipment item, “radiofrequency kit for destruction by neurolytic agent” 

(EQ354) as a placeholder direct PE input for the codes until we receive more information 

regarding the item. The direct PE inputs are displayed in the final CY 2013 direct PE input 

database, available on the CMS website under the downloads for the CY 2013 PFS final rule at 

www.cms.gov/PhysicianFeeSched/. 

(10) Diagnostic Radiology: Spine and Pelvis (CPT Code 72120, 72170) 
459 

In establishing interim final direct PE inputs for 2012, CMS refined the direct PE inputs for CPT 

codes 72120 (Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views) and 

72170 (Radiologic examination, pelvis; 1 or 2 views) by reducing the number of minutes 

allocated to the clinical labor for cleaning the room and equipment to one. 

Comment: A commenter disagreed with the revision and suggested that CMS should use 

the standard 3 minutes for this activity. 

 Response: We appreciate the commenter’s interest in CMS using the standard number of 

minutes for clinical labor tasks. As we explained in our refinements regarding reducing 

recommendations that exceeded the standard number of minutes, we believe that the standard 

number of minutes generally accommodates the range of minutes likely to be typical for such 

activities. We agree that it would be appropriate to include the standard minutes for these 

services. 

 After consideration of these comments, we are finalizing the direct PE inputs for CPT 

codes 72120 and 72170, with the additional refinement of allocating two additional minutes to 

the clinical labor and the associated equipment inputs for cleaning the room and equipment. The 

direct PE inputs are displayed in the final CY 2013 direct PE input database, available on the 

CMS website under the downloads for the CY 2013 PFS final rule at 

www.cms.gov/PhysicianFeeSched/. 

(11) Nuclear Medicine: Diagnostic (CPT Codes 78226, 78227, 78579, 78580, 78582, 78597, 

78598) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT codes 78226 (Hepatobiliary system imaging, including gallbladder 

when present;), 78227(Hepatobiliary system imaging, including gallbladder when present; with 

pharmacologic intervention, including quantitative measurement(s) when performed), 78579 
460 

(Pulmonary ventilation imaging (eg, aerosol or gas)), 78580 (Pulmonary perfusion imaging (eg, 

particulate)), 78582 (Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging), 78597 

(Quantitative differential pulmonary perfusion, including imaging when performed), and 78598 

(Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including 

imaging when performed) by refining equipment time allocations as described in section 

III.M.2.b above. 

 Comment: One commenter disagreed with those refinements and urged CMS to identify 

the clinical labor tasks associated with the minutes excluded from the equipment allocation. 

 Response: We refer the commenter to the discussion above regarding the general 

principles of accurate assignment of equipment minutes. In the case of this family of codes, we 

believe that it is appropriate to allocate equipment minutes for clinical labor tasks of preparing 

the room, positioning the patient, placing the IV, acquiring images during the procedure itself, 

and cleaning the room, including additional minutes of cleaning for regulatory compliance. We 

do not believe that expensive equipment is typically unavailable for use for other patients while 

clinical staff performs such tasks as greeting and gowning the patient, reviewing mandatory 

radiation education, helping the patient to the waiting room, completing diagnostic forms or 

making lab and X-ray requisitions. The minutes allocated to the equipment in the direct PE input 

database reflect the application of these principles as specifically determined through CMS 

clinical review. 

CMS also refined the recommended direct PE inputs for CPT codes 78226, 78227, 

78579, 78580, 78582, 78597, 78598 by examining all of the educational tasks included in the 

AMA RUC’s recommendation and refining the sum of those times to a total number of minutes 

considered accurate under CMS clinical review. The AMA RUC recommendation included 6 
461 

minutes of education by the nuclear medicine technologist. CMS refined the total number of 

minutes allocated for educational tasks to 4. 

Comment: One commenter disagreed with the refinement to remove the minutes 

allocated for providing patient counseling while the patient is being taken back to the waiting 

area. This commenter suggested that CMS may be confusing the recommended minutes for this 

task with the concurrent recommendation to include the standard number of minutes for patient 

education. The commenter suggested that since nuclear medicine patients are radioactive when 

they leave departments, they require more education than other services, especially since patients 

need to be reminded about the dangers of radioactivity after they leave the office. 

Response: We agree with the commenter that it is reasonable for more time to be 

allocated to these services for patient education. We also note that our interim refinements 

included more education time than typical for PFS services. However, we believe that it would 

be appropriate to include a total of 5 minutes for clinical labor patient education activities for 

these services in consideration of the comments received. 

CMS also refined the recommended direct PE inputs for CPT codes 78226, 78227, 

78579, 78580, 78582, 78597, 78598 by examining all of the cleaning tasks included in the AMA 

RUC’s recommendation and refining the sum of those times to a total number of minutes 

considered accurate under CMS clinical review. The AMA RUC recommendation included 13 

minutes of cleaning tasks by a nuclear medicine technologist. CMS refined the total number of 

minutes allocated for educational tasks to 10. 

Comment: One commenter suggested that the full 13 minutes of cleaning per service 

should be allocated on a standard basis for these codes to account for the number of minutes 

required to meet cleaning regulatory cleaning standards for services that use radioactive 
462 

pharmaceuticals. The commenter also noted that this allocation has been included in similar 

services. 

Response: Upon clinical review, we continue to doubt that nuclear medicine 

technologists typically clean the room and equipment for 13 minutes following every service. 

However, we acknowledge that there is an additional cleaning burden for these services, and we 

also agree with the commenter that other services that use similar substances incorporate the 

same number of minutes for mandated cleaning. Therefore, we believe it is appropriate that 

these services include these additional minutes for cleaning. 

After consideration of these comments, we are finalizing the direct PE inputs for CPT 

codes 78226, 78227, 78579, 78580, 78582, 78597, 78598 with the additional refinement of 

allocating 1 additional clinical labor minute for patient education tasks and an additional 3 

minutes to the clinical labor and equipment items to account for mandatory cleaning tasks. The 

direct PE inputs are displayed in the final CY 2013 direct PE input database, available on the 

CMS website under the downloads for the CY 2013 PFS final rule at 

www.cms.gov/PhysicianFeeSched/. 

(12) Pulmonary: Diagnostic Testing and Therapies (CPT Codes 94728) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT code 94728 (Airway resistance by impulse oscillometry) by adding 

the body plethysmograph autobox (EQ044) as direct equipment input for the service based on the 

item’s inclusion as a direct PE input for related services. 

Comment: One commenter noted that this code is used to describe services furnished 

primarily for children and that the equipment item cannot be used with pediatric patients. 

Response: We appreciate the additional information regarding the appropriate use of the 

equipment. 
463 

After consideration of these comments, we are finalizing the direct PE inputs for CPT 

code 94728 with the additional refinement of removing the equipment item discussed above as a 

direct PE input for the service. The direct PE inputs are displayed in the final CY 2013 direct PE 

input database, available on the CMS website under the downloads for the CY 2013 PFS final 

rule at www.cms.gov/PhysicianFeeSched/. 

(13) Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and 

Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent 

Administration (CPT Codes 96413, 96416) 

In establishing interim final direct PE inputs for 2012, CMS refined the AMA RUC’s 

recommendations for CPT code 96413 (Chemotherapy administration, intravenous infusion 

technique; up to 1 hour, single or initial substance/drug) by not including the 6 clinical labor 

minutes in the pre-service period for completing pre-service diagnostic and referral forms and 

coordinating pre-surgery services since these tasks are not generally allocated for services 

without global periods. 

Comment: Several commenters suggested that the recommended times for these tasks 

reflects the time for the oncology nurse to document the upcoming chemotherapy session based 

on the physician's orders, coordinate the service under the physician's direction, ensure that the 

planned infusion is consistent with physician's direction, and confirm that there is no change in 

the drugs to be infused, anti-emetics to be supplied, or post-treatment instructions. The 

commenter also noted that the minutes allocated for those tasks in CPT code 96416 

(Chemotherapy administration, intravenous infusion technique; initiation of prolonged 

chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump) 

were removed in the same recommendation in order to account for the overlap in tasks since 

CPT code 96413 is typically also reported whenever CPT code 96416 is reported. 
464 

Response: We agree with the commenter’s recommendation to include those six minutes 

in CPT code 96413 and exclude those minutes in CPT code 96416, consistent with the AMA 

RUC recommendation. 

CMS refined the recommended direct PE inputs for CPT code 96416 by not including the 

4 minutes assigned to the clinical labor for reviewing the charts and obtain 

chemotherapyrelated medical history. This refinement reflected that CMS clinical review 

concluded that these tasks are already accounted for in the clinical labor minutes assigned to 

CPT code 96413 and would typically not be repeated when CPT code 96416 is reported. 

Comment: Several commenters claimed that the nurse must perform these tasks and that 

the time is appropriately valued at 4 minutes. 

Response: We agree with the commenters that the time for the tasks is appropriately 

estimated at 4 minutes, but we maintain our belief that the tasks fully overlap with the same tasks 

associated with CPT code 96413, which is typically also reported whenever CPT code 96416 is 

reported. Therefore, we do not believe those 4 minutes should be allocated to both services. 

CMS also refined the recommended direct PE inputs for CPT code 96416 by examining 

all of the tasks described in the AMA RUC’s recommendation for monitoring the patient and 

removing the minutes that overlap with monitoring included in CPT code 96413. This 

refinement assumed no monitoring was necessary beyond the monitoring time already associated 

with CPT code 96413. 

Comment: One commenter objected to the refinement of the intra-service time since the 

clinical labor performs the procedure. 

Response: We agree with the commenter that the recommendation reflects that the 

clinical staff is performing the procedure. The rationale for our refinement of the minutes for the 

task “assist physician performing the procedure” was described broadly as “conforming to 
465 

physician time” in the CY 2012 PFS final rule (76 FR 73264), but was specifically intended to 

address the overlap in minutes allocated for monitoring the patient following the administration. 

We continue to believe that some of the 18 recommended minutes for monitoring tasks in CPT 

code 96416 overlap with the 24 minutes included in CPT code 96413 for monitoring. However, 

upon further clinical review, we believe that the overlap is not complete and that it would be 

appropriate to increase the total clinical labor minutes allocated in the service period by an 

additional 11 minutes to account for the additional monitoring that would typically occur when 

CPT code 96416 is furnished. 

After consideration of these comments, we are finalizing the direct PE inputs for CPT 

codes 96413 and 96416 with the additional refinements of including an additional 6 minutes of 

clinical labor time in the pre-service period for CPT code 96413 and including an additional 11 

minutes of clinical labor time in the service period for CPT code 96416. We also note that the 

minutes allocated to the equipment inputs will increase based on our standard allocation policies. 

The direct PE inputs are displayed in the final CY 2013 direct PE input database, available on the 

CMS website under the downloads for the CY 2013 PFS final rule at 

www.cms.gov/PhysicianFeeSched/. 

For all other CY 2012 new, revised, or potentially misvalued codes with CY 2012 interim 

final RVUs that are not specifically discussed in this final rule with comment period, we are 

finalizing, without modification, the interim final direct PE inputs that we initially adopted for 

CY 2012. 

c. Finalizing CY 2012 Interim and Proposed Malpractice Crosswalks for CY 2013 

Consistent with our malpractice methodology described in section III.C.1. of this final 

rule with comment period, for the CY 2012 PFS final rule, we assigned malpractice RVUs for 

CY 2012 new and revised codes by utilizing crosswalks to source codes that have a similar 
466 

malpractice risk-of-service. After reviewing the AMA RUC-recommended malpractice source 

code crosswalks for CY 2012 new and revised codes, we accepted nearly all of them on an 

interim final basis for CY 2012. As detailed in the CY 2012 final rule with comment period (76 

FR 73264 through 73265), for four CPT codes describing multi-layer compression systems, we 

assigned a malpractice crosswalk different from the malpractice crosswalk recommended by the 

AMA RUC and HCPAC. 

In the CY 2012 PFS final rule with comment period, for CPT codes 29581 (Application 

of multi-layer compression system; leg (below knee), including ankle and foot), 29582 

(Application of multi-layer compression system; thigh and leg, including ankle and foot, when 

performed), 29583 (Application of multi-layer compression system; upper arm and forearm), and 

29584 (Application of multi-layer compression system; upper arm, forearm, hand, and fingers), 

we assigned an interim final malpractice crosswalk from CPT code 97140 (Manual therapy 

techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or 

more regions, each 15 minutes). CPT codes 29582, 29583, and 29584 were new for CY 2012. 

The AMA RUC recommended, and we agreed, that the estimated utilization for CPT codes 

29582, 29583, and 29584 would have previously been reported using CPT code 97140. After 

review, we believed that CPT code 97140 provides the most appropriate malpractice source code 

crosswalk for CPT codes 29582, 29583, and 29584. As discussed in section III.M.3 of this CY 

2013 final rule with comment period, in the CY 2012 PFS final rule with comment period we 

stated that we believe CPT codes 29581, 29582, 29583, and 29584 all describe similar services 

from a resource perspective, and we assigned CPT code 29581 the same interim work RVU as 

CPT code 29583. Because we find these services to be so similar, we stated that we also 

believed that it is appropriate for CPT codes 29581 and 29583 to have the same malpractice 

source code crosswalk. Therefore, we assigned CPT code 97140 as the malpractice source code 
467 

crosswalk for CPT codes 29581, 29582, 29583, and 29584. 

Additionally, for CY 2012 we created HCPCS G-code G0451 (Development testing, with 

interpretation and report, per standardized instrument form) to replace CPT code 96110 

(Developmental screening, with interpretation and report, per standardized instrument form). 

For CY 2012, we assigned CPT code 96110 as the malpractice source code crosswalk for 

HCPCS code G0451. 

In accordance with our malpractice methodology, we adjusted the malpractice RVUs for 

the CY 2012 new/revised codes for the difference in work RVUs (or, if greater, the clinical labor 

portion of the fully implemented PE RVUs) between the source codes and the new/revised codes 

to reflect the specific risk-of-service for the new/revised codes. The interim final malpractice 

crosswalks were listed in Table 22 of the CY 2012 PFS final rule with comment period (76 FR 

73266 through 73268). 

We received no comments on the CY 2012 interim final malpractice crosswalks and are 

finalizing them without modification for CY 2013. The malpractice RVUs for these services are 

reflected in Addendum B of this CY 2013 PFS final rule with comment period. 

d. Other New, Revised or Potentially Misvalued Codes with CY 2012 Interim Final RVUs 

or CY 2013 Proposed RVUs Not Specifically Discussed in the CY 2013 Final Rule with 

Comment Period 

For all other new, revised, or potentially misvalued codes with CY 2012 interim final 

RVUs or CY 2013 proposed RVUs that are not specifically discussed in this final rule with 

comment period, we received no public comments and, as such, we are finalizing, without 

modification, the interim final or proposed work and direct PE inputs we initially adopted in the 

CY 2012 final rule with comment period or the CY 2013 proposed rule, respectively. The time 

values for all codes appear on the CMS website at 
468 

www.cms.gov/PhysicianFeeSched/. Refer to Addenda B for a comprehensive list of all final 

values. 

3. Establishing Interim Final RVUs for CY 2013 

a. Establishing CY 2013 Interim Final Work RVUs 

 As previously discussed in section III.M.2 of this final rule with comment period, on an 

annual basis the AMA RUC and HCPAC, along with other public commenters, provide CMS 

with recommendations regarding physician work values for new and revised CPT codes. This 

section discusses services for which CMS disagreed with the recommended physician work RVU 

or time values for CY 2013 new or revised CPT codes, services that had interim or interim final 

values in CY 2012 and will continue to have interim or interim final values for CY 2013, as well 

as the physician work and time values for new and revised HCPCS G-codes. The interim or 

interim final work RVUs for all codes in this section, including those where CMS agreed with 

the recommended work RVU, appear in Table 2 at the start of this section. Unless otherwise 

indicated, we agreed with the time values recommended by the AMA RUC or HCPAC for all 

codes addressed in this section. The time values for all codes appear on the CMS website at: 

www.cms.gov/PhysicianFeeSched/. 

 We note that in addition to the CPT codes discussed in this section, the CPT Editorial 

created, and the AMA RUC reviewed, many new CPT codes for molecular pathology tests. 

These services will be payable on the Medicare Clinical Laboratory Fee Schedule and are 

discussed in detail in section III.I of this CY 2013 PFS final rule with comment period. 

i. Code-specific Issues 

TABLE 30: Work RVUs for CY 2013 New, Revised, and Potentially Misvalued Codes 
469 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time* 

10120 Remove foreign body 1.25 1.25 1.22 Disagree Yes 

11055 Trim skin lesion 0.43 0.43 0.35 Disagree Yes 

11056 Trim skin lesions 2 to 4 0.50 0.50 0.50 Agree No 

11057 Trim skin lesions over 4 0.79 0.79 0.65 Disagree Yes 

11300 Shave skin lesion 0.5 cm/< 0.51 0.60 0.60 Agree No 

11301 Shave skin lesion 0.6-1.0 cm 0.85 0.90 0.90 Agree No 

11302 Shave skin lesion 1.1-2.0 cm 1.05 1.16 1.05 Disagree No 

11303 Shave skin lesion >2.0 cm 1.24 1.25 1.25 Agree No 

11305 Shave skin lesion 0.5 cm/< 0.67 0.80 0.80 Agree No 

11306 Shave skin lesion 0.6-1.0 cm 0.99 1.18 0.96 Disagree No 

11307 Shave skin lesion 1.1-2.0 cm 1.14 1.20 1.20 Agree No 

11308 Shave skin lesion >2.0 cm 1.41 1.46 1.46 Agree No 

11310 Shave skin lesion 0.5 cm/< 0.73 1.19 0.80 Disagree No 

11311 Shave skin lesion 0.6-1.0 cm 1.05 1.43 1.10 Disagree No 

11312 Shave skin lesion 1.1-2.0 cm 1.20 1.80 1.30 Disagree No 

11313 Shave skin lesion >2.0 cm 1.62 2.00 1.68 Disagree No 

11719 Trim nail(s) any number 0.17 0.17 0.17 Agree No 

G0127 Trim nail(s) 0.17 N/A 0.17 N/A N/A 

12035 Intmd wnd repair s/a/t/ext 3.50 3.60 3.50 Disagree No 

12036 Intmd wnd repair s/a/t/ext 4.23 4.50 4.23 Disagree Yes 

12037 Intmd wnd repair s/tr/ext 5.00 5.25 5.00 Disagree No 

12045 Intmd wnd repair n-hf/genit 3.75 3.90 3.75 Disagree Yes 

12046 Intmd wnd repair n-hf/genit 4.30 4.60 4.30 Disagree Yes 

12047 Intmd wnd repair n-hf/genit 4.95 5.50 4.95 Disagree Yes 

12055 Intmd wnd repair face/mm 4.50 4.65 4.50 Disagree Yes 

12056 Intmd wnd repair face/mm 5.30 5.50 5.30 Disagree Yes 

12057 Intmd wnd repair face/mm 6.00 6.20 6.00 Disagree Yes 

13100 Cmplx rpr trunk 1.1-2.5 cm 3.17 3.00 3.00 Agree Yes 

13101 Cmplx rpr trunk 2.6-7.5 cm 3.96 3.50 3.50 Agree Yes 

13102 Cmplx rpr trunk addl 5cm/< 1.24 1.24 1.24 Agree No 

13120 Cmplx rpr s/a/l 1.1-2.5 cm 3.35 3.23 3.23 Agree Yes 

13121 Cmplx rpr s/a/l 2.6-7.5 cm 4.42 4.00 4.00 Agree Yes 

13122 Cmplx rpr s/a/l addl 5 cm/> 1.44 1.44 1.44 Agree No 

13131 Cmplx rpr f/c/c/m/n/ax/g/h/f 3.83 3.73 3.73 Agree Yes 

13132 Cmplx rpr f/c/c/m/n/ax/g/h/f 6.58 4.78 4.78 Agree Yes 

13133 Cmplx rpr f/c/c/m/n/ax/g/h/f 2.19 2.19 2.19 Agree No 

13150 Cmplx rpr e/n/e/l 1.0 cm/< 3.85 N/A 3.58 N/A N/A 

13151 Cmplx rpr e/n/e/l 1.1-2.5 cm 4.49 4.34 4.34 Agree Yes 

13152 Cmplx rpr e/n/e/l 2.6-7.5 cm 6.37 5.34 4.90 Disagree Yes 

13153 Cmplx rpr e/n/e/l addl 5cm/< 2.38 2.38 2.38 Agree No 

20985 Cptr-asst dir ms px 2.50 2.50 2.50 Agree No 

22586 Prescrl fuse w/ instr l5/s1 New N/A 28.12 N/A N/A 

23350 Injection for shoulder x-ray 1.00 1.00 1.00 Agree No 

23331 Remove shoulder foreign body 7.63 7.63 7.63 Interim No 

23332 Remove shoulder foreign body 12.37 12.37 12.37 Interim No 

23472 Reconstruct shoulder joint 22.65 22.13 22.13 Interim No 

23473 Revis reconst shoulder joint New 25.00 25.00 Interim No 

23474 Revis reconst shoulder joint New 27.21 27.21 Interim No 

23600 Treat humerus fracture 3.11 3.00 3.00 Agree No 

24160 Remove elbow joint implant 8.00 8.00 8.00 Interim No 

24363 Replace elbow joint 22.65 22.00 22.00 Interim Yes 
470 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time* 

24370 Revise reconst elbow joint New 23.55 23.55 Interim No 

24371 Revise reconst elbow joint New 27.50 27.50 Interim No 

28470 Treat metatarsal fracture 2.03 2.03 2.03 Agree No 

29075 Application of forearm cast 0.77 0.77 0.77 Agree No 

29581 Apply multlay comprs lwr leg 0.25 0.60 0.25 Disagree No 

29582 Apply multlay comprs upr leg 0.35 0.35 0.35 Agree No 

29583 Apply multlay comprs upr arm 0.25 0.25 0.25 Agree No 

29584 Appl multlay comprs arm/hand 0.35 0.35 0.35 Agree No 

29824 Shoulder arthroscopy/surgery 8.98 8.98 8.98 Interim No 

29826 Shoulder arthroscopy/surgery 3.00 3.00 3.00 Interim No 

29827 Arthroscop rotator cuff repr 15.59 15.59 15.59 Interim No 

29828 Arthroscopy biceps tenodesis 13.16 13.16 13.16 Interim No 

31231 Nasal endoscopy dx 1.10 1.10 1.10 Agree Yes 

31647 Bronchial valve init insert New 4.40 4.40 Agree No 

31648 Bronchial valve addl insert New 4.20 4.20 Agree No 

31649 Bronchial valve remov init New 2.00 1.44 Disagree No 

31651 Bronchial valve remov addl New 1.58 1.58 Agree No 

31660 Bronch thermoplsty 1 lobe New 4.50 4.25 Disagree No 

31661 Bronch thermoplsty 2/> lobes New 5.00 4.50 Disagree No 

32440 Remove lung pneumonectomy 27.28 N/A 27.28 Interim N/A 

32480 Partial removal of lung 25.82 N/A 25.82 Interim N/A 

32482 Bilobectomy 27.44 N/A 27.44 Interim N/A 

32491 Lung volume reduction 25.24 N/A 25.24 Interim N/A 

32551 Insertion of chest tube 3.29 3.50 3.29 Disagree No 

32554 Aspirate pleura w/o imaging New 1.82 1.82 Agree No 

32555 Aspirate pleura w/ imaging New 2.27 2.27 Agree Yes 

32556 Insert cath pleura w/o image New 2.50 2.50 Agree No 

32557 Insert cath pleura w/ image New 3.62 3.12 Disagree Yes 

32663 Thoracoscopy w/lobectomy 24.64 24.64 24.64 Interim No 

32668 Thoracoscopy w/w resect diag 3.00 4.00 3.00 Interim No 

32669 Thoracoscopy remove segment 23.53 23.53 23.53 Interim No 

32670 Thoracoscopy bilobectomy 28.52 28.52 28.52 Interim No 

32671 Thoracoscopy pneumonectomy 31.92 31.92 31.92 Interim No 

32672 Thoracoscopy for lvrs 27.00 27.00 27.00 Interim No 

32673 Thoracoscopy w/thymus resect 21.13 21.13 21.13 Interim No 

32701 Thorax stereo rad targetw/tx New 4.18 4.18 Agree No 

33361 Replace aortic valve perq New 29.50 25.13 Disagree Yes 

33362 Replace aortic valve open New 32.00 27.52 Disagree Yes 

33363 Replace aortic valve open New 33.00 28.50 Disagree Yes 

33364 Replace aortic valve open New 34.87 30.00 Disagree Yes 

33365 Replace aortic valve open New 37.50 33.12 Disagree No 

33367 Replace aortic valve w/byp New 11.88 11.88 Agree No 

33368 Replace aortic valve w/byp New 14.39 14.39 Agree No 

33369 Replace aortic valve w/byp New 19.00 19.00 Agree No 

33405 Replacement of aortic valve 41.32 41.32 41.32 Interim No 

33430 Replacement of mitral valve 50.93 50.93 50.93 Interim No 

33533 Cabg arterial single 33.75 34.98 33.75 Interim No 

33990 Insert vad artery access New 8.15 8.15 Agree No 

33991 Insert vad art&vein access New 11.88 11.88 Agree No 

33992 Remove vad different session New 4.00 4.00 Agree No 

33993 Reposition vad diff session New 4.17 3.51 Disagree No 
471 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time* 

35475 Repair arterial blockage 9.48 6.60 5.75 Disgaree No 

35476 Repair venous blockage 6.03 5.10 4.71 Disagree No 

36221 Place cath thoracic aorta New 4.51 4.17 Disagree Yes 

36222 Place cath carotid/inom art New 6.00 5.53 Disagree Yes 

36223 Place cath carotid/inom art New 6.50 6.00 Disagree Yes 

36224 Place cath carotd art New 7.55 6.50 Disagree Yes 

36225 Place cath subclavian art New 6.50 6.00 Disagree Yes 

36226 Place cath vertebral art New 7.55 6.50 Disagree Yes 

36227 Place cath xtrnl carotid New 2.32 2.09 Disagree No 

36228 Place cath intracranial art New 4.25 4.25 Agree No 

37197 Remove intrvas foreign body New 6.72 6.29 Disagree No 

37211 Thrombolytic art therapy New 8.00 8.00 Agree No 

37212 Thrombolytic venous therapy New 7.06 7.06 Agree No 

37213 Thromblytic art/ven therapy New 5.00 5.00 Agree No 

37214 Cessj therapy cath removal New 3.04 2.74 Disagree No 

38240 Transplt allo hct/donor 2.24 4.00 3.00 Disagree No 

38241 Transplt autol hct/donor 2.24 3.00 3.00 Agree No 

38242 Transplt allo lymphocytes 1.71 2.11 2.11 Agree No 

38243 Transplj hematopoietic boost New 2.13 2.13 Agree No 

40490 Biopsy of lip 1.22 1.22 1.22 Agree No 

43206 Esoph optical endomicroscopy New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

43252 Uppr gi opticl endomicrscopy New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

44705 Prepare fecal microbiota New 1.42 Invalid N/A N/A 

G0455 Fecal microbiota prep instill New N/A 0.97 N/A N/A 

45330 Diagnostic sigmoidoscopy 0.96 0.96 0.96 Agree No 

47562 Laparoscopic cholecystectomy 11.76 11.76 10.47 Disagree Yes 

47563 Laparo cholecystectomy/graph 11.47 11.47 11.47 Agree No 

47600 Removal of gallbladder 17.48 20.00 17.48 Disagree No 

47605 Removal of gallbladder 15.98 21.00 18.48 Disagree No 

49505 Prp i/hern init reduc >5 yr 7.96 7.96 7.96 Agree No 

50590 Fragmenting of kidney stone 9.77 9.77 9.77 Agree No 

52214 Cystoscopy and treatment 3.70 3.50 3.50 Agree No 

52224 Cystoscopy and treatment 3.14 4.05 4.05 Agree Yes 

52234 Cystoscopy and treatment 4.62 4.62 4.62 Agree No 

52235 Cystoscopy and treatment 5.44 5.44 5.44 Agree No 

52240 Cystoscopy and treatment 9.71 8.75 7.50 Disagree No 

52287 Cystoscopy chemodenervation New 3.20 3.20 Agree No 

52351 Cystouretero & or pyeloscope 5.85 5.75 5.75 Agree No 

52352 Cystouretero w/stone remove 6.87 6.75 6.75 Agree No 

52353 Cystouretero w/lithotripsy 7.96 7.88 7.50 Disagree No 

52354 Cystouretero w/biopsy 7.33 8.58 8.00 Disagree No 

52355 Cystouretero w/excise tumor 8.81 10.00 9.00 Disagree No 

53850 Prostatic microwave thermotx 10.08 10.08 10.08 Agree No 

60520 Removal of thymus gland 17.16 N/A 17.16 Interim N/A 

60521 Removal of thymus gland 19.18 N/A 19.18 Interim N/A 

60522 Removal of thymus gland 23.48 N/A 23.48 Interim N/A 

64450 N block other peripheral 1.27 0.75 0.75 Agree No 

64612 Destroy nerve face muscle 2.01 1.41 1.41 Interim No 

64613 Destroy nerve neck muscle 2.01 N/A 2.01 Interim N/A 
472 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time* 

64614 Destroy nerve extrem musc 2.20 N/A 2.20 Interim N/A 

64615 Chemodenerv musc migraine New 1.85 1.85 Interim No 

64640 Injection treatment of nerve 2.81 1.23 1.23 Agree No 

65222 Remove foreign body from eye 0.93 0.93 0.84 Disagree Yes 

65800 Drainage of eye 1.91 1.53 1.53 Agree No 

66982 Cataract surgery complex 15.02 11.08 11.08 Agree No 

66984 Cataract surg w/iol 1 stage 10.52 8.52 8.52 Agree No 

67028 Injection eye drug 1.44 1.44 1.44 Agree No 

67810 Biopsy eyelid & lid margin 1.48 1.18 1.18 Agree Yes 

68200 Treat eyelid by injection 0.49 0.49 0.49 Agree Yes 

69200 Clear outer ear canal 0.77 0.77 0.77 Agree Yes 

69433 Create eardrum opening 1.57 1.57 1.57 Agree No 

72040 X-ray exam neck spine 3/<vws 0.22 0.22 0.22 Agree No 

72050 X-ray exam neck spine 4/5vws 0.31 0.31 0.31 Agree No 

72052 X-ray exam neck spine 6/>vws 0.36 0.36 0.36 Agree No 

72191 Ct angiograph pelv w/o&w/dye 1.81 N/A 1.81 Interim N/A 

73221 Mri joint upr extrem w/o dye 1.35 1.35 1.35 Agree No 

73721 Mri jnt of lwr extre w/o dye 1.35 1.35 1.35 Agree No 

74170 Ct abdomen w/o & w/dye 1.40 1.40 1.40 Agree No 

74174 Ct angio abd&pelv w/o&w/dye 2.20 2.20 2.20 Interim No 

74175 Ct angio abdom w/o & w/dye 1.90 N/A 1.90 Interim N/A 

74247 Contrst x-ray uppr gi tract 0.69 0.69 0.69 Agree No 

74280 Contrast x-ray exam of colon 0.99 0.99 0.99 Agree No 

74400 Contrst x-ray urinary tract 0.49 0.49 0.49 Agree No 

75896 X-rays transcath therapy 

1.31 (PC), 

Contractor 

Priced (TC) 

Contractor 

Priced 

1.31 (PC), 

Contractor 

Priced (TC) Interim N/A 

75898 Follow-up angiography 

1.65 (PC), 

Contractor 

Priced (TC) 

Contractor 

Priced 

1.65 (PC), 

Contractor 

Priced (TC) Interim N/A 

76830 Transvaginal us non-ob 0.69 0.69 0.69 Agree Yes 

76872 Us transrectal 0.69 0.69 0.69 Agree No 

77001 Fluoroguide for vein device 0.38 N/A 0.38 Interim N/A 

77002 Needle localization by xray 0.54 N/A 0.54 Interim N/A 

77003 Fluoroguide for spine inject 0.60 0.60 0.60 Interim No 

77080 Dxa bone density axial 0.20 0.20 0.20 Agree No 

77082 Dxa bone density vert fx 0.17 0.17 0.17 Agree No 

77301 Radiotherapy dose plan imrt 7.99 7.99 7.99 Agree Yes 

78012 Thyroid uptake measurement New 0.19 0.19 Agree No 

78013 Thyroid imaging w/blood flow New 0.37 0.37 Agree No 

78014 Thyroid imaging w/blood flow New 0.50 0.50 Agree No 

78070 Parathyroid planar imaging 0.82 0.80 0.80 Agree No 

78071 Parathyrd planar w/wo subtrj New 1.20 1.20 Agree No 

78072 Parathyrd planar w/spect&ct New 1.60 1.60 Agree No 

78278 Acute gi blood loss imaging 0.99 0.99 0.99 Agree No 

78472 Gated heart planar single 0.98 0.98 0.98 Agree No 

G0452 Molecular pathology interpr New N/A 0.37 N/A N/A 

86153 Cell enumeration phys interp New 0.69 0.69 Agree Yes 

88120 Cytp urne 3-5 probes ea spec 1.20 1.20 1.20 Interim No 

88121 Cytp urine 3-5 probes cmptr 1.00 1.00 1.00 Interim No 

88312 Special stains group 1 0.54 0.54 0.54 Agree No 
473 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time* 

88365 Insitu hybridization (fish) 1.20 N/A 1.20 Interim N/A 

88367 Insitu hybridization auto 1.30 N/A 1.30 Interim N/A 

88368 Insitu hybridization manual 1.40 N/A 1.40 Interim N/A 

88375 Optical endomicroscpy interp New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

G0416 Sat biopsy 10-20 3.09 N/A 3.09 N/A N/A 

90785 Psytx complex interactive New 

Contractor 

Priced 0.11 Interim N/A 

90791 Psych diagnostic evaluation New 3.00 2.80 Interim No 

90792 Psych diag eval w/med srvcs New 3.25 2.96 Interim No 

90832 Psytx pt&/family 30 minutes New 1.50 1.25 Interim No 

90833 Psytx pt&/fam w/e&m 30 min New 1.50 0.98 Interim No 

90834 Psytx pt&/family 45 minutes New 2.00 1.89 Interim No 

90836 Psytx pt&/fam w/e&m 45 min New 1.90 1.60 Interim No 

90837 Psytx pt&/family 60 minutes New 3.00 2.83 Interim No 

90838 Psytx pt&/fam w/e&m 60 min New 2.50 2.56 Interim No 

90839 Psytx crisis initial 60 min New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

90840 Psytx crisis ea addl 30 min New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

90845 Psychoanalysis 1.79 2.10 1.79 Interim Yes 

90846 Family psytx w/o patient 1.83 2.40 1.83 Interim Yes 

90847 Family psytx w/patient 2.21 2.50 2.21 Interim Yes 

90853 Group psychotherapy 0.59 0.59 0.59 Interim Yes 

90863 Pharmacologic mgmt w/psytx New 

Contractor 

Priced Invalid N/A N/A 

91112 Gi wireless capsule measure New 2.10 2.10 Agree No 

92083 Visual field examination(s) 0.50 0.50 0.50 Agree No 

92100 Serial tonometry exam(s) 0.92 0.61 0.61 Agree No 

92235 Eye exam with photos 0.81 0.81 0.81 Agree No 

92286 Internal eye photography 0.66 0.40 0.40 Agree No 

92920 Prq cardiac angioplast 1 art New 9.00 10.10 Disagree Yes 

92921 Prq cardiac angio addl art New 4.00 Bundled N/A N/A 

92924 Prq card angio/athrect 1 art New 11.00 11.99 Disagree Yes 

92925 Prq card angio/athrect addl New 5.00 Bundled N/A N/A 

92928 Prq card stent w/angio 1 vsl New 10.49 11.21 Disagree Yes 

92929 Prq card stent w/angio addl New 4.44 Bundled N/A N/A 

92933 Prq card stent/ath/angio New 12.32 12.54 Disagree Yes 

92934 Prq card stent/ath/angio New 5.50 Bundled N/A N/A 

92937 Prq revasc byp graft 1 vsl New 10.49 11.20 Disagree Yes 

92938 Prq revasc byp graft addl New 6.00 Bundled N/A N/A 

92941 Prq card revasc mi 1 vsl New 12.32 12.56 Disagree No 

92943 Prq card revasc chronic 1vsl New 12.32 12.56 Disagree Yes 

92944 Prq card revasc chronic addl New 6.00 Bundled N/A N/A 

93015 Cardiovascular stress test 0.75 0.75 0.75 Agree No 

93016 Cardiovascular stress test 0.45 0.45 0.45 Agree No 

93018 Cardiovascular stress test 0.30 0.30 0.30 Agree No 

93308 Tte f-up or lmtd 0.53 0.53 0.53 Agree No 

93653 Ep & ablate supravent arrhyt New 15.00 15.00 Agree No 

93654 Ep & ablate ventric tachy New 20.00 20.00 Agree No 

93655 Ablate arrhythmia add on New 9.00 7.50 Disagree No 
474 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time* 

93656 Tx atrial fib pulm vein isol New 20.02 20.02 Agree No 

93657 Tx l/r atrial fib addl New 10.00 7.50 Disagree No 

93925 Lower extremity study 0.58 0.90 0.80 Disagree Yes 

93926 Lower extremity study 0.39 0.70 0.50 Disagree Yes 

93970 Extremity study 0.68 0.70 0.70 Agree No 

93971 Extremity study 0.45 0.45 0.45 Agree No 

95017 Perq & icut allg test venoms New 0.07 0.07 Agree No 

95018 Perq&ic allg test drugs/boil New 0.14 0.14 Agree No 

95076 Ingest challenge ini 120 min New 1.50 1.50 Agree No 

95079 Ingest challenge addl 60 min New 1.38 1.38 Agree No 

95782 Polysom <6 yrs 4/> paramtrs New 3.00 2.60 Disagree No 

95783 Polysom <6 yrs cpap/bilvl New 3.20 2.83 Disagree No 

95860 Muscle test one limb 0.96 0.96 0.96 Agree No 

95861 Muscle test 2 limbs 1.54 1.54 1.54 Agree No 

95863 Muscle test 3 limbs 1.87 1.87 1.87 Agree No 

95864 Muscle test 4 limbs 1.99 1.99 1.99 Agree No 

95865 Muscle test larynx 1.57 1.57 1.57 Agree No 

95866 Muscle test hemidiaphragm 1.25 1.25 1.25 Agree No 

95867 Muscle test cran nerv unilat 0.79 0.79 0.79 Agree No 

95868 Muscle test cran nerve bilat 1.18 1.18 1.18 Agree No 

95869 Muscle test thor paraspinal 0.37 0.37 0.37 Agree No 

95870 Muscle test nonparaspinal 0.37 0.37 0.37 Agree No 

95885 Musc tst done w/nerv tst lim 0.35 0.35 0.35 Agree No 

95886 Musc test done w/n test comp 0.92 0.92 0.70 Disagree No 

95887 Musc tst done w/n tst nonext 0.73 0.73 0.47 Disagree No 

95905 Motor &/ sens nrve cndj test 0.05 0.05 0.05 Agree No 

95907 Motor&/sens 1-2 nrv cndj tst New 1.00 1.00 Agree No 

95908 Motor&/sens 3-4 nrv cndj tst New 1.37 1.25 Disagree Yes 

95909 Motor&/sens 5-6 nrv cndj tst New 1.77 1.50 Disagree Yes 

95910 Motor&sens 7-8 nrv cndj test New 2.80 2.00 Disagree No 

95911 Motor&sen 9-10 nrv cndj test New 3.34 2.50 Disagree No 

95912 Motor&sen 11-12 nrv cnd test New 4.00 3.00 Disagree No 

95913 Motor&sens 13/> nrv cnd test New 4.20 3.56 Disagree No 

95921 Autonomic nrv parasym inervj 0.90 0.90 0.90 Agree No 

95922 Autonomic nrv adrenrg inervj 0.96 0.96 0.96 Agree No 

95923 Autonomic nrv syst funj test 0.90 0.90 0.90 Agree No 

95924 Ans parasymp & symp w/tilt New 1.73 1.73 Agree No 

95925 Somatosensory testing 0.54 N/A 0.54 Interim N/A 

95926 Somatosensory testing 0.54 N/A 0.54 Interim N/A 

95928 C motor evoked uppr limbs 1.50 N/A 1.50 Interim N/A 

95929 C motor evoked lwr limbs 1.50 N/A 1.50 Interim N/A 

95938 Somatosensory testing 0.86 0.86 0.86 Interim No 

95939 C motor evoked upr&lwr limbs 2.25 2.25 2.25 Interim No 

95940 Ionm in operatng room 15 min New 0.60 0.60 Agree No 

95941 Ionm remote/>1 pt or per hr New 2.00 Invalid N/A N/A 

G0453 Cont intraop neuro monitor New N/A 0.50 N/A N/A 

95943 Parasymp&symp hrt rate test New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

96920 Laser tx skin < 250 sq cm 1.15 1.15 1.15 Agree No 

96921 Laser tx skin 250-500 sq cm 1.17 1.30 1.30 Agree No 

96922 Laser tx skin >500 sq cm 2.10 2.10 2.10 Agree No 
475 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU* 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time* 

97150 Group therapeutic procedures 0.27 0.29 0.29 Agree No 

G0456 Neg pre wound <=50 sq cm New N/A 

Contractor 

Priced N/A N/A 

G0457 Neg pres wound >50 sq cm New N/A 

Contractor 

Priced N/A N/A 

99485 Suprv interfacilty transport New 1.50 Bundled N/A N/A 

99486 Suprv interfac trnsport addl New 1.30 Bundled N/A N/A 

99487 Cmplx chron care w/o pt vsit New 1.00 Bundled N/A N/A 

99488 Cmplx chron care w/ pt vsit New 2.50 Bundled N/A N/A 

99489 Complx chron care addl30 min New 0.50 Bundled N/A N/A 

99495 Trans care mgmt 14 day disch New 2.11 2.11 Agree No 

99496 Trans care mgmt 7 day disch New 3.05 3.05 Agree Yes 

G0454 MD document visit by NPP New N/A 0.18 N/A N/A 

*Some of the CPT codes in this table were first reviewed for CY2011 and/or CY2012 and we held them interim 

pending the receipt of additional information. As a result, for some CPT codes, the AMA RUC/HCPAC 

recommendation reflects the CY2011 or CY2012 AMA RUC/HCPAC recommendation. For the majority of CPT 

codes in this table, the values reflect the CY 2013 AMA RUC/HCPAC recommendation. Where N/A is listed, 

either we did not receive a recommendation from the AMA RUC/HCPAC, the code is not nationally priced, or the 

code is not separately payable/payable. 

(1) Integumentary System: Skin, Subcutaneous, and Accessory Structures 

TABLE 31: Integumentary System: Skin, Subcutaneous, and Accessory Structures 

HCPCS 

Code Short Descriptor 

CY 2012 

Work 

RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

10120 Remove foreign body 1.25 1.25 1.22 Disagree Yes 

11055 Trim skin lesion 0.43 0.43 0.35 Disagree Yes 

11056 Trim skin lesions 2 to 4 0.50 0.50 0.50 Agree No 

11057 Trim skin lesions over 4 0.79 0.79 0.65 Disagree Yes 

11300 Shave skin lesion 0.5 cm/< 0.51 0.60 0.60 Agree No 

11301 Shave skin lesion 0.6-1.0 cm 0.85 0.90 0.90 Agree No 

11302 Shave skin lesion 1.1-2.0 cm 1.05 1.16 1.05 Disagree No 

11303 Shave skin lesion >2.0 cm 1.24 1.25 1.25 Agree No 

11305 Shave skin lesion 0.5 cm/< 0.67 0.80 0.80 Agree No 

11306 Shave skin lesion 0.6-1.0 cm 0.99 1.18 0.96 Disagree No 

11307 Shave skin lesion 1.1-2.0 cm 1.14 1.20 1.20 Agree No 

11308 Shave skin lesion >2.0 cm 1.41 1.46 1.46 Agree No 

11310 Shave skin lesion 0.5 cm/< 0.73 1.19 0.80 Disagree No 

11311 Shave skin lesion 0.6-1.0 cm 1.05 1.43 1.10 Disagree No 

11312 Shave skin lesion 1.1-2.0 cm 1.20 1.80 1.30 Disagree No 

11313 Shave skin lesion >2.0 cm 1.62 2.00 1.68 Disagree No 

 CPT code 10120 was identified as potentially misvalued using the Harvard-valued-- 

Utilization over 30,000 screen. 
476 

After clinical review of CPT code 10120 (Incision and removal of foreign body, 

subcutaneous tissues; simple) we believe that the specialty society survey 25th percentile work 

RVU of 1.22 accurately reflects the work of this service. Medicare claims data from 2011 

indicate that this service is typically furnished to the beneficiary by the provider on the same day 

as an E/M visit. We believe that some of the activities furnished during the pre- and post-service 

period of the procedure code and the E/M visit overlap. After review, we believe that the AMA 

RUC appropriately accounted for this overlap in its recommendation of pre-service time, but 

failed to account for the overlap in post-service time. To account for this overlap, we reduced 

the AMA RUC-recommended post-service time for this procedure by one-third, from 5 minutes 

to 3 minutes. We believe that 3 minutes accurately reflects the post-service time involved in 

furnishing this procedure and is more in line with similar services. Because we reduced the 

AMA RUC-recommended procedure time for this code by 2 minutes, given a standard postservice work intensity of .0224 RVUs per minute, we believe that the specialty society survey 

25th percentile work RVU of 1.22 is more appropriate for this service than the AMA RUCrecommended work RVU of 1.25. In sum, on an interim final basis for CY 2013, we are 

assigning a work RVU of 1.22 to CPT code 10120, with a refinement to the AMA RUCrecommended time. A complete list of the interim final times associated with this procedure is 

available on the CMS website at www.cms.gov/physicianfeesched/. 

 CPT code 11056 was identified for review because it is on the multispecialty points of 

comparison (MPC) list—a list of CPT codes commonly used as reference codes in the valuation 

of other codes. 

We reviewed CPT code 11056 (Paring or cutting of benign hyperkeratotic lesion (eg, 

corn or callus); 2 to 4 lesions) in CY 2012, and accepted the HCPAC-recommended work RVU 

of 0.50, the specialty society survey 25th percentile value, on an interim basis for CY 2012. At 
477 

that time, we requested that the specialty society re-review CPT code 11056 along with related 

CPT codes 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single 

lesion) and 11057 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more 

than 4 lesions) to ensure appropriate relativity between the three services (76 FR 73190). The 

specialty society declined to survey CPT codes 11055 or 11057, and, in its recommendations to 

CMS, the AMA RUC noted that there are no apparent rank order anomalies among the three 

services. 

For CY 2013, we reviewed CPT codes 11055, 11056, and 11057 together. After clinical 

review, we did not have evidence that the relativity of the services to each other had changed 

over time, and since the HCPAC and CMS agreed that the work associated with CPT code 11056 

had decreased, we believe it is appropriate to reduce the work of CPT codes 11055 and 11057 

relative to the decrease in work of CPT code 11056. In CY 2012, the HCPAC recommended 

that CPT code 11056 be reduced from a CY 2011 work RVU of 0.61 to a CY 2012 work RVU of 

0.50. Therefore, to maintain relativity, we are reducing CPT code 11055 from a work RVU of 

0.43 to a work RVU of 0.35, and we are reducing CPT code 11057 from a work RVU of 0.79 to 

a work RVU of 0.65 on an interim final basis for CY 2013. 

 Regarding physician time, CPT codes 11055 and 11057 currently (CY 2012) are assigned 

2 minutes of pre-service time and 5 minutes of post-service time. Before it was reviewed by the 

HCPAC for CY 2012, CPT code 11056 was also assigned 2 minutes of pre-service time and 5 

minutes of post service time. Through its review, the HCPAC recommended adjusting the time 

of CPT code to include 7 minutes of pre-service time and 2 minutes of post-service time, and we 

agreed. We believe that these are also the appropriate pre- and post- service times for CPT codes 

11055 and 11057. On an interim final basis for CY 2013, we are refining the times of CPT 

codes 11055 and 11057 to 7 minutes of pre-service time and 2 minutes of post-service time. We 
478 

believe the current intra-service times of 4 minutes for CPT code 11055 and 15 minutes for CPT 

code 11057 remain appropriate. A complete list of the interim final times associated with these 

procedures is available on the CMS website at www.cms.gov/physicianfeesched/. 

 For CY 2013 CPT codes 11300 through 11313, which describe procedures related to the 

shaving of epidermal or dermal lesions, were surveyed by their related specialty society to 

establish current relative values for these procedures. The specialty society and the AMA RUC 

reviewed the survey results for CPT codes 11300 through 11313 and recommended the survey 

25th percentile work RVU for nearly all the codes in the family. After clinical review, we believe 

that the survey 25th percentile for all the codes in the family reflects the appropriate relativity of 

the services both within the family, as well as relative to other services on the PFS. On an 

interim final basis for CY 2013 we are assigning a work RVU of 0.60 for CPT code 11300 

(Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm 

or less); a work RVU of 0.90 for CPT code 11301 (Shaving of epidermal or dermal lesion, single 

lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm); a work RVU of 1.05 for CPT code 

11302 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 

1.1 to 2.0 cm); a work RVU of 1.25 for CPT code 11303 (Shaving of epidermal or dermal lesion, 

single lesion, trunk, arms or legs; lesion diameter over 2.0 cm); a work RVU of 0.80 for CPT 

code 11305 (Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, 

genitalia; lesion diameter 0.5 cm or less); a work RVU of 0.96 for CPT code 11306 (Shaving of 

epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 

to 1.0 cm); a work RVU of 1.20 for CPT code 11307 (Shaving of epidermal or dermal lesion, 

single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm); a work RVU of 

1.46 for CPT code 11308 (Shaving of epidermal or dermal lesion, single lesion, scalp, neck, 

hands, feet, genitalia; lesion diameter over 2.0 cm); a work RVU of 0.80 for CPT code 11310 
479 

(Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous 

membrane; lesion diameter 0.5 cm or less); a work RVU of 1.10 for CPT code 11311 (Shaving 

of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; 

lesion diameter 0.6 to 1.0 cm); a work RVU of 1.30 for CPT code 11312 (Shaving of epidermal 

or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 

1.1 to 2.0 cm); and a work RVU of 1.68 for CPT code 11313 (Shaving of epidermal or dermal 

lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 

cm). 

(2) Integumentary System: Repair (Closure) 

TABLE 32: Integumentary System: Repair (Closure) 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

12035 Intmd wnd repair s/a/t/ext 3.50 3.60 3.50 Disagree No 

12036 Intmd wnd repair s/a/t/ext 4.23 4.50 4.23 Disagree Yes 

12037 Intmd wnd repair s/tr/ext 5.00 5.25 5.00 Disagree No 

12045 

Intmd wnd repair nhf/genit 3.75 3.90 3.75 Disagree Yes 

12046 

Intmd wnd repair nhf/genit 4.30 4.60 4.30 Disagree Yes 

12047 

Intmd wnd repair nhf/genit 4.95 5.50 4.95 Disagree Yes 

12055 Intmd wnd repair face/mm 4.50 4.65 4.50 Disagree Yes 

12056 Intmd wnd repair face/mm 5.30 5.50 5.30 Disagree Yes 

12057 Intmd wnd repair face/mm 6.00 6.20 6.00 Disagree Yes 

13100 

Cmplx rpr trunk 1.1-2.5 

cm 3.17 3.00 3.00 Agree Yes 

13101 

Cmplx rpr trunk 2.6-7.5 

cm 3.96 3.50 3.50 Agree Yes 

13102 

Cmplx rpr trunk addl 

5cm/< 1.24 1.24 1.24 Agree No 

13120 Cmplx rpr s/a/l 1.1-2.5 cm 3.35 3.23 3.23 Agree Yes 

13121 Cmplx rpr s/a/l 2.6-7.5 cm 4.42 4.00 4.00 Agree Yes 

13122 

Cmplx rpr s/a/l addl 5 

cm/> 1.44 1.44 1.44 Agree No 

13131 

Cmplx rpr 

f/c/c/m/n/ax/g/h/f 3.83 3.73 3.73 Agree Yes 

13132 

Cmplx rpr 

f/c/c/m/n/ax/g/h/f 6.58 4.78 4.78 Agree Yes 

13133 

Cmplx rpr 

f/c/c/m/n/ax/g/h/f 2.19 2.19 2.19 Agree No 
480 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

13150 Cmplx rpr e/n/e/l 1.0 cm/< 3.85 N/A 3.58 N/A N/A 

13151 

Cmplx rpr e/n/e/l 1.1-2.5 

cm 4.49 4.34 4.34 Agree Yes 

13152 

Cmplx rpr e/n/e/l 2.6-7.5 

cm 6.37 5.34 4.90 Disagree Yes 

13153 

Cmplx rpr e/n/e/l addl 

5cm/< 2.38 2.38 2.38 Agree No 

 CPT codes 12031, 12051, and 13101 were identified as potentially misvalued using the 

Harvard-valued—Utilization over 30,000 screen. As a result of this screen, in the Fourth FiveYear Review of Work, we reviewed the family of intermediate wound repair CPT codes (12031 

through 12057), along with two complex wound repair codes (13100 and 13101). 

In the Fourth Five-Year Review, we disagreed with the AMA RUC-recommended work 

RVUs for the larger of the intermediate wound repair codes: CPT codes 12035 (Repair, 

intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 

cm to 20.0 cm), 12036 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities 

(excluding hands and feet); 20.1 cm to 30.0 cm), 12037 (Repair, intermediate, wounds of scalp, 

axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm), 12045 (Repair, 

intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm), 12046 

(Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm), 

12047 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 

cm), 12055 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous 

membranes; 12.6 cm to 20.0 cm), 12056 (Repair, intermediate, wounds of face, ears, eyelids, 

nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm) and 12057 (Repair, intermediate, 

wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm) (76 FR 32431 

through 32432). As discussed in the CY 2012 PFS final rule with comment period, after review 
481 

by the refinement panel, we maintained the proposed RVUs published in the Fourth Five-Year 

Review of Work (76 FR 73113 through 73114). We stated that we would hold these codes 

interim for another year rather than finalizing the codes, so that we could review these larger 

intermediate wound repair codes alongside the family complex wound repair codes, which we 

anticipated reviewing for CY 2013. 

 In the Fourth Five-Year Review of Work, we stated that we would maintain the current 

(CY 2011) work RVUs and times for complex wound repair CPT codes 13100 (Repair, complex, 

trunk; 1.1 cm to 2.5 cm) and 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm), and requested 

that the AMA RUC review the entire set of codes in the complex wound repair family together to 

assess the appropriate gradation of the work RVUs in the family (76 FR 32434 through 32435). 

 For CY 2013, we received new recommendations from the AMA RUC on CPT codes 

13100 and 13101, as well as recommendations on the rest of the CPT codes in the complex 

wound repair family CPT codes 13100 through 13102, 13120 through 13122, 13131 through 

13133, and 13150 through 13153, excluding CPT code 13150 (Repair, complex, eyelids, nose, 

ears and/or lips; 1.0 cm or less), which the AMA RUC referred to the CPT Editorial Panel for 

deletion in CY 2014. We agree with the AMA RUC recommendations for all the codes in the 

complex wound repair family, except one. After reviewing CPT code 13152 (Repair, complex, 

eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm), we believe that the AMA RUC-recommended 

work RVU of 5.34 is too high relative to similar CPT code 13132 (Repair, complex, forehead, 

cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm ), which has an 

AMA RUC-recommended work RVU of 4.78, and CPT code 13151 (Repair, complex, eyelids, 

nose, ears and/or lips; 1.1 cm to 2.5 cm), which has an AMA RUC-recommended work RVU of 

4.34. We believe that the specialty society 25th percentile work RVU of 4.90 more appropriately 

reflects the relative work involved in furnishing this service. On an interim final basis for CY 
482 

2013, we are assigning a work RVU of 4.90 to CPT code 13152. 

 The AMA RUC referred CPT code 13150 to the CPT Editorial Panel for deletion in CY 

2014. Because of this, the AMA RUC did not review this service with the other codes in this 

family. For CY 2013, we believe it is appropriate to reduce the work RVU of CPT code 13150 

proportionate to the other services in the family, so that the value of CPT code 13150 maintains 

appropriate proportionate rank order for CY 2013. For CY 2013, the work RVUs for the 12 

other CPT codes in this family are being reduced, on average, to 93 percent of their CY 2012 

value. Applying that reduction to CPT code 13150 results in a CY 2013 work RVU of 3.58, 

which we believe appropriately reflects the work associated with this procedure. Therefore, on 

an interim final basis for CY 2013, we are assigning a work RVU of 3.58 to CPT code 13150. In 

addition to these work RVU changes, we made small refinements to the AMA RUCrecommended times for many of the CPT codes in this family to ensure consistency between 

congruent services. A list of the interim final times associated with these procedures is available 

on the CMS website at www.cms.gov/physicianfeesched/. 

 After reviewing the family of complex wound repair CPT codes for CY 2013, we rereviewed the larger intermediate wound repair codes that we had been holding interim since the 

Fourth Five-Year Review of Work. We reviewed CPT codes 12035 through 12037, 12045 

through 12047, and 12055 through 12057 in relation to each other, the other intermediate wound 

repair CPT codes (12031 through 12034, 12041 through 12044, and 12051 through 12054) , the 

complex wound repair CPT codes, and other PFS services, and we continue to believe that the 

current interim values are appropriate relative to the other services. Therefore, on an interim 

final basis for CY 2013, are maintaining the following current (CY 2012) work values: a work 

RVU of 3.50 for CPT code 12035; a work RVU of 4.23 for CPT code 12036; a work RVU of 

5.00 for CPT code 12037; a work RVU of 3.75 for CPT code 12045; a work RVU of 4.30 for 
483 

CPT code 12046; a work RVU of 4.95 for CPT code 12047; a work RVU of 4.50 for CPT code 

12055; a work RVU of 5.30 for CPT code 12056, and a work RVU of 6.00 for CPT code 12057. 

 We also believe that it is appropriate to maintain the current (CY 2012) times for these 

procedures, as we believe that they reflect the time involved in furnishing these procedures and 

that they are well-aligned with each other and with the simple and complex wound repair CPT 

codes. One exception to this is CPT code 12045 (Repair, intermediate, wounds of neck, hands, 

feet and/or external genitalia; 12.6 cm to 20.0 cm), which includes 10 minutes of pre-service 

evaluation time, while CPT codes 12046 (Repair, intermediate, wounds of neck, hands, feet 

and/or external genitalia; 20.1 cm to 30.0 cm) and 12047 (Repair, intermediate, wounds of neck, 

hands, feet and/or external genitalia; over 30.0 cm) both include 9 minutes of pre-service 

evaluation time. We believe it is appropriate to reduce the pre-service evaluation time of CPT 

code 12045 to match the pre-service evaluation time of CPT codes 12046 and 12047. Therefore, 

for CY 2013, we are assigning an interim final pre-service evaluation time of 9 minutes to CPT 

12045. A complete list of the interim final times associated with these procedures is available on 

the CMS website at www.cms.gov/physicianfeesched/. 

 (3) Musculoskeletal System: Spine (Vertebral Column) 

TABLE 33: Musculoskeletal System: Spine (Vertebral Column) 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

22586 Prescrl fuse w/ instr l5/s1 New N/A 28.12 N/A N/A 

 For CY 2013, the CPT Editorial Panel created CPT code 22586 (Arthrodesis, pre-sacral 

interbody technique, including disc space preparation, discectomy, with posterior 

instrumentation, with image guidance, includes bone graft when performed, l5-s1 interspace). 

The specialty societies related to this CPT code that participate in the AMA RUC declined to 
484 

survey this new CPT code and the AMA RUC issued no work RVU recommendation to us for 

this service for CY 2013. A related specialty society that does not participate in the AMA RUC 

conducted a survey of its members regarding the physician work and time associated with this 

procedure and submitted a recommendation to CMS. In determining the appropriate value for 

this CPT code, we reviewed the survey results and recommendations submitted to us, literature 

on the procedure, and the Medicare claims data. Ultimately, we used a building block approach 

based on Medicare 2011 same day billing combinations to develop the interim final value for this 

procedure. 

New CPT code 22586 is a bundled lumbar arthrodesis procedure that includes grafting, 

posterior instrumentation, and fixation. To value this service we used CPT code 22558 

(Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace 

(other than for decompression); lumbar) as a reference service, as it is a similar procedure but it 

does not include additional grafting, instrumentation, and fixation. To assess the appropriate 

relative work increase from unbundled CPT code 22558 to the new bundled CPT code 22586, we 

used Medicare claims data to assess which grafting, instrumentation, and fixation services are 

commonly billed with CPT code 22558 and how often. We used those data to create a utilization 

weighted work RVU for the grafting component of CPT code 22586, the instrumentation 

component of the 22586, and the fixation component of 22586. We added those components to 

the base service of CPT code 22558 to create a work RVU of 28.12. We believe this work RVU 

reflects the appropriate incremental difference in work between the base reference CPT code 

22558 and new CPT code 22586. For CY 2013 we are assigning a work RVU of 28.12 to CPT 

code 22586 for CY 2013, and we request additional public input on the appropriate valuation of 

this service. 

We assigned CPT code 22586 a global period of 90-days, which is consistent with similar 
485 

service. Regarding physician time for CPT code 22586, after reviewing the physician time and 

post-operative visits for similar services, we believe this service includes 40 minutes of preservice evaluation time, 20 minutes of pre-service positioning time, 20 minutes of pre-service 

scrub, dress and wait time, 180 minutes of intra-service time, and 30 minutes of immediate postservice time. In the post-operative period, we believe the typical case for this service includes 2 

CPT code 99231 visits, 1 CPT code 99323 visit, 1 CPT code 99238 visit, and 4 CPT code 99213 

visits. A list of the interim final times associated with this procedure is available on the CMS 

website at www.cms.gov/physicianfeesched / 

(4) Musculoskeletal System: Shoulder 

TABLE 34: Musculoskeletal System: Shoulder 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

23350 

Injection for shoulder xray 1.00 1.00 1.00 Agree No 

23331 

Remove shoulder foreign 

body 7.63 7.63 7.63 Interim No 

23332 

Remove shoulder foreign 

body 12.37 12.37 12.37 Interim No 

23472 Reconstruct shoulder joint 22.65 22.13 22.13 Interim No 

23473 

Revis reconst shoulder 

joint New 25.00 25.00 Interim No 

23474 

Revis reconst shoulder 

joint New 27.21 27.21 Interim No 

23600 Treat humerus fracture 3.11 3.00 3.00 Agree No 

For CY 2013, the CPT Editorial Panel created two new CPT codes for total shoulder 

revision, CPT code 23473 (Revision of total shoulder arthroplasty, including allograft when 

performed; humeral or glenoid component) and 23474 (Revision of total shoulder arthroplasty, 

including allograft when performed; humeral and glenoid component). The specialty society 

surveyed these codes along with the other codes in this family, which include CPT codes 23331 

(Removal of foreign body, shoulder; deep (eg, neer hemiarthroplasty removal)), 23332 (Removal 
486 

of foreign body, shoulder; complicated (eg, total shoulder)), and 23472 (Arthroplasty, 

glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total 

shoulder))). After reviewing the survey responses, the AMA RUC concluded that the descriptors 

for CPT codes 23331 and 23332 needed revision. The AMA RUC referred CPT codes 23331 

and 23332 to the CPT Editorial Panel for further clarification and recommended that we maintain 

the current (CY 2012) work RVUs of 7.63 for CPT code 23331, and 12.37 for CPT code 23332 

for CY 2013. The AMA RUC recommended the survey 25th percentile work RVU for the three 

other services in this family: a work RVU of 22.13 for CPT code 23472; a work RVU of 25.00 

for CPT code 23473; and a work RVU of 27.21 for CPT code 23474. We are accepting these 

work RVUs on an interim basis for CY 2013, and will review CPT codes 23472, 23473, and 

23474 alongside CPT codes 23331 and 23332 after the codes descriptors are changed, to ensure 

consistency within this family of CPT codes. 

(5) Musculoskeletal System: Humerus (Upper Arm) and Elbow 

TABLE 35: Musculoskeletal System: Humerus (Upper Arm) and Elbow 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

24160 

Remove elbow joint 

implant 8.00 8.00 8.00 Interim No 

24363 Replace elbow joint 22.65 22.00 22.00 Interim Yes 

24370 Revise reconst elbow joint New 23.55 23.55 Interim No 

24371 Revise reconst elbow joint New 27.50 27.50 Interim No 

For CY 2013, the CPT Editorial Panel created two new CPT codes for revision of a total 

elbow arthroplasty, CPT code 24370 (Revision of total elbow arthroplasty, including allograft 

when performed; humeral or ulnar component) and CPT code 24371 (Revision of total elbow 

arthroplasty, including allograft when performed; humeral and ulnar component). The specialty 

society surveyed these CPT codes along with component CPT codes 24160 (Implant removal; 
487 

elbow joint) and 24363 (Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic 

replacement (eg, total elbow)). After reviewing the survey responses, the AMA RUC concluded 

that the descriptor for CPT code 24160 needs revision. The AMA RUC referred CPT code 

24160 to the CPT Editorial Panel for revision of the descriptor and recommended that we 

maintain the current (CY 2012) work RVU of 8.00 for CPT code 24160 for CY 2013. The AMA 

RUC recommended the survey 25th percentile work RVU for the three other services in this 

family: a work RVU of 22.00 for CPT code 24363; a work RVU of 23.55 for CPT code 24370; 

and a work RVU of 27.50 for CPT code 24371. We are accepting these work RVUs on an 

interim basis for CY 2013, and will review CPT codes 24363, 24370, and 24371 alongside CPT 

code 24160 after the code descriptor is changed, to ensure consistency within this family of CPT 

codes. For CY 2013, we are refining the AMA RUC-recommended post-service time of CPT 

code 24363 to 20 minutes, from 30 minutes, to match the post-service times of CPT code 24370 

and 24371. A complete list of the interim final times associated with these procedures is 

available on the CMS website at www.cms.gov/physicianfeesched/. 

 

(6) Musculoskeletal System: Application of Casts and Strapping 

TABLE 36: Musculoskeletal System: Application of Casts and Strapping 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

29075 

Application of forearm 

cast 0.77 0.77 0.77 Agree No 

29581 

Apply multlay comprs lwr 

leg 0.25 0.60 0.25 Disagree No 

29582 

Apply multlay comprs upr 

leg 0.35 0.35 0.35 Agree No 

29583 

Apply multlay comprs upr 

arm 0.25 0.25 0.25 Agree No 

29584 

Appl multlay comprs 

arm/hand 0.35 0.35 0.35 Agree No 
488 

For CY 2013, the CPT Editorial Panel revised the descriptor of CPT code 29581, and 

created CPT codes 29582, 29583, and 29584 to describe the application of multi-layer 

compression to the upper and lower extremities. The CPT Editorial Panel and AMA RUC 

concluded that the revisions to the descriptor for CPT code 29581 were editorial only, and the 

AMA RUC related specialty society (Society for Vascular Surgery) believed that resurveying 

CPT code 29581 was not necessary. As such, the AMA RUC recommended "No Change" for 

CPT code 29581. For CY 2012, CPT codes 29582, 29583, and 29584 were surveyed through the 

American Physical Therapy Association (the expected dominant providers of the services), and 

the HCPAC reviewed the results and issued recommendations to CMS for these three CPT 

codes. 

We discussed CPT codes 29581 (Application of multi-layer compression system; leg 

(below knee), including ankle and foot), 29582 (Application of multi-layer compression system; 

thigh and leg, including ankle and foot, when performed), 29583 (Application of multi-layer 

compression system; upper arm and forearm), and 29584 (Application of multi-layer 

compression system; upper arm, forearm, hand, and fingers) in the CY 2012 final rule with 

comment period (76 FR 73192 through 73193). In the CY 2012 PFS final rule with comment 

period, we stated that after clinical review, we believed that CPT code 29581, in relation to CPT 

codes 29582 through 29584, described a similar service from a resource perspective and should 

be valued similarly to those codes. We stated that we believed a work RVU of 0.60 for CPT 

code 29581 is inappropriately high in relation to the HCPAC-reviewed codes 29582, 29583, and 

29584. We believed that the HCPAC-recommended work RVUs of 0.35 for CPT code 29682, 

0.25 for CPT code 29583, and 0.35 for CPT code 29584 accurately reflected the work associated 

with these services. Additionally, we stated that we believed that the clinical conditions treated 

by CPT codes 29581 and 29583 are essentially the same, namely the treatment of venous ulcers 
489 

and lymphedema. We stated that we recognized that there would be mild differences and 

variation in the application of a multi-layer compression system to the upper extremity versus the 

lower extremity, which is accounted for in the intra-service times of the codes. As such, we 

believed that a work RVU of 0.25 appropriately accounts for the work associated with CPT code 

29581. 

Ultimately, we stated that we believed that a survey that addressed all 4 CPT codes 

together as a family and gathers responses from all clinicians who furnish the services described 

by CPT codes 29581 through 29584 would help us to further consider the appropriate gradation 

in valuation of these 4 services. We assigned a work RVU of 0.25 to CPT code 29581 on an 

interim basis for CY 2012, and anticipated reviewing CPT code 29581 along with CPT codes 

29582, 29583, and 29584 with new survey data for CY 2013. 

 In response to the CY 2012 PFS final rule with comment period, commenters stated that 

they believe the CPT Editorial Panel revisions to CPT code 29581 were editorial only and 

resurveying CPT code 29581 was unnecessary, and no changes should be made to the work RVU 

for this code. Commenters disagreed with our methodology to value CPT code 29581 similar to 

HCPAC-reviewed codes 29582, 29583, and 29584, stating that the beneficiaries who receive 

services under CPT code 29581 are more complex. Commenters noted that the work descriptor 

for CPT code 29581 includes evaluation and cleansing of the venous ulcer, while there is no such 

parallel service for CPT codes 29582, 29583, and 29584. Commenters argued that CPT code 

29581 was reviewed by the AMA RUC in April 2009 and those survey results should not be 

invalided by crosswalking CPT code 29581 to HCPAC-reviewed codes 29582, 29583, and 

29584. Commenters noted that no completed RUC survey data was submitted to the HCPAC for 

CPT codes 29582, 29583 or 29584--a single specialty presented crosswalk values to the HCPAC, 

and they were accepted. Commenters recommended we maintain the 2009 valued AMA RUC 
490 

work RVU of 0.60 for CPT code 29581. 

 In response to our assertion that a survey that addressed all 4 CPT codes together as a 

family and gathers responses from all clinicians who furnish the services described by CPT 

codes 29581 through 29584 would help assure the appropriate gradation in valuation of these 4 

services, the AMA RUC noted that when CPT codes 29582, 29583, and 29584 were created no 

physician (MD/DO) specialty societies had an interest in surveying the codes, so they were 

surveyed and reviewed by only the HCPAC. The AMA RUC noted that another survey process 

would not mean that these codes would be surveyed together as we had requested. 

In response to comments received, we referred CPT code 29581 to the CY 2012 multispecialty refinement panel for further review. The refinement panel median work RVU for CPT 

code 29581 was 0.50. Typically, we finalize the work values for CPT codes after reviewing the 

results of the refinement panel. However, for CY 2012 we assigned interim RVUs for CPT 

codes 29581, 29582, 29583, and 29584 and requested additional information, with the intention 

of re-reviewing the services for CY 2013 with the new information we had received, and setting 

interim final values at that time. We recognize that CPT code 29581 received only editorial 

changes; however, we continue to believe the HCPAC-reviewed codes 29582, 29583, and 29584 

describe similar services. While the services are performed by different specialties, they do 

involve similar work. For example, prior to the application of the compression bandage, CPT 

code 29581 includes the work furnishing a physical exam to assesses adequate arterial flow, the 

presence of infection, the degree of swelling, and the size/depth of the lower extremity ulcer, 

while CPT code 29583 includes the work of furnishing a physical exam to assesses skin 

integrity, cardiopulmonary status, and peripheral vascular status. We believe these services 

involve the same amount of physician work. Therefore, after consideration of the public 

comments, refinement panel results, and our clinical review we continue to believe that the 
491 

crosswalk methodology is appropriate to value CPT code 29581 and the resulting work RVU 

accurately reflects the work associated with this service. Accordingly, on an interim final basis 

for CY 2012, we are assigning a work RVU of 0.25 to CPT code 29581; a work RVU of 0.35 to 

CPT code 29582; a work RVU of 0.25 to CPT code 29583; and a work RVU of 0.35 to CPT 

code 29584. 

(7) Musculoskeletal System: Endoscopy/Arthroscopy 

TABLE 37: Musculoskeletal System: Endoscopy/Arthroscopy 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

29824 

Shoulder 

arthroscopy/surgery 8.98 8.98 8.98 Interim No 

29826 

Shoulder 

arthroscopy/surgery 3.00 3.00 3.00 Interim No 

29827 

Arthroscop rotator cuff 

repr 15.59 15.59 15.59 Interim No 

29828 

Arthroscopy biceps 

tenodesis 13.16 13.16 13.16 Interim No 

CPT codes 29824, 29826, 29827, and 29828 were identified as potentially misvalued 

through the Codes Reported Together 75 percent or More screen. CPT code 29826 was also 

identified as potentially misvalued through the Harvard-valued—Utilization over 30,000 screen, 

and CPT code 29828 was also identified for additional review because it was on the New 

Technology list. 

 We reviewed CPT code 29826 (Arthroscopy, shoulder, surgical; decompression of 

subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, 

when performed (list separately in addition to code for primary procedure)) for CY 2012 and 

agreed with the AMA RUC recommended work RVU of 3.00, which was the specialty society 

survey 25th percentile work RVU (76 FR 73193). For CY 2013, the AMA RUC reviewed CPT 

codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular 
492 

surface (mumford procedure)) and 29827 (Arthroscopy, shoulder, surgical; with rotator cuff 

repair), however the specialty society did not survey these CPT codes. Without survey 

information, the AMA RUC affirmed that the current work RVU of 8.82 for CPT code 29824 

and the current work RVU of 15.59 for CPT code 29827 are correct and not overlapping with 

CPT code 29826. For CY 2013, the AMA RUC also reviewed CPT code 29828 (Arthroscopy, 

shoulder, surgical; biceps tenodesis), which, as stated above, was on the New Technology list. 

The specialty society surveyed CPT code 29828, and the AMA RUC recommended the current a 

work RVU of 13.16, which was between the survey 25th percentile and median work RVU. As 

we have stated many times, we believe families of services should be reviewed together to 

ensure relativity between the services and consistency in inputs. We do not find the AMA 

RUC’s affirmation that the work RVUs of CPT codes 29824 and 29827 have not changed to be 

sufficient evidence that the current RVUs continue to accurately reflect the work associated with 

furnishing those services. We request additional information from commenters on the 

appropriate values for these services. To clarify, we do not believe the specialty society needs to 

resurvey CPT codes 29826 and 29828, however we would welcome data on the valuation of CPT 

codes 29824 and 29827. We anticipate re-reviewing this family of services together for CY 

2014. On an interim basis for CY 2013, we are assigning the current (CY 2012) work RVUs to 

these four services: a work RVU of 8.98 to CPT code 29824; a work RVU of 3.00 to CPT code 

29826; a work RVU of 15.59 to CPT code 29827; and a work RVU of 13.16 to CPT code 29828. 

(8) Respiratory System: Accessory Sinuses 

TABLE 38: Respiratory System: Accessory Sinuses 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

31231 Nasal endoscopy dx 1.10 1.10 1.10 Agree Yes 
493 

CPT code 31231 was identified for review because it is on the MPC list. After clinical 

review of CPT code 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate 

procedure)) we believe that the current work RVU of 1.10, the survey 25th percentile value and 

the AMA RUC recommendation accurately reflects the work associated with this procedure. 

Medicare claims data from 2011 indicate that this service is typically furnished to the beneficiary 

on the same day as an E/M visit. We believe that some of the activities furnished during the preand post-service period of the procedure code and the E/M visit overlap. After review, we 

believe that the AMA RUC appropriately accounted for this overlap in its recommendation of 

pre-service time, but failed to account for the overlap in post-service time. To account for this 

overlap, we reduced the AMA RUC-recommended post-service time for this procedure by onethird, from 5 minutes to 3 minutes. We believe 3 minutes accurately reflects the post-service 

time involved in furnishing this procedure, and is more in line with similar services. A complete 

list of the interim final times associated with this procedure is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

 (9) Respiratory System: Trachea and Bronchi 

 TABLE 39: Respiratory System: Trachea and Bronchi 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

31647 Bronchial valve init insert New 4.40 4.40 Agree No 

31648 Bronchial valve addl insert New 4.20 4.20 Agree No 

31649 Bronchial valve remov init New 2.00 1.44 Disagree No 

31651 

Bronchial valve remov 

addl New 1.58 1.58 Agree No 

31660 Bronch thermoplsty 1 lobe New 4.50 4.25 Disagree No 

31661 

Bronch thermoplsty 2/> 

lobes New 5.00 4.50 Disagree No 

For CY 2013, the CPT Editorial Panel created CPT codes 31647, 31648, 31649, and 

31651 to replace 0250T, 0251T and 0252T; as well as CPT codes 31660 and 31661 to replace 
494 

0276T and 0277T. 

 After clinical review, we agree with the AMA RUC-recommended work RVU of 4.40 for 

CPT code 31647 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 

performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and 

insertion of bronchial valve(s), initial lobe) and the AMA RUC recommended work RVU of 1.58 

for CPT code 31651 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 

performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and 

insertion of bronchial valve(s), each additional lobe (list separately in addition to code for 

primary procedure[s])) which is the associated add-on code for CPT code 31647. We also agree 

with the AMA RUC-recommended RVU of 4.20 for CPT code 31648 (Bronchoscopy, rigid or 

flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), 

initial lobe), which is somewhat less work than CPT code 31647. We do not agree with the 

AMA RUC-recommended work RVU of 2.00 for CPT code 31649 (Bronchoscopy, rigid or 

flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), 

each additional lobe (list separately in addition to code for primary procedure)). CPT code 

31647 has a higher work RVU than CPT code 31648, so to maintain the appropriate relativity 

between these services, we believe that the add-on code associated with CPT code 31647 (which 

is CPT code 31651) should have a higher RVU than the add-on code associated with CPT code 

31648 (which is CPT code 31649). As such, we believe that the survey 25th percentile work 

RVU of 1.44 for CPT code 31649 places these services in the appropriate rank-order. On an 

interim final basis for CY 2013 we are assigning a work RVU of 4.40 to CPT code 31647; a 

work RVU of 4.20 to CPT code 31648; a work RVU of 1.44 to CPT code 31649; and a work 

RVU of 1.58 to CPT code 31651. 

 After reviewing CPT codes 31660 (Bronchoscopy, rigid or flexible, including 
495 

fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe) and 31661 

(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 

bronchial thermoplasty, 2 or more lobes) we believe that the specialty society survey 25th

percentile work RVUs of 4.25 for CPT code 31660 and 4.50 for CPT code 31661 appropriately 

reflect the relativity of these services to each other and to other fee schedule services. The AMA 

RUC recommended the specialty society survey median work RVUs of 4.50 for CPT code 31660 

and 5.00 for CPT code 31661. On an interim final basis for CY 2013, we are assigning a work 

RVU of 4.25 for CPT code 31660 and a work RVU of 4.50 to CPT code 31661. 

(10a) Respiratory System: Lungs and Pleura 

TABLE 40: Respiratory System: Lungs and Pleura 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

32551 Insertion of chest tube 3.29 3.50 3.29 Disagree No 

32554 

Aspirate pleura w/o 

imaging New 1.82 1.82 Agree No 

32555 

Aspirate pleura w/ 

imaging New 2.27 2.27 Agree Yes 

32556 

Insert cath pleura w/o 

image New 2.50 2.50 Agree No 

32557 

Insert cath pleura w/ 

image New 3.62 3.12 Disagree Yes 

32701 

Thorax stereo rad 

targetw/tx New 4.18 4.18 Agree No 

CPT codes 32420, 32421, 32422, and 32551 were identified as potentially misvalued 

through the Harvard-valued—Utilization over 30,000 screen. For CY 2013, the CPT Editorial 

Panel deleted CPT codes 32420, 32421, and 32422 and replaced them with CPT codes 32554, 

32555, 32556, and 32557. 

 After clinical review of CPT code 32551 (Tube thoracostomy, includes connection to 

drainage system (eg, water seal), when performed, open (separate procedure)), we believe that 
496 

the current work RVU of 3.29 appropriately reflects the work associated with service. The AMA 

RUC recommended the specialty society survey 25th percentile work RVU of 3.50, however we 

believe that an increase in work RVU is not warranted for this service, especially considering the 

substantial drops in recommended physician time. Additionally, we believe that a work RVU of 

3.29 places this service in the appropriate rank order with the other similar CPT codes reviewed 

for CY 2013. On an interim final basis for CY 2013, we are assigning a work RVU of 3.29 for 

CPT code 32551. 

 After clinical review of CPT codes 32554 (Thoracentesis, needle or catheter, aspiration of 

the pleural space; without imaging guidance), 32555 (Thoracentesis, needle or catheter, 

aspiration of the pleural space; with imaging guidance), and 32556 (Pleural drainage, 

percutaneous, with insertion of indwelling catheter; without imaging guidance) we agree with the 

AMA RUC-recommended work RVUs. On an interim final basis for CY 2013, we are assigning 

a work RVU of 1.82 to CPT code 32554; a work RVU of 2.27 to CPT code 32555, and a work 

RVU of 2.50 to CPT code 32556. 

 After clinical review of CPT code 32557 (Pleural drainage, percutaneous, with insertion 

of indwelling catheter; with imaging guidance), we believe that a work RVU of 3.12 

appropriately reflects the work of this service. The AMA RUC recommended a work RVU of 

2.50 for CPT code 32556 and a work RVU of 3.62 for CPT code 32557. We believe the AMA 

RUC-recommended work RVU of 3.62 overstates the difference between CPT codes 32556 and 

32557. The specialty societies that surveyed CPT code 32556 recommended to the AMA RUC a 

work RVU of 3.00 for CPT code 32556 and a work RVU of 3.62 for CPT code 32557. We 

believe this difference in work RVU of 0.62 more accurately captures the relative difference 

between these two services. Therefore, since we assigned CPT code 32556 an interim final work 

RVU of 2.50, we believe a work RVU of 3.12 appropriately reflects the work of CPT code 
497 

32557. On an interim final basis for CY 2013, we are assigning a work RVU of 3.12 to CPT 

code 32557. 

Additionally, on an interim final basis for CY 2013, we are refining the AMA RUC 

recommended pre-service evaluation time to 13 minutes from 15 minutes for CPT codes 32555 

and 32557 to match the pre-service evaluation times of CPT codes 32554 and 32556. A 

complete list of the times associated with these procedures is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

(10b) Respiratory System: Lungs and Pleura 

TABLE 41: Respiratory System: Lungs and Pleura 

HCPCS 

Code Short Descriptor 

CY 

2012 

Work 

RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

32440 

Remove lung 

pneumonectomy 27.28 N/A 27.28 Interim N/A 

32480 Partial removal of lung 25.82 N/A 25.82 Interim N/A 

32482 Bilobectomy 27.44 N/A 27.44 Interim N/A 

32491 Lung volume reduction 25.24 N/A 25.24 Interim N/A 

32663 

Thoracoscopy 

w/lobectomy 24.64 24.64 24.64 Interim No 

32668 

Thoracoscopy w/w 

resect diag 3.00 4.00 3.00 Interim No 

32669 

Thoracoscopy remove 

segment 23.53 23.53 23.53 Interim No 

32670 

Thoracoscopy 

bilobectomy 28.52 28.52 28.52 Interim No 

32671 

Thoracoscopy 

pneumonectomy 31.92 31.92 31.92 Interim No 

32672 Thoracoscopy for lvrs 27.00 27.00 27.00 Interim No 

32673 

Thoracoscopy w/thymus 

resect 21.13 21.13 21.13 Interim No 

60520 

Removal of thymus 

gland 17.16 N/A 17.16 Interim N/A 

60521 

Removal of thymus 

gland 19.18 N/A 19.18 Interim N/A 

60522 

Removal of thymus 

gland 23.48 N/A 23.48 Interim N/A 

 The CPT Editorial Panel reviewed the lung resection family of codes and deleted 8 codes, 

revised 5 codes, and created 18 new codes for CY 2012. During our clinical review for the CY 
498 

2012 PFS final rule with comment period, we were concerned with the varying differentials in 

the AMA RUC-recommended work RVUs and times between some of the open surgery lung 

resection codes and their endoscopic analogs. Rather than assign alternate interim final RVUs 

and times in this large restructured family of codes, we accepted the AMA RUC 

recommendations on an interim basis and requested that the AMA RUC re-review the surgical 

services along with their endoscopic analogs. 

In the CY 2012 PFS final rule with comment period we made this request on a code-bycode basis. However, there was an inadvertent typographical error in our request---we referred 

to “open heart surgery analogs”, instead of just “open surgery analogs”. For example, we stated, 

“For CPT code 32663 (Thoracoscopy, surgical; with lobectomy (single lobe)), the AMA RUC 

recommended a work RVU of 24.64. Upon clinical review, we have determined that it is most 

appropriate to accept the AMA RUC recommended work RVU of 24.64 on a provisional basis, 

pending review of the open heart surgery analogs, in this case CPT code 32480. We are 

requesting the AMA RUC look at the incremental difference in RVUs and times between the 

open and laparoscopic surgeries and recommend a consistent valuation of RVUs and time for 

CPT code 32663 and other services within this family with this same issue. Accordingly, we are 

assigning a work RVU of 24.64 for CPT code 32663 on an interim basis for CY 2012” (76 FR 

73195). 

In response to this request, the specialty society noted that these are not open heart 

surgery codes and therefore are not relevant. The AMA RUC requested further information from 

CMS on why these services should be reviewed as part of a family. We understand that our 

request would have been more clear if we had referred to “open surgery codes” instead of “open 

heart surgery codes” and if we had written “endoscopic procedures” instead of “laparoscopic 

surgeries”. With this clarification, we re-request public comment on the appropriate work RVU 
499 

and time values for the interim codes in the table above. These codes are discussed in greater 

detail in the CY 2012 PFS final rule with comment period, pages 73193 through 73195. For CY 

2013, we are maintaining the current (CY 2012) values for these services on an interim basis. 

We intend to review these CPT codes in CY 2013 and set interim final values for CY 2014. 

 (11) Cardiovascular System: Heart and Pericardium 

TABLE 42: Cardiovascular System: Heart and Pericardium 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

33361 Replace aortic valve perq New 29.50 25.13 Disagree Yes 

33362 Replace aortic valve open New 32.00 27.52 Disagree Yes 

33363 Replace aortic valve open New 33.00 28.50 Disagree Yes 

33364 Replace aortic valve open New 34.87 30.00 Disagree Yes 

33365 Replace aortic valve open New 37.50 33.12 Disagree No 

33367 

Replace aortic valve 

w/byp New 11.88 11.88 Agree No 

33368 

Replace aortic valve 

w/byp New 14.39 14.39 Agree No 

33369 

Replace aortic valve 

w/byp New 19.00 19.00 Agree No 

33405 

Replacement of aortic 

valve 41.32 41.32 41.32 Interim No 

33430 

Replacement of mitral 

valve 50.93 50.93 50.93 Interim No 

33533 Cabg arterial single 33.75 34.98 33.75 Interim No 

33990 Insert vad artery access New 8.15 8.15 Agree No 

33991 Insert vad art&vein access New 11.88 11.88 Agree No 

33992 

Remove vad different 

session New 4.00 4.00 Agree No 

33993 

Reposition vad diff 

session New 4.17 3.51 Disagree No 

The CPT Editorial Panel deleted four Category III codes (0256T through 0259T) and approved 

nine CPT codes (33361 through 33369) to report transcatheter aortic valve replacement (TAVR) 

procedures for CY 2012. 

On May 1, 2012, CMS issued a National Coverage Determination (NCD) covering TAVR under 

Coverage with Evidence Development (CED). The NCD identifies numerous detailed requirements, 

including that covered TAVR requires a cardiothoracic surgeon and an interventional cardiologist. Under 
500 

this CED, coverage is limited to services furnished under specific conditions targeted to developing data on 

the safety and efficacy of the service for Medicare beneficiaries. Like their predecessor Category III codes 

(0256T through 0259T), the new Category I CPT codes 33361 through 33365 require the work of an 

interventional cardiologist and cardiothoracic surgeon to jointly participate in the intra-operative technical 

aspects of TAVR as co-surgeons. Claims processing instructions for the CED (CR 7897 transmittal 

2552) require each physician to bill with modifier-62 indicating that co-surgery payment applies. 

Medicare pays each co-surgeon 62.5 percent of the fee schedule amount. The three add-on 

cardiopulmonary bypass support services (CPT codes 33367 through 33369) are only reported by the 

cardiothoracic surgeon; therefore the AMA RUC-recommended work RVUs for those services reflect 

only the work of one physician. The AMA RUC-recommended work RVUs for each of the co-surgery 

CPT codes (33361 through 33365) reflect the combined work of both physicians, irrespective of the cosurgery payment policy. We debated whether it was appropriate to continue our co-surgery payment policy 

at 62.5 percent of the physician fee schedule amount for each physician for these codes if the work value 

reflected 100 percent of the work for two physicians. Ultimately, we decided to set work RVU values to 

reflect the total physician work of the procedures, and to continue to follow our co-surgery payment policy 

allowing the services to be billed by two physicians, in part because co-surgery is a requirement under 

Medicare policy for these services. We are not sure this is the appropriate long-term payment policy. We 

intend to reassess payment for this family of codes when we review national coverage for TAVR. For the 

time package, the AMA RUC accounted for the time each physician separately spends obtaining consent 

and reviewing the procedure with the patient. We are concerned that time for each physician to obtain 

consent and review the procedure with the patient is inconsistent with a framework for valuing the service as 

a single service. 

After clinical review of CPT code 33361 (Transcatheter aortic valve replacement (TAVR/TAVI) 

with prosthetic valve; percutaneous femoral artery approach), we believe that the specialty society survey 

25th percentile work RVU of 25.13 appropriately captures the total work of the service. The AMA RUC 

recommended the survey median work RVU of 29.50. Regarding physician time, for CPT 33361, as well 

as CPT codes 33362 through 33364, we believe 45 minutes of pre-service evaluation time, which is the 
501 

survey median time, is more consistent with the work of this service than the AMA RUC-recommended 

pre-service evaluation time of 50 minutes. Accordingly, we are assigning a work RVU of 25.13 to CPT 

code 33361, with a refinement of 45 minutes of pre-service evaluation time, on an interim basis for CY 

2013. A complete listing of the times associated with this code is available on the CMS website at: 

www.cms.gov/PhysicianFeeSched/. 

After clinical review of CPT code 33362 (Transcatheter aortic valve replacement (TAVR/TAVI) 

with prosthetic valve; open femoral artery approach), we believe that the specialty society survey 25th

percentile work RVU of 27.52 appropriately captures the total work of the service. The AMA RUC 

recommended the survey median work RVU of 32.00. Like CPT code 33361, we also believe 45 minutes 

of pre-service evaluation time is more appropriate for this service than the AMA RUC-recommended preservice evaluation time of 50 minutes. Accordingly, we are assigning a work RVU of 27.52 to CPT code 

33362, with a refinement to 45 minutes of pre-service evaluation time, on an interim basis for CY 2013. A 

complete listing of the times associated with this code is available on the CMS website at 

www.cms.gov/PhysicianFeeSched/. 

 After clinical review of CPT code 33363 (Transcatheter aortic valve replacement (TAVR/TAVI) 

with prosthetic valve; open axillary artery approach), we believe that the specialty society survey 25th

percentile work RVU of 28.50 appropriately captures the total work of the service. The AMA RUC 

reviewed the survey results and recommended the survey median work RVU of 33.00. Like CPT codes 

33361 and 33362, we also believe 45 minutes of pre-service evaluation time is more appropriate for this 

service than the AMA RUC-recommended time of 50 minutes. Accordingly, we are assigning a work 

RVU of 28.50 to CPT code 33363, with a refinement to 45 minutes of pre-service evaluation time, on an 

interim basis for CY 2013. A complete listing of the times associated with this code is available on the 

CMS website at www.cms.gov/PhysicianFeeSched/. 

After clinical review of CPT code 33364 (Transcatheter aortic valve replacement (TAVR/TAVI) 

with prosthetic valve; open iliac artery approach), we believe that the specialty society survey 25th

percentile work RVU of 30.00 more appropriately captures the total work of the service. The AMA RUC 

reviewed the survey results and recommended the survey median work RVU of 34.87. Like CPT codes 
502 

33361 through 33363, we also believe 45 minutes of pre-service evaluation time is more appropriate for this 

service than the AMA RUC-recommended time of 50 minutes. Accordingly, we are assigning a work 

RVU of 30.00 to CPT code 33364, with a refinement to 45 minutes of pre-service evaluation time, on an 

interim basis for CY 2013. A complete listing of the times associated with this code is available on the 

CMS website at: www.cms.gov/PhysicianFeeSched/. 

After clinical review of CPT code 33365 (Transcatheter aortic valve replacement 

(TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, 

mediastinotomy), we believe a work RVU of 33.12 accurately reflects the work associated with 

this service. The AMA RUC reviewed the survey results and recommended the survey median 

work RVU of 37.50. After clinical review, we determined that the work associated with this 

service is very similar to reference CPT code 33410 (Replacement, aortic valve, with 

cardiopulmonary bypass; with stentless tissue valve) (work RVU = 46.41), which has a 90-day 

global period that includes inpatient hospital and office visits. Because CPT code 33365 has a 0-

day global period that does not include post-operative visits, we calculated the value of the preoperative and post-operative visits in the global period of CPT code 33410, which totaled 13.29 

work RVUs, and subtracted that from the total work RVU of 46.41 for CPT code 33410 to 

determine the appropriate work RVU for CPT code 33365. With regard to time, we decided to 

maintain the 50 minutes of pre-service evaluation time because we believe that the procedure 

described by CPT code 33365 involves more pre-service evaluation time since it is performed by 

surgically opening the chest via median sternotomy. Accordingly, we are assigning a work RVU 

of 33.12 for CPT code 33365 on an interim basis for CY 2013. 

CPT codes 33405, 33430, and 33533 were identified as potentially misvalued through the 

High Expenditure Procedure Code screen. 

When reviewing these services, the specialty society utilized data from the Society of 

Thoracic Surgeons (STS) National Adult Cardiac Database in developing recommended times 
503 

and RVUs for CPT codes 33405 (Replacement, aortic valve, with cardiopulmonary bypass; with 

prosthetic valve other than homograft or stentless valve), 33430 (Replacement, mitral valve, with 

cardiopulmonary bypass), and 33533 (Coronary artery bypass, using arterial graft(s); single 

arterial graft), and did not conduct a survey of physician work and time. After reviewing the 

mean procedure times for these services in the STS database alongside other information relating 

to the value of these services, the specialty society and AMA RUC concluded that CPT codes 

33405 and 33430 are valued appropriately and that the current work RVUs of 41.32 for CPT 

code 33405, and 50.93 for CPT code 33430 should be maintained. After reviewing the mean 

procedure time for CPT code 33533 in the STS database alongside other information relating to 

the value of the service, the specialty society and AMA RUC concluded that the work associated 

with CPT code 33553 had increased since this service was last reviewed. The AMA RUC 

recommended a work RVU of 34.98 for CPT code 33533, which is a direct crosswalk to CPT 

code 33510 (Coronary artery bypass, vein only; single coronary venous graft). 

We believe the STS database, which captures outcome data in addition to time and visit 

data, is a useful resource in the valuation of PFS services. However, the AMA RUC 

recommendations on these services show only the STS database mean time for CPT codes 

33405, 33430, and 33533. We are interested in seeing the distribution of times, including the 

25th percentile, median, and 75th percentile values (which are the data points reported on the 

specialty society surveys), in addition to any other information STS believes would be relevant 

to the valuation of the services, such as case-mix, or time data for similar services. The STS 

database is a robust source of information and we believe it would be helpful to review 

additional data points for these three services beyond the mean time provided by the AMA RUC. 

In order to complete our clinical review of these services, we would like to see the distribution of 

procedure times for CPT codes 33405, 33430, and 33533. We are also interested in more 
504 

information on the methodology used to develop the recommended work RVUs based on the 

time data, and, using that methodology, the different RVUs that correspond to the 25th percentile, 

median, and 75th percentile time data. We previously have expressed our concerns regarding the 

manner in which data derived from the STS database was used (71 FR 37224 through 37225). 

We are committed to reviewing and evaluating all services using an approach that maintains the 

appropriate relativity among fee schedule services. For CY 2013 we are maintaining the current 

work RVUs for these services on an interim basis. We will consider additional time and other 

data submitted in response to comments on this final rule with comment period in the CY 2014 

PFS final rule with comment period. Specifically, we are maintaining a work RVU of 41.32 for 

CPT code 33405; a work RVU of 50.93 for CPT code 33430; and a work RVU of 33.75 for CPT 

code 33533. 

(12) Cardiovascular System: Arteries and Veins 

TABLE 43: Cardiovascular System: Arteries and Veins 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

35475 Repair arterial blockage 9.48 6.60 5.75 Disgaree No 

35476 Repair venous blockage 6.03 5.10 4.71 Disagree No 

36221 Place cath thoracic aorta New 4.51 4.17 Disagree Yes 

36222 Place cath carotid/inom art New 6.00 5.53 Disagree Yes 

36223 Place cath carotid/inom art New 6.50 6.00 Disagree Yes 

36224 Place cath carotd art New 7.55 6.50 Disagree Yes 

36225 Place cath subclavian art New 6.50 6.00 Disagree Yes 

36226 Place cath vertebral art New 7.55 6.50 Disagree Yes 

36227 Place cath xtrnl carotid New 2.32 2.09 Disagree No 

36228 Place cath intracranial art New 4.25 4.25 Agree No 

37197 

Remove intrvas foreign 

body New 6.72 6.29 Disagree No 

37211 Thrombolytic art therapy New 8.00 8.00 Agree No 

37212 

Thrombolytic venous 

therapy New 7.06 7.06 Agree No 

37213 

Thromblytic art/ven 

therapy New 5.00 5.00 Agree No 

37214 

Cessj therapy cath 

removal New 3.04 2.74 Disagree No 
505 

In CY 2011, CPT codes 35475 and 35476 were identified in the CMS High Expenditure 

Procedure Codes Screen. 

 After clinical review of CPT code 35475 (Transluminal balloon angioplasty, percutaneous; 

brachiocephalic trunk or branches, each vessel), we believe a work RVU of 5.75 appropriately captures 

the work of the service. To develop a recommended value for this service, the AMA RUC started with the 

work RVU of CPT code 37224 (Revascularization, endovascular, open or percutaneous, femoral, popliteal 

artery(s), unilateral; with transluminal angioplasty) (work RVU of 9.00), which the AMA RUC believed 

was a comperable service to CPT code 35475, then removed RVUs to account for overlap in work resulting 

from same day billing with CPT codes 36147 (Introduction of needle and/or catheter, arteriovenous shunt 

created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, 

including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, 

and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow 

including the inferior or superior vena cava)) and 75962 (Transluminal balloon angioplasty, peripheral 

artery other than renal, or other visceral artery, iliac or lower extremity, radiological supervision and 

interpretation). Using these calculations, the AMA RUC recommended a work RVU of 6.60 for CPT code 

35475. We agree with this approach, but believe that CPT code 37220 (Revascularization, endovascular, 

open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty) (work RVU 8.15) 

is more similar to CPT code 35475 and therefore a better starting point for the reductions. After accounting 

for overlap with other services typically reported with CPT code 35475, we determined that a work RVU 

of 5.75 is appropriate for this service. Accordingly, we are assigning a work RVU of 5.75 to CPT code 

35475 on an interim final basis for CY 2013. 

 After clinical review of CPT code 35476 (Transluminal balloon angioplasty, 

percutaneous; venous), we believe a work RVU of 4.71 more appropriately captures the work of 

the service. The AMA RUC reviewed the survey results and recommended a work RVU of 5.50, 

the survey 25th percentile value. We determined that the work associated with CPT code 35476 

was similar in terms of physician time and intensity to CPT code 37191 (Insertion of 
506 

intravascular vena cava filter, endovascular approach including vascular access, vessel selection, 

and radiological supervision and interpretation, intraprocedural roadmapping, and imaging 

guidance (ultrasound and fluoroscopy), when performed), which has a work RVU of 4.71. We 

believe the work RVU of 4.71 appropriately captures the relative difference between this service 

and CPT code 35475. Therefore, we are assigning a work RVU of 4.71 for CPT code 35476 on 

an interim final basis for CY 2013. 

CPT codes 36221 through32668 were identified as potentially misvalued through the Codes 

Reported Together 75 percent or More screen. For CY 2012, the AMA RUC requested that CPT 

Editorial Panel create eight new codes to bundle selective catheter placement with radiological 

supervision and interpretation, including angiography. Additionally, the specialty society recognized that 

non-invasive vascular imaging has replaced diagnostic angiography as a screening test. 

 After clinical review of CPT code 36221(Non-selective catheter placement, thoracic aorta, with 

angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and 

all associated radiological supervision and interpretation, includes angiography of the cervicocerebral 

arch, when performed), we believe a work RVU of 4.17 more appropriately captures the work of the 

service, with refinement of 30 minutes to the post-service time. The AMA RUC reviewed the survey 

results, and after a comparison to similar CPT codes, recommended a value of 4.51 work RVUs and a 

post-service time of 40 minutes. The AMA RUC used a direct crosswalk to the two component codes 

being bundled, CPT code 32600 (Introduction of catheter, aorta) (work RVU = 3.02) and CPT code 

75650 (Angiography, cerviocerebral, catheter, including vessel origin, radiological supervision and 

interpretation) (work RVU=1.49) and the recommended value of 4.51 is the sum of the RVUs for these 

component codes. We believe that that there are efficiencies gained when services are bundled. We 

believe crosswalking to the work RVU of CPT code 32550 (Insertion of indwelling tunneled pleural 

catheter with cuff), which has a work RVU of 4.17, appropriately accounts for the physician time and 

intensity with CPT code 36221. Additionally, we believe that the survey post-service time of 30 minutes 

more accurately accounts for the time involved in furnishing this service than the AMA RUC-
507 

recommended post-service time of 40 minutes. Therefore, we are assigning a work RVU of 4.17 with 

refinement to time for CPT code 36221 on an interim final basis for CY 2013. A complete listing of the 

times associated with this code is available on the CMS website at www.cms.gov/PhysicianFeeSched /. 

After clinical review of CPT code 36222 ((Non-selective catheter placement, thoracic aorta, with 

angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and 

all associated radiological supervision and interpretation, includes angiography of the cervicocerebral 

arch, when performed).), we believe the survey 25th percentile work RVU of 5.53 appropriately captures 

the work of this service, particularly the efficiencies when two services are bundled together. The AMA 

RUC recommended the survey median work RVU of 6.00. Like CPT code 36221, we believe the survey 

post-service time of 30 minutes is more appropriate than the AMA RUC-recommended post-service time 

of 40 minutes. We are assigning a work RVU of 5.53 with refinement to time for CPT code 36222 as 

interim final for CY 2013. A complete listing of the times associated with this code is available on the 

CMS website at: www.cms.gov/PhysicianFeeSched/. 

After clinical review of CPT code 36223(Selective catheter placement, common carotid or 

innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid 

circulation and all associated radiological supervision and interpretation, includes angiography of the 

extracranial carotid and cervicocerebral arch, when performed), we believe a work RVU value of 6.00, 

the survey 25th percentile value, appropriately captures the work of the service, particularly efficiencies 

when two services are bundled together. The AMA RUC reviewed the survey results, and after a 

comparison to similar CPT codes, recommended a work RVU of 6.50. Like many of the other CPT codes 

in this family, we believe the survey post-service time of 30 minutes is more appropriate than the AMA 

RUC-recommended time of 40 minutes. We are assigning a work RVU of 6.00 with refinement to time 

for CPT code 36223 as interim final for CY 2013. A complete listing of the times associated with this 

code is available on the CMS website at: www.cms.gov/PhysicianFeeSched/. 

After clinical review of CPT code 36224(Selective catheter placement, internal carotid artery, 

unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological 

supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, 
508 

when performed), we believe a work RVU of 6.50, the survey 25th percentile value, appropriately captures 

the work of the service, particularly efficiencies when two services are bundled together. We believe 30 

minutes of post-service times more appropriately accounts for the work of this service. The AMA RUC 

reviewed the survey results, and after a comparison to similar CPT codes, recommended a value of 7.55 

and a post-service time of 40 minutes for CPPT code 36224. Accordingly, we are assigning a work RVU 

of 6.50 with refinement to time for CPT code 36224 as interim final for CY 2013. A complete listing of 

the times associated with this code is available on the CMS website at: 

www.cms.gov/PhysicianFeeSched/. 

After clinical review of CPT code 36225 (Selective catheter placement, subclavian or innominate 

artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological 

supervision and interpretation, includes angiography of the cervicocerebral arch, when performed), we 

believe that this code should be valued the same as the CPT code 36223, to which we are assigning a 

work RVU of 6.00. Comparable to CPT code 36223, we also believe 30 minutes of post-service times 

more appropriately accounts for the work of this service. The AMA RUC reviewed the survey results and 

recommended the survey median work RVU of 6.50 and a post-service time of 40 minutes for CPT code 

36225. We are assigning a work RVU of 6.00 with refinement to time for CPT code 36225 as interim 

final for CY 2013. A complete listing of the times associated with this code is available on the CMS 

website at: www.cms.gov/PhysicianFeeSched/. 

After clinical review of CPT code 36226 (Selective catheter placement, vertebral artery, unilateral, 

with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and 

interpretation, includes angiography of the cervicocerebral arch, when performed), we believe that this CPT 

code should be valued the same as CPT code 36224, which has a work RVU as 6.50. Comparable to CPT 

code 36224, we also believe 30 minutes of post-service times more appropriately accounts for the work of 

this service. The AMA RUC reviewed the survey results, and after a comparison to similar CPT codes, 

recommended a value of 7.55 and a post-service time of 40 minutes for CPT code 36226. We are 

assigning a work RVU of 6.50 with refinement to time for CPT code 36226 as interim final for CY 2013. 
509 

After clinical review of CPT code 36227 (Selective catheter placement, external carotid artery, 

unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological 

supervision and interpretation (list separately in addition to code for primary procedure)), we determined 

that there are efficiencies gained when services are bundled, and identified a work RVU of 2.09 for this 

service. This work RVU reflects the application of a very conservative estimate of 10 percent for the 

work efficiencies that we would expect to occur when multiple component codes are bundled together to 

the sum of the work RVUs for the component codes. The AMA RUC reviewed the survey results, and 

after a comparison to similar CPT codes, recommended a value of 2.32 for CPT code 36227. The AMA 

RUC used a direct crosswalk to the two component codes being bundled, CPT code 36218 (Selective 

catheter placement, arterial system; additional second order, third order, and beyond, thoracic or 

brachiocephalic branch, within a vascular family (list in addition to code for initial second or third order 

vessel as appropriate) (work RVU= 1.01) and CPT code 75660 (Angiography, external carotid, unilateral, 

selective, radiological supervision and interpretation) (work RVU = 1.31). We are assigning a work RVU 

of 2.09 as the interim final value of CPT code 36227 for CY 2013. 

(13) Hemic and Lymphatic System: General 

TABLE 44: Hemic and Lymphatic System: General 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

38240 Transplt allo hct/donor 2.24 4.00 3.00 Disagree No 

38241 Transplt autol hct/donor 2.24 3.00 3.00 Agree No 

38242 Transplt allo lymphocytes 1.71 2.11 2.11 Agree No 

38243 

Transplj hematopoietic 

boost New 2.13 2.13 Agree No 

CPT codes 38240, 38241, 38242, and 38243 were revised by the CPT Editorial Panel for 

CY 2013. 

 After clinical review, we agree with the AMA RUC-recommended work RVUs for CPT 

codes 38241 (Hematopoietic progenitor cell (hpc); autologous transplantation), 38242 
510 

(Allogeneic lymphocyte infusions), and 38243 (Hematopoietic progenitor cell (hpc); hpc boost). 

On an interim final basis for CY 2013 we are assigning a work RVU of 3.00 to CPT code 38241; 

a work RVU of 2.11 to CPT code 38242; and a work RVU of 2.13 to CPT code 38243. 

 After clinical review, we believe CPT code 38240 should have the same work RVU as 

CPT code 38241, because we believe the two services involve the same amount of work. The 

AMA RUC recommended a work RVU of 4.00 for CPT code 38240. On an interim final basis 

for CY 2013 we are assigning CPT code 38240 a work RVU of 3.00. 

(14) Digestive System: Intestines (Except Rectum) 

TABLE 45: Digestive System: Intestines (Except Rectum) 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

44705 Prepare fecal microbiota New 1.42 Invalid N/A N/A 

G0455 

Fecal microbiota prep 

instill New N/A 0.97 N/A N/A 

The CPT Editorial Panel created CPT code 44705 (Preparation of fecal microbiota for 

instillation, including assessment of donor specimen) for CY 2013. The AMA RUC 

recommended a work RVU of 1.42, which is a direct crosswalk to CPT code 99203 (Level 3 

office or other outpatient visit, new patient). This service is currently (CY 2012) reported under 

CPT code 44799 (Unlisted procedure, intestine), as is the instillation of the microbiota. Within 

Medicare, payment for the preparation of the donor specimen would only be made if the 

specimen is ultimately used for the treatment of a beneficiary as Medicare is not authorized to 

pay for any costs not directly related to the diagnosis and treatment of a beneficiary. Because of 

this policy, we believe it is appropriate to bundle the preparation and instillation into one payable 

HCPCS code. For CY 2013, we have created HCPCS code G0455 (Preparation with instillation 

of fecal microbiota by any method, including assessment of donor specimen). HCPCS code 
511 

G0455 will replace new CPT code 44705 (Preparation of fecal microbiota for instillation, 

including assessment of donor specimen) which will have a PFS procedure status indicator of I 

(Not valid for Medicare purposes), and includes both the work of preparation and instillation of 

the microbiota. 

After reviewing the preparation and instillation work associated with this procedure, we 

believe that CPT code 99213 (Level 3 office or other outpatient visit, established patient) is an 

appropriate crosswalk for the work and time of HCPCS code G0455. Therefore, on an interim 

final basis for CY 2013, we are assigning a work RVU of 0.97 to HCPCS code G0455. A list of 

the interim final times associated with this procedure is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

(15) Digestive System: Biliary Tract 

TABLE 46: Digestive System: Biliary Tract 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

47562 

Laparoscopic 

cholecystectomy 11.76 11.76 10.47 Disagree Yes 

47563 

Laparo 

cholecystectomy/graph 11.47 11.47 11.47 Agree No 

47600 Removal of gallbladder 17.48 20.00 17.48 Disagree No 

47605 Removal of gallbladder 15.98 21.00 18.48 Disagree No 

In CY 2011, we received comments regarding a potential relativity problem between 

CPT codes 47600 (Cholecystectomy;) and 47605 (Cholecystectomy; with cholangiography), as 

CPT code 47600 has a higher work RVU and more post-operative visits than CPT code 47605. 

In the CY 2012 PFS proposed rule, we requested that the AMA RUC review these two CPT 

codes and thanked commenters for bringing this to our attention (76 FR 42796). Currently (CY 

2012), CPT code 47600 has a work RVU of 17.48, and CPT code 47605 has a work RVU of 

15.98, which is clearly an anomalous relationship. For CY 2013, the related specialty societies 
512 

resurveyed these two CPT codes. After review, we believe that the work RVU of 17.48 

appropriately reflects the work of CPT code 47600, and that the work RVU of CPT code 47605 

should be increased to reflect the increase in work related to the addition of cholangiography. 

After clinical review, we agree with the AMA RUC and specialty societies that a work RVU of 

1.00 is the correct difference between CPT code 47600 and 47605. Therefore, we believe a work 

RVU of 18.48 accurately accounts for the work associated with CPT code 47605. We do not 

believe that the work of CPT code 47600 has increased over time. The AMA RUC 

recommended a work RVU of 20.00 for CPT code 47600 and a work RVU of 21.00 for CPT 

code 47605. Both values are the specialty society survey median work RVUs. On an interim 

final basis for CY 2013, we are assigning a work RVU of 17.48 to CPT code 47600 and a work 

RVU of 18.48 to CPT code 47605. 

 In their review of these CPT codes, the specialty societies indicated and the AMA RUC 

agreed that the typical patient undergoing an open cholecystectomy is scheduled and started with 

a laparoscopic approach and is then converted to the open procedure. We are concerned that the 

vignettes associated with these procedures imply that the work of the failed laparoscopic 

approach is included in the work of the cholecystectomy. We request that the AMA RUC review 

the vignettes for these services. 

 CPT codes 47562 and 47563 were identified as potentially misvalued through the High 

Expenditure Procedure Code screen. 

Though these service were identified by CMS as potentially misvalued, the related 

specialty societies declined to survey CPT codes 47562 (Laparoscopy, surgical; 

cholecystectomy) and 47563 (Laparoscopy, surgical; cholecystectomy with cholangiography), 

because, they said, the codes had been resurveyed many times, with CPT code 47563 last 

surveyed and reviewed as recently as the Fourth Five-Year Review (CY 2011). The AMA RUC 
513 

Relativity Assessment Workgroup concluded that these services have not changed since last 

reviewed and that resurveying the codes would not produce different values. The AMA RUC 

reaffirmed the current (CY 2012) work RVU of 11.76 for CPT code 47562 and the current (CY 

2012) work RVU of 11.47 for CPT code 47563. 

After clinical review, we noticed a rank-order anomaly in these services similar to the 

rank-order problem discussed above for CPT codes 47600 and 47605. CPT code 47563, which 

includes cholangiography, is currently (CY 2012) valued lower than CPT code 47562 which 

describes the same procedure without cholangiography. After reviewing these two services, we 

agree with the AMA RUC that the recently-reviewed current work RVU of 11.47 for CPT code 

47563 continues to accurately reflect the work of this service. As discussed above, we believe 

that a work RVU of 1.00 reflects the incremental difference between cholecystectomy with 

cholangiography and cholecystectomy alone. Therefore, we believe that CPT code 47562 should 

be valued 1.00 RVU lower than CPT code 47563. On an interim final basis for CY 2013, we are 

assigning a work RVU of 10.47 to CPT code 47562 and a work RVU of 11.47 to CPT code 

47563. 

Regarding physician time, we changed the pre-service time of CPT code 47562 to match 

the pre-service time of CPT code 47563, leading to small increase in pre-service time for the 

service. A complete listing of the interim final times assigned to these services is available on 

the CMS website at www.cms.gov/physicianfeesched/. 

 (16) Urinary System: Bladder 

TABLE 47: Urinary System: Bladder 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

52214 Cystoscopy and treatment 3.70 3.50 3.50 Agree No 

52224 Cystoscopy and treatment 3.14 4.05 4.05 Agree Yes 
514 

52234 Cystoscopy and treatment 4.62 4.62 4.62 Agree No 

52235 Cystoscopy and treatment 5.44 5.44 5.44 Agree No 

52240 Cystoscopy and treatment 9.71 8.75 7.50 Disagree No 

52287 

Cystoscopy 

chemodenervation New 3.20 3.20 Agree No 

52351 

Cystouretero & or 

pyeloscope 5.85 5.75 5.75 Agree No 

52352 

Cystouretero w/stone 

remove 6.87 6.75 6.75 Agree No 

52353 Cystouretero w/lithotripsy 7.96 7.88 7.50 Disagree No 

52354 Cystouretero w/biopsy 7.33 8.58 8.00 Disagree No 

52355 

Cystouretero w/excise 

tumor 8.81 10.00 9.00 Disagree No 

CPT code 52235 was identified as potentially misvalued under the Harvard-valued—

Utilization over 30,000 screen. CPT codes 52234, 52240, and 52351 through 52355 were 

identified as a part of this family for review. 

 After clinical review, we agreed with the AMA RUC-recommended work RVUs for the 

majority of codes in this family. However, we disagreed with the AMA RUC-recommended 

work RVUs for CPT codes 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; 

with lithotripsy (ureteral catheterization is included)), 52354 (Cystourethroscopy, with 

ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic 

lesion), 52355 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of 

ureteral or renal pelvic tumor), and 52240 (Cystourethroscopy, with fulguration (including 

cryosurgery or laser surgery) and/or resection of; large bladder tumor(s)). For CPT codes, 

52353, 52354, and 52355, we believe that the survey 25th percentile work RVUs represent a 

more appropriate incremental difference over the base code, CPT code 52351 

(Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic), to which we are 

assigning an interim final work RVU of 5.75, than the AMA RUC recommended work RVUs of 

7.88, 8.58, 10.00, respectively. Additionally, we believe the survey 25th percentile work RVUs 

more appropriately account for the significant reduction in intra-service time of these three CPT 

codes. Therefore, on an interim final basis for CY 2013, we are assigning a work RVU of 7.50 
515 

for CPT 52353; a work RVU of 8.00 for CPT code 52354; and a work RVU of 9.00 for CPT 

code 52355. 

 After reviewing CPT code 52240, we believe this service should be valued the same as 

CPT code 52353, as the services have the same times and describe very similar procedures. 

Therefore, on an interim final basis for CY 2013, we are assigning a work RVU of 7.50 to CPT 

code 52240. 

 Regarding physician time, we refined the AMA RUC-recommended pre-service time for 

CPT code 52224 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) 

or treatment of minor (less than 0.5 cm) lesion(s) with or without biopsy) from 32 minutes to 29 

minutes to match the pre-service time of CPT code 52214 (Cystourethroscopy, with fulguration 

(including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or 

periurethral glands) which has very similar pre-service work. A complete list of the interim final 

times associated with these procedures is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

(17) Nervous System: Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System 

TABLE 48: Nervous System: Extracranial Nerves, Peripheral Nerves, and Autonomic 

Nervous System 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

64450 N block other peripheral 1.27 0.75 0.75 Agree No 

64612 Destroy nerve face muscle 2.01 1.41 1.41 Interim No 

64613 

Destroy nerve neck 

muscle 2.01 N/A 2.01 Interim N/A 

64614 

Destroy nerve extrem 

musc 2.20 N/A 2.20 Interim N/A 

64615 

Chemodenerv musc 

migraine New 1.85 1.85 Interim No 

64640 

Injection treatment of 

nerve 2.81 1.23 1.23 Agree No 

The CPT Editorial Panel created CPT code 64615 and revised CPT codes 64612, 64613, 
516 

and 64614 for CY 2013. 

 When the AMA RUC and related specialty societies reviewed CPT codes 64613 

(Chemodenervation of muscle(s); neck muscle(s) (eg, for spasmodic torticollis, spasmodic 

dysphonia)) and 64614 (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) (eg, 

for dystonia, cerebral palsy, multiple sclerosis)), they determined that both CPT codes should be 

divided into additional codes, and referred CPT codes 64613 and 64614 to the CPT Editorial 

Panel. The AMA RUC recommended the survey median work RVU of 1.41 for CPT code 

64612 (Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for 

blepharospasm, hemifacial spasm)), a decrease from the current work RVU of 2.01, and 

recommended the survey median work RVU of 1.85 for new CPT code 64615 

(Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and 

accessory nerves, bilateral (eg, for chronic migraine)). We are accepting the AMA RUCrecommended work RVUs for CPT codes 64612 and 64615 on an interim basis, and will review 

these services alongside CPT codes 64613 and 64614 (or their successor CPT codes) after they 

are reviewed by the CPT Editorial Panel. 

 The AMA RUC requested a change in the global period of CPT code 64615 from 10 days 

to 0 days. We believe that a global period of 10 days is most appropriate for this service, and 

maintains consistency within this family of CPT codes, as the other services in this family also 

have 10-day global periods. 

(18) Eye and Ocular Adnexa: Eyeball 

TABLE 49: Eye and Ocular Adnexa: Eyeball 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

65222 

Remove foreign body 

from eye 0.93 0.93 0.84 Disagree Yes 
517 

CPT code 65222 was identified as potentially misvalued under the Harvard-valued---

Utilization over 30,000 screen. 

 Medicare claims data from 2011 indicate that CPT code 65222 (Removal of foreign 

body, external eye; corneal, with slit lamp) is typically furnished to the beneficiary on the same 

day as an E/M visit. We believe that some of the activities furnished during the pre- and postservice period of the procedure code and the E/M visit overlap. After review, we do not believe 

that the AMA RUC appropriately accounted for this overlap in its recommendation of pre- and 

post- service time. To account for this overlap, we reduced the AMA RUC-recommended preservice evaluation time by one-third, from 7 minutes to 5 minutes, and the AMA RUCrecommended post-service time by one-third, from 5 minutes to 3 minutes. We believe that 5 

minutes of pre-service evaluation time and 3 minutes of post-service time accurately reflect the 

time involved in furnishing the pre- and post-service work of this procedure, and that these times 

are well-aligned with similar services. Because we reduced the AMA RUC-recommended 

procedure time for this code by 4 minutes, at a standard work intensity of .0224 RVUs per 

minute, we believe that it is also appropriate to remove 0.09 RVUs from the current/AMA RUCrecommended RVU of 0.93. In sum, on an interim final basis for CY 2013, we are assigning a 

work RVU of 0.84 to CPT code 65222, with a refinement to the AMA RUC recommended time. 

A complete list of the interim final times associated with this procedure is available on the CMS 

website at www.cms.gov/physicianfeesched/. 

(19) Eye and Ocular Adnexa: Ocular Adnexa 
518 

TABLE 50: Eye and Ocular Adnexa: Ocular Adnexa 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

67810 

Biopsy eyelid & lid 

margin 1.48 1.18 1.18 Agree Yes 

CPT code 67810 was identified as potentially misvalued under the Harvard-valued---

Utilization over 30,000 screen. 

 Medicare claims data from 2011 indicate that CPT code 67810 (Incisional biopsy of 

eyelid skin including lid margin) is typically furnished to the beneficiary on the same day as an 

E/M visit. We believe that some of the activities furnished during the pre- and post-service 

period of the procedure code and the E/M visit overlap. After review, we believe that the AMA 

RUC appropriately accounted for this overlap in its recommendation of pre-service time, but that 

the AMA RUC-recommended post-service time, while reduced from the survey time, is still high 

relative to similar services performed on the same day as an E/M service. To better account for 

this overlap, and to value this service relative to similar services, we reduced the AMA RUCrecommended post-service time for this procedure by one-third, from 5 minutes to 3 minutes. 

After reviewing CPT code 67810 and assessing the overlap in time and work, we agree 

with the AMA RUC-recommended work RVU of 1.18 for this service, which is a decrease from 

the CY 2012 work RVU of 1.48. In sum, on an interim final basis for CY 2013, we are assigning 

a work RVU of 1.18 to CPT code 67810, with a refinement to the AMA RUC recommended 

time. A complete list of the interim final times associated with this procedure is available on the 

CMS website at www.cms.gov/physicianfeesched/. 

(20) Eye and Ocular Adnexa: Conjunctiva 

TABLE 51: Eye and Ocular Adnexa: Conjunctiva 
519 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

68200 Treat eyelid by injection 0.49 0.49 0.49 Agree Yes 

CPT code 68200 was identified as potentially misvalued under the Harvard-valued---

Utilization over 30,000 screen. 

 Medicare claims data from 2011 indicate that CPT code 68200 (Subconjunctival 

injection) is typically furnished to the beneficiary on the same day as an E/M visit. We believe 

that some of the activities furnished during the pre- and post-service period of the procedure 

code and the E/M visit overlap. After review, we believe that the AMA RUC appropriately 

accounted for this overlap in its recommendation of pre-service time, but that the AMA RUC did 

not adequately account for the overlap in the post-service time. To better account for the overlap 

in post-service time, we reduced the AMA RUC-recommended post-service time for this 

procedure by one-third, from 5 minutes to 3 minutes. 

After reviewing CPT code 68200 and assessing the overlap in time and work, we agree 

with the AMA RUC-recommended work RVU of 0.49 for this service. In sum, on an interim 

final basis for CY 2013, we are assigning a work RVU of 0.49 to CPT code 68200, with a 

refinement to the AMA RUC recommended time. A complete list of the interim final times 

associated with this procedure is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

(21) Auditory System: External Ear 

TABLE 52: Auditory System: External Ear 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

69200 Clear outer ear canal 0.77 0.77 0.77 Agree Yes 
520 

CPT code 69200 was identified as potentially misvalued under the Harvard-valued---

Utilization over 30,000 screen. 

 Medicare claims data from 2011 indicate that CPT code 69200 (Removal foreign body 

from external auditory canal; without general anesthesia) is typically furnished to the beneficiary 

on the same day as an E/M visit. We believe that some of the activities furnished during the preand post-service period of the procedure code and the E/M visit overlap. To account for this 

overlap, we removed one-third of the pre-service evaluation time from the pre-service time 

package, reducing the pre-service evaluation time from 7 minutes to 5 minutes. Additionally, we 

reduced the AMA RUC-recommended post-service time for this procedure by one-third, from 5 

minutes to 3 minutes. 

After reviewing CPT code 69200 and assessing the overlap in time and work, we agree 

with the AMA RUC-recommended work RVU of 0.77 for this service. In sum, on an interim 

final basis for CY 2013, we are assigning a work RVU of 0.77 to CPT code 69200, with a 

refinement to the AMA RUC recommended time. A complete list of the interim final times 

associated with this procedure is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

 (22) Diagnostic Radiology (Diagnostic Imaging) 
521 

TABLE 53: Diagnostic Radiology (Diagnostic Imaging) 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

72040 

X-ray exam neck spine 

3/<vws 0.22 0.22 0.22 Agree No 

72050 

X-ray exam neck spine 

4/5vws 0.31 0.31 0.31 Agree No 

72052 

X-ray exam neck spine 

6/>vws 0.36 0.36 0.36 Agree No 

72191 

Ct angiograph pelv 

w/o&w/dye 1.81 N/A 1.81 Interim N/A 

73221 

Mri joint upr extrem w/o 

dye 1.35 1.35 1.35 Agree No 

73721 

Mri jnt of lwr extre w/o 

dye 1.35 1.35 1.35 Agree No 

74170 Ct abdomen w/o & w/dye 1.40 1.40 1.40 Agree No 

74174 

Ct angio abd&pelv 

w/o&w/dye 2.20 2.20 2.20 Interim No 

74175 

Ct angio abdom w/o & 

w/dye 1.90 N/A 1.90 Interim N/A 

74247 Contrst x-ray uppr gi tract 0.69 0.69 0.69 Agree No 

74280 

Contrast x-ray exam of 

colon 0.99 0.99 0.99 Agree No 

74400 Contrst x-ray urinary tract 0.49 0.49 0.49 Agree No 

75896 X-rays transcath therapy 

1.31 (PC), 

Contractor 

Priced (TC) 

Contractor 

Priced 

1.31 (PC), 

Contractor 

Priced (TC) Interim N/A 

75898 Follow-up angiography 

1.65 (PC), 

Contractor 

Priced (TC) 

Contractor 

Priced 

1.65 (PC), 

Contractor 

Priced (TC) Interim N/A 

CPT codes 74175 and 72191 were identified as potentially misvalued through the Codes 

Reported Together 75 percent or More screen. The CPT Editorial Panel created CPT code 

74174, which bundles the work of CPT codes 74175 and 72191, for CY 2012. 

 We reviewed CPT code 74174 (Computed tomographic angiography, abdomen and 

pelvis, with contrast material(s), including noncontrast images, if performed, and image 

postprocessing) for CY 2012. We stated in the CY 2012 PFS final rule with comment period 

that we are accepting the AMA RUC-recommended work RVU of 2.20 for CPT code 74174 on 

an interim basis, and request that the AMA RUC review the component CPT codes: 74175 

(Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast 
522 

images, if performed, and image postprocessing) and 72191 (Computed tomographic 

angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and 

image postprocessing) (76 FR 73200). 

In response to this request, some commenters stated that the AMA RUC operates under 

the premise that the values assigned to all the service paid under the PFS are assumed to be 

accurate and therefore, our request to review the physician work component of CPT codes 74175 

and 72191 is unnecessary. Commenters noted that CPT codes 74175 and 72191 were used as 

important building blocks in the work valuation of CPT code 74174, and that the AMA RUC 

considered their individual values, which in many ways equates to an AMA RUC review. 

Commenters stated that to review individual codes solely because they are bundled to create a 

new code, risks rank-order anomalies within families, which could threaten the relativity of the 

values for services on the PFS. Therefore, commenters stated that they believe an AMA RUC 

review of CPT codes 74175 and 72191 is unnecessary. 

The AMA RUC Relativity Assessment Workgroup referred component CPT codes 74175 

and 72191 to the PE Subcommittee of the AMA RUC to review the direct practice expense 

inputs, but the AMA RUC did not review the physician work or time. 

We have stated many times our belief that when codes are bundled, the new codes should 

be reviewed along with their component codes to ensure consistency in RVUs and inputs. 

Therefore, we reviewed CPT codes 74174, 72191, and 74175 for CY 2013. During this review, 

we saw an anomalous relationship between the physician times assigned to these services. CPT 

code 74174 describes computed tomographic angiography (CTA) of both the abdomen and 

pelvis together. This CPT code includes 5 minutes of pre-service time, 30 minutes of intraservice time, and 5 minutes of post-service time, which is in line with several other similar 

bundled CPT codes. CPT code 74175 describes CTA of the abdomen only, and includes 10 
523 

minutes of pre-service time, 30 minutes of intra-service time, and 10 minutes of post-service 

time. Similarly, CPT code 72191 describes CTA of the pelvis only, and includes 9 minutes of 

pre-service time, 30 minutes of intra-service time, and 10 minutes of post-service time. We do 

not believe that CTA of just the abdomen or just the pelvis should include more pre- and postservice time than the combined code. Also, while we believe furnishing the bundled code does 

not involve much more time than furnishing the stand-alone codes, we find it unlikely that the 

bundled service requires exactly the same intra-service time as the component services. We 

request recommendations from the AMA RUC and other pubic commenters on the appropriate 

work and time values for these services. We are maintaining the current (CY 2012) work RVUs 

and times for CPT codes 74174, 72191, and 74175 on an interim basis for CY 2013, and 

anticipate re-reviewing these services for CY 2014 considering any recommendations that we 

receive. 

 CPT code 75896 was identified as potentially misvalued through the Codes Reported 

Together 75 percent or More screen. 

The associated specialty societies and the AMA RUC intend to survey and review CPT 

code 75896 (Transcatheter therapy, infusion, other than for thrombolysis, radiological 

supervision and interpretation) and related CPT code 75898 (Angiography through existing 

catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for 

thrombolysis) for CY 2014. The AMA RUC recommended carrier pricing these two services for 

CY 2014. Currently (CY 2012) both codes have a national payment rate for the professional 

component of the service, and the technical component of the service is contractor priced. We 

believe it is appropriate to maintain the current national price on the professional component, and 

to contractor price the technical component until we are able to establish a national price that 

appropriately values the practice expenses associated with this service. Therefore, on an interim 
524 

basis for CY 2013, we are assigning a work RVU of 1.31 to the professional component of CPT 

code 75896, and a work RVU of 1.65 to the professional component of CPT code 75898. The 

technical component and global billing for both CPT codes will be contractor priced. We 

anticipate reviewing these services again after reviewing the AMA RUC recommendations for 

these services in CY 2014. 

(23) Diagnostic Ultrasound: Pelvis 

TABLE 54: Diagnostic Ultrasound: Pelvis 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

76830 Transvaginal us non-ob 0.69 0.69 0.69 Agree Yes 

CPT code 76830 was identified as potentially misvalued through the High Expenditure 

Procedure Code screen. 

We reviewed CPT code 76830 (Ultrasound, transvaginal) and believe that the current 

work RVU of 0.69 continues to accurately reflect the work of this services. The AMA RUC also 

recommended maintaining the current work RVU of this service. We are refining the AMA 

RUC-recommended post-service time for this procedure from 10 minutes to 8 minutes to match 

the post-service time of CPT code 76817 (Ultrasound, pregnant uterus, real time with image 

documentation, transvaginal), which, we believe, involves very similar post-service work. In 

sum, on an interim final basis for CY 2013, we are assigning a work RVU of 0.69 to CPT code 

76830, with a refinement to the AMA RUC recommended time. A complete list of the interim 

final times associated with this procedure is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

(24) Radiologic Guidance: Fluoroscopic Guidance 

 TABLE 55: Radiologic Guidance: Fluoroscopic Guidance 
525 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

77001 

Fluoroguide for vein 

device 0.38 N/A 0.38 Interim N/A 

77002 

Needle localization by 

xray 0.54 N/A 0.54 Interim N/A 

77003 

Fluoroguide for spine 

inject 0.60 0.60 0.60 Interim No 

CPT code 77003 was identified as potentially misvalued through the High Expenditure 

Procedure Code screen. 

 We reviewed CPT code 77003 (Fluoroscopic guidance and localization of needle or 

catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 

subarachnoid)), and believe it is necessary to review this service alongside very similar CPT 

codes 77001 (Fluoroscopic guidance for central venous access device placement, replacement 

(catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and 

catheter manipulation, any necessary contrast injections through access site or catheter with 

related venography radiologic supervision and interpretation, and radiographic documentation of 

final catheter position) (list separately in addition to code for primary procedure)) and 77002 

(Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization 

device)) to determine the appropriate relative value for this high volume, high expenditure 

procedure code. The AMA RUC reviewed CPT code 77003 for CY 2013 and concluded that the 

current work RVU of 0.60 is appropriate for this service. It is our understanding that the AMA 

RUC does not intend to review CPT codes 77001 and 77002. We anticipate reviewing CPT 

codes 77001, 77002, and 77003 together in CY 2013 for CY 2014 and request public comments 

on the appropriate work and time values for these services. On an interim basis for CY 2013, we 

are maintaining the current work RVU of 0.60 for CPT code 77003. 

(25) Radiation Oncology: Medical Radiation Physics, Dosimetry, Treatment Devices, and 
526 

Special Services 

TABLE 56: Radiation Oncology: Medical Radiation Physics, Dosimetry, Treatment 

Devices, and Special Services 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

77301 

Radiotherapy dose plan 

imrt 7.99 7.99 7.99 Agree Yes 

CPT code 77301 was identified as potentially misvalued through the High Expenditure 

Procedure Code screen. 

 We reviewed CPT code 77301 (Intensity modulated radiotherapy plan, including dosevolume histograms for target and critical structure partial tolerance specifications) and do not 

believe the work associated with this procedure has changed. The AMA RUC also 

recommended the current work RVU of 7.99 for this service. On an interim final basis for CY 

2013 we are assigning a work RVU of 7.99 to CPT code 77301. Regarding the physician time 

for this service, CPT code 77301 currently (CY 2012) includes 30 minutes of pre-service time, 

131 minutes of intra-service time, and 35 minutes of post-service time. The AMA RUC 

recommended moving the pre-service time associated with this procedure into the intra-service 

period. We do not believe this is appropriate, as we think the physician work associated with 

those 30 minutes is pre-service work and should remain in the pre-service period. Therefore, we 

are assigning an interim final pre-service evaluation time of 30 minutes, intra-service time of 130 

minutes, and post-service time of 35 minutes to CPT code 77301 for CY 2013. 

(26) Molecular Pathology 

TABLE 57: Molecular Pathology 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 
527 

G0452 

Molecular pathology 

interpr New N/A 0.37 N/A N/A 

The AMA CPT Editorial Panel has created new CPT codes to replace the codes used to 

bill for molecular pathology services that will be deleted at the end of CY 2012. The new codes 

describe distinct molecular pathology tests and test methods. The CPT Editorial Panel created 

101 new molecular pathology CPT codes for CY 2012 and another 14 new molecular pathology 

codes for CY 2013. As discussed in detail in section III.I. of this CY 2013 PFS final rule with 

comment period, these new molecular pathology CPT codes will be paid on the CLFS for CY 

2013. 

One of the molecular pathology CPT codes that is being deleted for CY 2012 is payable 

on the PFS: CPT code 83912-26 (Molecular diagnostics; interpretation and report). To replace 

this CPT code, we have created HCPCS code G0452 (molecular pathology procedure; physician 

interpretation and report) to describe medically necessary interpretation and written report of a 

molecular pathology test, above and beyond the report of laboratory results. This professional 

component-only HCPCS G-code will be considered a “clinical laboratory interpretation service,” 

which is one of the current categories of PFS pathology services under the definition of 

physician pathology services at §415.130(b)(4). Section §415.130(b)(4) of the regulations and 

section 60 of the Claims Processing Manual (IOM 100-04, Ch. 12, section 60.E.) specify certain 

requirements for billing the professional component of certain clinical laboratory services 

including that the interpretation (1) must be requested by the patient’s attending physician, (2) 

must result in a written narrative report included in the patient’s medical record, and (3) requires 

the exercise of medical judgment by the consultant physician. We note that a hospital’s standing 

order policy can be used as a substitute for the individual request by a patient’s attending 

physician. The current CPT code for interpretation and report, 83912-26, is included on the 
528 

current list of clinical laboratory interpretation services but will be deleted at the end of CY 

2012. 

As discussed in section III.I. of this CY 2013 PFS final rule with comment period, we 

reviewed the work associated with this procedure, and we believe it is appropriate to directly 

crosswalk the work RVUs and times of CPT code 83912-26 to HCPCS code G0452, because we 

do not believe this coding change reflects a change in the service or in the resources involved in 

furnishing the service. Accordingly, we are assigning a work RVU of 0.37, with 5 minutes of 

pre-service time, 10 minutes of intra-service time, and 5 minutes of post-service time to HCPCS 

code G0452 on an interim final basis for CY 2013. 

(27) Immunology 

TABLE 58: Immunology 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

86153 

Cell enumeration phys 

interp New 0.69 0.69 Agree Yes 

The CPT Editorial Panel created CPT codes 86152 and 86153 to replace CPT Category 

III codes 0279T and 0280T. 

 CPT code 86153 (Cell enumeration using immunologic selection and identification in 

fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when 

required) will be payable on the PFS for the physician interpretation and report of CPT code 

86152 (Cell enumeration using immunologic selection and identification in fluid specimen (eg, 

circulating tumor cells in blood)) which will be payable on the Clinical Laboratory Fee Schedule 

(CLFS). Like HCPCS code G0452 discussed above, CPT code 86153 is a professional 

component-only CPT code that will be considered a “clinical laboratory interpretation service,” 
529 

which is one of the current categories of PFS pathology services under the definition of 

physician pathology services at §415.130(b)(4). This code must be billed with the “26” modifier 

to be paid under the PFS. 

 After reviewing CPT code 86153, we believe that the AMA RUC-recommended work 

RVU of 0.69 appropriately accounts for the work of this service. Accordingly, we are assigning 

a work RVU of 0.69 to CPT code 86153 on an interim final basis for CY 2013. Regarding 

physician time, the AMA RUC recommended 20 minutes of intra-service time and 5 minutes of 

post-service time for CPT code 86153. We believe that all the work of this service belongs in 

the intra-service period, and that 20 minutes accurately captures the time involved in furnishing 

this service. Therefore, we are assigning 0 minutes pre-service time, 20 minutes intra-service 

time, and 0 minutes post-service time to CPT code 86153 on an interim final basis for CY 2013. 

(28) Cytopathology and Surgical Pathology 

TABLE 59: Cytopathology and Surgical Pathology 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

88120 

Cytp urne 3-5 probes ea 

spec 1.20 1.20 1.20 Interim No 

88121 

Cytp urine 3-5 probes 

cmptr 1.00 1.00 1.00 Interim No 

88312 Special stains group 1 0.54 0.54 0.54 Agree No 

88365 Insitu hybridization (fish) 1.20 N/A 1.20 Interim N/A 

88367 Insitu hybridization auto 1.30 N/A 1.30 Interim N/A 

88368 

Insitu hybridization 

manual 1.40 N/A 1.40 Interim N/A 

88375 

Optical endomicroscpy 

interp New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

G0416 Sat biopsy 10-20 3.09 N/A 3.09 N/A N/A 

The CPT Editorial Panel created CPT codes 88120 (Cytopathology, in situ hybridization 

(eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each 

specimen; manual) and 88121 (Cytopathology, in situ hybridization (eg, FISH), urinary tract 
530 

specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computerassisted technology) to describe in situ hybridization testing using urine samples, effective for 

CY 2011. Prior to CY 2011, all in situ hybridization testing was billed using CPT codes 88365 

(In situ hybridization (eg, FISH), each probe), 88367 (Morphometric analysis, in situ 

hybridization (quantitative or semi-quantitative) each probe; using computer-assisted 

technology), and 88368 (Morphometric analysis, in situ hybridization (quantitative or semiquantitative) each probe; manual). The appropriate code would be billed one time for each probe 

used in the performance of the test, regardless of the medium of the specimen (that is, blood, 

tissue, tumor, bone marrow, or urine). We stated in the CY 2012 PFS proposed rule that because 

the descriptors for the new CPT codes 88120 and 88121 include the use of approximately 4 

probes, and existing CPT codes 88367 and 88368 include only 1 probe, we were concerned 

about potential payment discrepancies between the new and existing codes (76 FR 42795 

through 42796). Unlike the new codes for urinary tract specimens, the existing codes (for all 

other specimens) allow for multiple units of each code to be billed. We asked the AMA RUC to 

review the work and PE for existing CPT codes 88365, 88367, and 88368 alongside CPT codes 

88120 and 88121 to ensure the appropriate relativity between these two sets of services (76 FR 

73153 through 73154). 

 In response to that request, the College of American Pathologists (CAP) indicated that 

they would develop a CPT Assistant article clarifying the appropriate usage of each code. The 

AMA RUC stated that it intends to review these services in CY 2013 for CY 2014, after CY 

2012 utilization data are available to assess how these services are being billed. We agree with 

this approach, and are maintaining the current (CY 2012) work RVUs of 1.20 for CPT code 

88120, and 1.00 for CPT code 88121, as interim until we review CPT codes 88120 and 88121 

alongside CPT codes 88365, 88367, and 88368 for CY 2014. 
531 

 We have received information from stakeholders that the current (CY 2012) descriptor 

for HCPCS code G0416 (Surgical pathology, gross and microscopic examination for prostate 

needle saturation biopsy sampling, 1-20 specimens) should be revised to better reflect the 

interaction of this service, and associated RVUs, with billing for surgical pathology. After 

reviewing the service, we agree with stakeholders. For CY 2013, we are revising the descriptor 

for HCPCS code G0416 to the following: Surgical pathology, gross and microscopic 

examination for prostate needle saturation biopsy sampling, 10-20 specimens. HCPCS code 

G0416 will be interim final, and open for public comment for CY 2013. 

(29) Psychiatry 

TABLE 60: Psychiatry 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

90785 Psytx complex interactive New 

Contractor 

Priced 0.11 Interim N/A 

90791 

Psych diagnostic 

evaluation New 3.00 2.80 Interim No 

90792 

Psych diag eval w/med 

srvcs New 3.25 2.96 Interim No 

90832 

Psytx pt&/family 30 

minutes New 1.50 1.25 Interim No 

90833 

Psytx pt&/fam w/e&m 30 

min New 1.50 0.98 Interim No 

90834 

Psytx pt&/family 45 

minutes New 2.00 1.89 Interim No 

90836 

Psytx pt&/fam w/e&m 45 

min New 1.90 1.60 Interim No 

90837 

Psytx pt&/family 60 

minutes New 3.00 2.83 Interim No 

90838 

Psytx pt&/fam w/e&m 60 

min New 2.50 2.56 Interim No 

90839 Psytx crisis initial 60 min New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

90840 Psytx crisis ea addl 30 min New 

Contractor 

Priced 

Contractor 

Priced N/A N/A 

90845 Psychoanalysis 1.79 2.10 1.79 Interim Yes 

90846 Family psytx w/o patient 1.83 2.40 1.83 Interim Yes 

90847 Family psytx w/patient 2.21 2.50 2.21 Interim Yes 

90853 Group psychotherapy 0.59 0.59 0.59 Interim Yes 

90863 

Pharmacologic mgmt 

w/psytx New 

Contractor 

Priced Invalid N/A N/A 
532 

In preparation for the Fourth Five-Year Review of Work, we received comments 

indicating that psychiatry/psychotherapy CPT codes 90801 through 90880 may be potentially 

misvalued. In response to these comments, we requested that the AMA RUC review these 

services. Ultimately, the AMA RUC concluded that the entire section of 

psychiatry/psychotherapy services would benefit from re-structuring within CPT. After a year of 

analysis, the CPT Editorial Panel replaced the current psychiatry/psychotherapy CPT codes with 

a new structure that allows for the separate reporting of E/M codes, eliminates the site-of-service 

differential, establishes CPT codes for crisis, and creates a series of add-on CPT codes to 

psychotherapy to describe interactive complexity and medication management. 

We appreciate all the work that has been completed to date by the CPT Editorial Panel, 

AMA RUC, and involved specialty societies in revising this family of CPT codes. Below we 

discuss the specific CY 2013 work RVUs for the new psychotherapy family of CPT codes. We 

note that related specialty societies have not yet surveyed some of the new CPT codes, namely, 

the new CPT codes for psychotherapy for crisis, interactive complexity, and pharmacologic 

management. The AMA RUC and HCPAC have recommended contractor pricing for these 

services until the surveys are complete. After the specialty societies have completed the survey 

process for all the codes in the new code set, we intend to review the values for all codes in the 

family again. It is our policy to value a family of codes together to ensure more accurate 

valuation and proper relativity. We will take into consideration the AMA RUC and HCPAC 

recommendations, specialty society recommendations, public comments, Medicare utilization 

data, and other available information. For CY 2013, our general approach was to maintain the 

current CPT code values, or adopt values that approximate the values for the current CPT codes 

after adjusting for differences in code structure between CY 2012 and 2013, for all psychiatry 
533 

services on an interim basis, pending a final review of the values for the entire family of CPT 

codes. 

The first major change in the new coding framework involves changes to the CPT codes 

for initial psychiatric evaluation. For CY 2013, the CPT Editorial Panel is deleting CPT codes 

90801 (Psychiatric diagnostic interview examination) (work RVU = 2.80) and 90802 (Interactive 

psychiatric diagnostic interview examination using play equipment, physical devices, language 

interpreter, or other mechanisms of communication) (work RVU = 3.01), and replacing them 

with new CPT codes 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric 

diagnostic evaluation with medical service). CPT code 90791 describes psychiatric diagnostic 

evaluation without medical work. We are assigning an interim work RVU of 2.80, the work 

RVU of deleted CPT code 90801, to this service for CY 2013. CPT code 90792 describes 

psychiatric diagnostic evaluation involving medical work. We are assigning an interim work 

RVU of 2.96 to this service for CY 2013. Currently (CY 2012) the psychotherapy with E/M 

services are valued on average 0.16 work RVUs higher than the psychotherapy without E/M 

services. We believe this is the appropriate differential between the diagnostic evaluation with 

medical services and diagnostic evaluation without medical services CPT codes. Therefore, to 

assign a work RVU to CPT code 90792, which includes medical services, we added 0.16 work 

RVUs to the work RVU of CPT code 90791, which does not include medical services. 

Regarding coding and payment for these CPT codes, we note that CPT prefatory 

language for these new psychiatric diagnosis codes allows for reporting of these codes more than 

once when an informant is “seen in lieu of the patient.” Medicare only pays for services 

provided to diagnose or treat a Medicare beneficiary. Obtaining information from relatives or 

close associates is appropriate in some circumstances, but should not substitute entirely for an 

evaluation of the patient. 
534 

We previously have addressed the delivery of mental health services to caregivers in 

Chapter 1, section 70.1 of the Medicare National Coverage Determinations Manual, Pub. 100-03, 

which provides guidance specifically for current CPT code 90846 (family psychotherapy without 

the patient present). It states that, “In certain types of medical conditions, including when a 

patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician 

may contact relatives and close associates to secure background information to assist in 

diagnosis and treatment planning. When a physician contacts their patient’s relatives or 

associates for this purpose, expenses of such interviews are properly chargeable as physician’s 

services to the patient on whose behalf the information was secured. A physician may also have 

contacts with a patient’s family and associates for purposes other than securing background 

information. In some cases, the physician will provide counseling to members of the household. 

Family counseling services are covered only where the primary purpose of such counseling is the 

treatment of the patient’s condition. For example, two situations where family counseling 

services would be appropriate are as follows: (1) where there is a need to observe the patient’s 

interaction with family members; and/or (2) where there is a need to assess the capability of and 

assist the family members in aiding in the management of the patient. Counseling principally 

concerned with the effects of the patient’s condition on the individual being interviewed would 

not be reimbursable as part of the physician’s personal services to the patient.” Therefore, we 

believe that CPT codes 90791 and 90792 may be used for diagnosis through a relative or close 

associate providing direct care for the patient when the focus of the service is gathering 

additional information about the beneficiary, and cannot substitute for an evaluation of the 

beneficiary. We are concerned that multiple diagnostic evaluations with family members should 

not replace a detailed evaluation of the beneficiary, and we intend to monitor the frequency of 

billing for diagnostic evaluations per patient.
535 

The second major change in the new coding framework involves psychotherapy 

procedure codes without medical services, which we typically expect will be billed by clinical 

psychologists and licensed clinical social workers. For CY 2013, the CPT Editorial Panel 

created stand-alone psychotherapy CPT codes 90832 (Psychotherapy, 30 minutes with patient 

and/or family member), 90834 (Psychotherapy, 45 minutes with patient and/or family member), 

and 90837 (Psychotherapy, 60 minutes with patient and/or family member), that are not site-ofservice specific. These services are currently reported using outpatient and interactive 

outpatient, and inpatient and interactive inpatient psychotherapy CPT codes. To assign interim 

work RVUs to these services that approximate the current values for these services under the 

current CPT coding structure, we assigned each new stand-alone psychotherapy CPT code the 

work RVU of the current corresponding inpatient psychotherapy code. Specifically, we are 

assigning an interim work RVU of 1.25 to CPT code 90832, which is the current work RVU of 

CPT code 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-to-face with the patient;); an interim work RVU of 1.89 to CPT code 90834, 

which is the current work RVU of CPT code 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-to-face with the patient;); and an interim work 

RVU of 2.83 to CPT code 90837, which is the current work RVU of CPT code 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-to-face with the patient;). For CY 2013, the additional work involved in psychotherapy 

with higher interactive complexity will be captured using an interactive complexity add-on CPT 

code, discussed below. 
536 

Regarding coding and payment for these psychotherapy CPT codes, we note that the CY 

2012 CPT codes describe time spent face-to-face with the patient, while the CY 2013 CPT codes 

describe time spent with the patient and/or family member. As discussed above in relation to 

CPT codes 90791 and 90792, Medicare only pays for services provided to diagnose or treat a 

Medicare beneficiary. Obtaining information from relatives or close associates is appropriate in 

some circumstances, but should not substitute for direct treatment of the beneficiary. We would 

expect psychotherapy to be billed only when the beneficiary is present for a significant portion of 

the service. 

The third major change in the new coding framework involves psychotherapy services 

furnish alongside an E/M service. For CY 2013, the CPT Editorial Panel created CPT codes 

90833 (Psychotherapy, 30 minutes with patient and/or family member when performed with an 

evaluation and management service (list separately in addition to the code for primary 

procedure)), 90836 (Psychotherapy, 45 minutes with patient and/or family member when 

performed with an evaluation and management service (list separately in addition to the code for 

primary procedure)) and 90838 (Psychotherapy, 60 minutes with patient and/or family member 

when performed with an evaluation and management service (list separately in addition to the 

code for primary procedure)). These services are currently reported using outpatient and 

interactive outpatient, and inpatient and interactive inpatient psychotherapy with E/M CPT 

codes. For CY 2013, physicians and qualified nonphysician practitioners that can bill for E/M 

services will now bill for psychotherapy with evaluation and management using the existing E/M 

structure and a choice of one add-on psychotherapy time-based code, 30, 45 or 60 minutes. At 

this time, we believe that the work involved in furnishing the psychotherapy add-on CPT codes 

is very similar to the work of furnishing the stand-alone psychotherapy CPT codes (CPT codes 

90832, 90834, and 90837). We believe the difference in work between the psychotherapy add-
537 

on codes and stand-alone psychotherapy CPT codes is not in the intensity of the services; rather, 

it is in amount of time involved in furnishing them. The AMA RUC has recommended, and we 

agree, that the psychotherapy add-on CPT codes include 12 minutes less time than the standalone psychotherapy CPT codes. The psychotherapy add-on CPT codes are furnished alongside 

an E/M service, so some of the activities in the stand-alone psychotherapy CPT codes should not 

be included in the psychotherapy add-on CPT codes because those activities (reviewing the 

record, coordinating care, and some documentation and reporting activities) are included in the 

E/M service with which the add-on codes will be billed. Accordingly, to assign interim work 

RVUs to each of the new psychotherapy add-on CPT codes, we started with the interim work 

RVU of the corresponding new stand-alone psychotherapy CPT code, and then reduced that 

RVU by 0.27 RVUs, to capture the 12 minutes less time assigned to these services (12 minutes at 

an intensity of 0.0224 RVUs per minute= 0.27 RVUs). Specifically, we are assigning an interim 

work RVU of 0.98 to CPT code 90833; an interim work RVU of 1.60 for CPT code 90836; and 

an interim work RVU of 2.56 for CPT code 90838. 

Like the stand-alone psychotherapy services, we note that the CY 2012 CPT codes 

describe time spent face-to-face with the patient, while the CY 2013 CPT codes describe time 

spent with the patient and/or family member. As discussed above, Medicare only pays for 

services provided to diagnose or treat a Medicare beneficiary. Obtaining information from 

relatives or close associates is appropriate in some circumstances, but should not substitute for 

direct treatment of the beneficiary. We would expect psychotherapy to be billed only when the 

beneficiary is present for a significant portion of the service. 

Additionally, the CY 2013 coding structure includes a new add-on CPT code for 

interactive complexity, CPT code 90785 (Interactive complexity (list separately in addition to the 

code for primary procedure)). The interactive complexity add-on CPT code, when billed with a 
538 

psychotherapy service, replaces the CY 2012 CPT codes for interactive psychotherapy. As 

stated above, this service has not yet been surveyed by the related specialty societies, and the 

AMA RUC recommended contractor pricing this service for CY 2013. However, given that 

services involving interactive complexity are nationally priced in the CY 2012 coding structure, 

we believe we have enough information to assign interim work RVUs for CPT code 90785 for 

CY 2013. In the 2012 coding structure, there are CPT codes for outpatient and inpatient 

psychotherapy services and corresponding CPT codes for outpatient and inpatient interactive 

psychotherapy services. For both the outpatient and inpatient services, the interactive service has 

a work RVU that is 0.11 RVUs higher than the corresponding service that is not interactive. We 

believe this reflects the current value of interactive services. Therefore, we are assigning an 

interim work RVU of 0.11 to CPT code 90785 for CY 2013. We are assigning this service 0 

minutes of physician time because the work RVU of 0.11 reflects only the incremental difference 

in intensity of the base procedure; the time of this service is captured in the time of the procedure 

with which it is billed. 

 Regarding coding and payment for CPT code 90785, the CPT prefatory language for this 

service states that psychiatric procedures may be reported with interactive complexity for 

“...Use of play equipment, other physical devices, interpreter or translator to communicate with 

the patient to overcome barriers to therapeutic or diagnostic interaction between the physician or 

other qualified health care professional and a patient who is not fluent in the same language as 

the physician or other qualified health care professional, or has not developed, or has lost, either 

the expressive language communication skills to explain his/her symptoms and response to 

treatment, or the receptive communication skills to understand the physician or other qualified 

health care professional if he/she were to use typical language for communication.” Given this 

language, we would like to clarify that CPT code 90785 generally should not be billed solely for 
539 

the purpose of translation or interpretation services. Federal laws prohibit discrimination, which 

in this case would take the form of higher beneficiary payments and copayments for the same 

service, based on disability or ethnicity. Billing for this service solely for translation or 

interpretation related to a beneficiary’s disability could implicate section 504 of the 

Rehabilitation Act of 1973 and the Americans with Disabilities Act, and billing for this service 

solely for translation or interpretation related to foreign language could implicate Title VI of the 

Civil Rights Act of 1964. 

The CPT Editorial Panel has created two new CPT codes for psychotherapy when a 

patient is in crisis, CPT codes 90839 (Psychotherapy for crisis; first 60 minutes) and 90840 

(Psychotherapy for crisis; each additional 30 minutes (list separately in addition to code for 

primary service)). As these CPT codes have not yet been surveyed, the AMA RUC has 

recommended contractor pricing for CPT codes 90839 and 90840 for CY 2013. We agree and 

are assigning CPT codes 90839 and 90840 a PFS procedure status of C (Contractors price the 

code. Contractors establish RVUs and payment amounts for these services on an interim basis 

for CY 2013. 

Additionally, for CY 2013, the CPT Editorial Panel has deleted CPT code 90862 

(Pharmacologic management, including prescription, use, and review of medication with no 

more than minimal medical psychotherapy). For CY 2013, psychiatrists will now bill the 

appropriate E/M code when furnishing pharmacologic management services. The CPT Editorial 

Panel also created CPT add-on code 90863 (Pharmacologic management, including prescription 

and review of medication, when performed with psychotherapy services (list separately in 

addition to the code for primary procedure) to describe medication management by a 

nonphysician when furnished with psychotherapy. We understand from our past meetings with 

stakeholders that the ability to prescribe medicine is predicated upon first providing evaluation 
540 

and management (E/M) services. We have discussed in previous rulemaking that Medicare does 

not recognize clinical psychologists to bill E/M services because they are not authorized to 

furnish those services under their state scope of practice (62 FR 59057). While clinical 

psychologists have been granted prescribing privileges in Louisiana and New Mexico, they are 

not licensed or authorized under their State scope of practice to furnish the full range of 

traditional E/M services. CPT code 90862 describes pharmacologic management, including 

prescription, use, and review of medication with no more than minimal medical psychotherapy. 

This descriptor reference to “medical psychotherapy” implies that the service furnished under 

CPT code 90862 is an E/M service, and therefore, clinical psychologists cannot bill Medicare for 

CPT code 90862. We also believe that clinical psychologists would continue to be precluded 

from billing Medicare for pharmacologic management services under new CPT code 90863, 

even in the absence of the reference to “medical psychotherapy” because pharmacologic 

management services require some knowledge and ability to perform evaluation and 

management services. Even though clinical psychologists in Louisiana and New Mexico have 

been granted prescribing privileges, clinical psychologists in those and other states are not 

licensed or authorized to furnish E/M services. Accordingly, on an interim basis for CY 2013, 

we are assigning CPT code 90863 a PFS procedure status indicator of I (Not valid for Medicare 

purposes. Medicare uses another code for the reporting of and the payment for these services.). 

We invite public comment on our interim assignment of this procedure status. 

 Finally, under the new coding structure, existing psychotherapy CPT codes 90845 

(Psychoanalysis), 90846 (Family psychotherapy (without the patient present)), 90847 (Family 

psychotherapy (conjoint psychotherapy) (with patient present)), and 90853 (Group 

psychotherapy (other than of a multiple-family group)) remain essentially unchanged for CY 

2013. We are maintaining the current (CY 2012) work RVUs and times for these services on an 
541 

interim basis for CY 2013. Specifically, we are assigning an interim work RVU of 1.79 for CPT 

code 90845; an interim work RVU of 1.83 for CPT code 90846; and interim work RVU of 2.21 

for CPT code 90847; and an interim work RVU of 0.59 for CPT code 90853. 

 The AMA RUC and HCPAC-recommended RVUs are listed in the table at the start of 

this section. Regarding physician time, we accepted the AMA RUC-recommended times for all 

the new CPT codes in this family. We are maintaining the current work RVUs and times for 

existing CPT codes 90845, 90846, 90847, and 90853 on an interim basis until we are able to 

review all the recommended values for this family of CPT codes. Regarding the utilization 

crosswalk, we made some refinements to the AMA RUC-recommended utilization crosswalks 

for the new psychotherapy CPT codes, based on our understanding of how these services will be 

billed for CY 2013. We will re-review these assumptions when we review all recommended 

values for this family of CPT codes. The CY 2013 physician time file and utilization crosswalk 

are available on the CMS website at www.cms.gov/physicianfeesched/. 

(30) Cardiovascular: Therapeutic Services and Procedures 

TABLE 61: Cardiovascular: Therapeutic Services and Procedures 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

92920 

Prq cardiac angioplast 1 

art New 9.00 10.10 Disagree Yes 

92921 Prq cardiac angio addl art New 4.00 Bundled N/A N/A 

92924 

Prq card angio/athrect 1 

art New 11.00 11.99 Disagree Yes 

92925 Prq card angio/athrect addl New 5.00 Bundled N/A N/A 

92928 

Prq card stent w/angio 1 

vsl New 10.49 11.21 Disagree Yes 

92929 

Prq card stent w/angio 

addl New 4.44 Bundled N/A N/A 

92933 Prq card stent/ath/angio New 12.32 12.54 Disagree Yes 

92934 Prq card stent/ath/angio New 5.50 Bundled N/A N/A 

92937 Prq revasc byp graft 1 vsl New 10.49 11.20 Disagree Yes 

92938 Prq revasc byp graft addl New 6.00 Bundled N/A N/A 

92941 Prq card revasc mi 1 vsl New 12.32 12.56 Disagree No 

92943 Prq card revasc chronic New 12.32 12.56 Disagree Yes 
542 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

1vsl 

92944 

Prq card revasc chronic 

addl New 6.00 Bundled N/A N/A 

CPT code 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous, 

with or without other therapeutic intervention, any method; single vessel) was identified for 

review because it is on the MPC list. After reviewing CPT code 92980, the related specialty 

societies believed that the family of percutaneous coronary intervention (PCI) codes should be 

revised to better reflect current practice, and referred the family of codes to the CPT Editorial 

Panel for review. 

The CPT Editorial Panel approved 13 new PCI CPT codes for CY 2013 to replace the 6 

existing codes. In the current (CY 2012) coding structure, CPT code 92980 describes the 

placement of a coronary stent in a single vessel, and add-on CPT code 92981 describes 

placement of a stent in each additional vessel. As currently described, a single vessel includes 

one artery and all its branches. Under this coding convention, if a physician placed a stent in one 

artery and one branch to that artery, the physician would bill only CPT code 92980. If that 

physician placed a stent in one artery and one branch of that artery, then went on to place a stent 

in a second artery and one branch of that artery, the physician would bill CPT code 92980 along 

with add-on CPT code 92981. 

The CY 2013 coding structure creates more codes and more granular coding. For CY 

2013, the placement of a stent in an artery is billed using a base code, and the placement of a 

stent in a branch of that artery is billed using an add-on code. Stenting each new artery is billed 

using a new base code and stenting each branch is billed using an add-on to that base code. If a 

physician placed a stent in one artery and one branch of that artery, and then went on to place a 
543 

stent in a second artery and one branch of that second artery, the physician would bill two base 

code/add-on pairs. 

The CPT Panel made similar changes to the current codes for angioplasty and 

atherectomy and added new codes for atherectomy with stenting, any revascularization of a 

coronary artery bypass graft, and any revascularization procedure through a chronic total 

occlusion of any coronary artery or graft. The CPT Panel created a separate base code for each 

procedure for each new artery and an add-on code for each branch within that artery. Finally, the 

CPT Panel created a new code for any revascularization procedure for an acute coronary artery 

occlusion during an acute myocardial infarction. This final code does not have an add-on code. 

We believe that this revised coding structure represents a CPT trend toward identifying 

greater granularity in codes describing the most intense and difficult work. As we discuss in 

section III.B.1. of this final rule with comment period, the agency has an interest in pursuing 

additional bundling in the PFS payment structure. Bundling is one method for structuring 

payment that can improve payment accuracy and efficiency. We believe that unbundling the 

placement of branch-level stents in a fee-for-service system may encourage increased placement 

of stents. To eliminate that incentive, on an interim final basis for CY 2013, we are rebundling 

the work associated with the placement of a stent in an arterial branch into the base code for the 

placement of a stent in an artery. 

Specifically, we are bundling the work of CPT code 92921 (Percutaneous transluminal 

coronary angioplasty; each additional branch of a major coronary artery (list separately in 

addition to code for primary procedure)) into CPT code 92920 (Percutaneous transluminal 

coronary angioplasty; single major coronary artery or branch); we are bundling the work of CPT 

code 92925 (Percutaneous transluminal coronary atherectomy, with coronary angioplasty when 

performed; each additional branch of a major coronary artery (list separately in addition to code 
544 

for primary procedure)) into CPT code 92924 (Percutaneous transluminal coronary atherectomy, 

with coronary angioplasty when performed; single major coronary artery or branch); we are 

bundling with work of CPT code 92929 (Percutaneous transcatheter placement of intracoronary 

stent(s), with coronary angioplasty when performed; each additional branch of a major coronary 

artery (list separately in addition to code for primary procedure)) into CPT code 92928 

(Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when 

performed; single major coronary artery or branch); we are bundling the work of CPT code 

92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary 

angioplasty when performed; each additional branch of a major coronary artery (list separately in 

addition to code for primary procedure)) into CPT code 92933 (Percutaneous transluminal 

coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; 

single major coronary artery or branch); we are bundling the work of CPT code 92938 

(Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal 

mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and 

angioplasty, including distal protection when performed; each additional branch subtended by 

the bypass graft (list separately in addition to code for primary procedure)) into CPT code 92937 

(Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal 

mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and 

angioplasty, including distal protection when performed; single vessel); and we are bundling the 

work of CPT code 92944 (Percutaneous transluminal revascularization of chronic total 

occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any 

combination of intracoronary stent, atherectomy and angioplasty; each additional coronary 

artery, coronary artery branch, or bypass graft (list separately in addition to code for primary 

procedure)) into CPT code 92943 (Percutaneous transluminal revascularization of chronic total 
545 

occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any 

combination of intracoronary stent, atherectomy and angioplasty; single vessel). 

To bundle the work of each new add-on code into its respective base code, we used the 

AMA RUC-recommended utilization crosswalk to determine what percentage of the base code 

utilization would be billed with the add-on code, and added that percentage of the add-on code 

AMA RUC-recommended work RVU to the base code AMA RUC-recommended work RVU. 

For example, the AMA RUC estimated that CPT code 92920 would have 26,848 Medicare 

allowed services in CY 2013, and that corresponding add-on CPT code 92921 would have 7,368 

Medicare allowed services in CY 2013. Therefore, the AMA RUC estimates that CPT code 

92920 will be billed without add-on CPT code 92921 for 73 percent of the Medicare allowed 

services, and that CPT code 92920 will be billed with add-on CPT code 92921 for 27 percent of 

the allowed services (7,368/26,848). To account for the additional work involved in 27 percent 

of the allowed services, we added a work RVU of 1.10 (27.44 percent of a work RVU of 4.00 for 

CPT code 92921) to the work RVU of 9.00 for CPT code 92920, to get to a work RVU of 10.10 

for the combined service. We followed this methodology to establish the combined work RVUs 

for all the new base code/add-on code pairs. Based this methodology, we are assigning the 

following interim final work RVUs for CY 2013: a work RVU of 10.10 to CPT code 92920; a 

work RVU of 11.99 to CPT code 92924; a work RVU of 11.21 to CPT code 92928; a work RVU 

of 12.54 to CPT code 92933; a work RVU of 11.20 to CPT code 92937; and a work RVU of 

12.56 to CPT code 92943. On an interim final basis for CY 2013, add-on CPT codes 92921, 

92925, 92929, 92934, 92938, and 92944 will have a PFS procedure status indicator of B 

(Bundled code. Payments for covered services are always bundled into payment for other 

services, which are not specified. If RVUs are shown, they are not used for Medicare payment. 
546 

If these services are covered, payment for them is subsumed by the payment for the services to 

which they are bundled) and will not be separately payable. 

We did not use this methodology directly to establish a work RVU for CPT code 92941 

(Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute 

myocardial infarction, coronary artery or coronary artery bypass graft, any combination of 

intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when 

performed, single vessel), which does not have a specific corresponding add-on code. After 

reviewing this service alongside the other services in this family, like the AMA RUC, we believe 

CPT code 92941 should have the same work RVU as CPT code 92943 to preserve the 

appropriate rank order of the services in this family. As we stated above, we are assigning a 

work RVU of 12.56 to CPT code 92943. Therefore, on an interim final basis for CY 2013 we 

are assigning a work RVU of 12.56 to CPT code 92941, with the AMA RUC-recommended 

intra-service time of 70 minutes. 

The AMA RUC recommended RVUs for these services are listed in the table above. The 

CY 2013 physician time file and utilization crosswalk are available on the CMS website at 

www.cms.gov/physicianfeesched/. 

(31) Cardiovascular: Intracardiac Electrophysiological Procedures/Studies 

 TABLE 62: Cardiovascular: Intracardiac Electrophysiological Procedures/Studies 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

93653 

Ep & ablate supravent 

arrhyt New 15.00 15.00 Agree No 

93654 Ep & ablate ventric tachy New 20.00 20.00 Agree No 

93655 Ablate arrhythmia add on New 9.00 7.50 Disagree No 

93656 Tx atrial fib pulm vein isol New 20.02 20.02 Agree No 

93657 Tx l/r atrial fib addl New 10.00 7.50 Disagree No 

CPT codes 93651 and 93652 were identified as potentially misvalued through the Codes 
547 

Reported Together 75 percent or More screen. The CPT Editorial Panel deleted CPT codes 

93651 and 93652, and replaced them with new CPT codes 93653 through 93657 for CY 2013. 

 We reviewed new CPT codes 93653 (Comprehensive electrophysiologic evaluation 

including insertion and repositioning of multiple electrode catheters with induction or attempted 

induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and 

recording, his recording with intracardiac catheter ablation of arrhythmogenic focus; with 

treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, 

accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or 

source of atrial re-entry), 93654 (Comprehensive electrophysiologic evaluation including 

insertion and repositioning of multiple electrode catheters with induction or attempted induction 

of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, 

his recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of 

ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 

3d mapping, when performed, and left ventricular pacing and recording, when performed), and 

93656 (Comprehensive electrophysiologic evaluation including transseptal catheterizations, 

insertion and repositioning of multiple electrode catheters with induction or attempted induction 

of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and 

recording, his bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with 

treatment of atrial fibrillation by ablation by pulmonary vein isolation). We believe that the 

survey 25th percentile work RVUs of 15.00 for CPT code 93653, 20.00 for CPT code 93654, and 

20.02 for CPT code 93656 accurately account for the work involved in furnishing these services. 

The AMA RUC recommended these values as well, with 180 minutes of intra-service time for 

CPT code 93653, and 240 minutes of intra-service time for CPT codes 93654 and 93656. We 

agree with these values. Accordingly, we are assigning a work RVU of 15.00 for CPT code 
548 

93653, a work RVU of 20.00 for 93654, and a work RVU of 20.02 for CPT code 93656, with no 

refinements to the AMA RUC-recommended time, on an interim final basis for CY 2013. 

 After reviewing CPT codes 93655 (Intracardiac catheter ablation of a discrete mechanism 

of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic 

maneuvers, to treat a spontaneous or induced arrhythmia (list separately in addition to code for 

primary procedure)) and 93657 (Additional linear or focal intracardiac catheter ablation of the 

left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary 

vein isolation (list separately in addition to code for primary procedure)), we believe these CPT 

codes have a very similar level of intensity as their related base codes: CPT codes 93653, 93654, 

and 93656. CPT codes 93653, 93654, and 93656 are all valued at 5.00 RVUs per 1 hour of intraservice time. We believe this is the appropriate increment for CPT codes 93655 and 93657 as 

well, which include 90 minutes of intra-service time. Therefore, we believe that a work RVU of 

7.50 accurately accounts for the work of these services and reflects the appropriate relativity 

within this family of CPT codes. The AMA RUC recommended a work RVU of 9.00 for CPT 

code 93655 and a work RVU of 10.00 for CPT code 93657. We are assigning a work RVU of 

7.50 to CPT codes 93655 and 93657 with no refinements to the AMA RUC-recommended time, 

on an interim final basis for CY 2013. 

(32) Noninvasive Vascular Diagnostic Studies: Extremity Arterial Studies (Including Digits) 

TABLE 63: Noninvasive Vascular Diagnostic Studies: Extremity Arterial Studies 

(Including Digits) 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

93925 Lower extremity study 0.58 0.90 0.80 Disagree Yes 

93926 Lower extremity study 0.39 0.70 0.50 Disagree Yes 

93970 Extremity study 0.68 0.70 0.70 Agree No 

93971 Extremity study 0.45 0.45 0.45 Agree No 
549 

CPT codes 93925 and 93926 were identified by the AMA RUC as potentially misvalued 

because the time and PE inputs for these services had never been reviewed by the AMA RUC 

and these services have utilization of 500,00 service per year. 

 After reviewing CPT codes 93925 (Duplex scan of lower extremity arteries or arterial 

bypass grafts; complete bilateral study) and 93926 (Duplex scan of lower extremity arteries or 

arterial bypass grafts; unilateral or limited study), we believe that the specialty society survey 

25th percentile work RVUs of 0.80 for CPT code 93925, and 0.50 for CPT code 93926 accurately 

account for the work involved in furnishing these services and appropriately captures the 

increase in work since these services were last valued. We believe that the AMA RUCrecommended the survey median work RVUs of 0.90 for CPT code 93925 and 0.70 for 93926 

overstate the increase in value for these services and that those values are too high relative to 

similar services. Regarding physician time, we have refined the AMA RUC-recommended preservice and post-service times from 5 minutes to 3 minutes to align with similar CPT codes 

93922 (Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, 

(eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior 

tibial/dorsalis pedis arteries plus bidirectional, doppler waveform recording and analysis at 1-2 

levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries 

plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and 

anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 

levels)) and 93923 (Complete bilateral noninvasive physiologic studies of upper or lower 

extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal 

posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure 

measurements with bidirectional doppler waveform recording and analysis, at 3 or more levels, 

or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
550 

segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal 

posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen 

tension measurements at 3 or more levels), or single level study with provocative functional 

maneuvers (eg, measurements with postural provocative tests, or measurements with reactive 

hyperemia). In sum, we are assigning a work RVU of 0.80 to CPT code 93925 and a work RVU 

of 0.50 to CPT code 93926, with refinements to the AMA RUC-recommended times, on an 

interim final basis for CY 2013. A complete list of the interim final times assigned to these 

procedures is available on the CMS website at www.cms.gov/physicianfeesched/. 

(33) Neurology and Neuromuscular Procedures: Sleep Medicine Testing 

 TABLE 64: Neurology and Neuromuscular Procedures: Sleep Medicine Testing 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

95782 

Polysom <6 yrs 4/> 

paramtrs New 3.00 2.60 Disagree No 

95783 Polysom <6 yrs cpap/bilvl New 3.20 2.83 Disagree No 

The CPT Editorial Panel created CPT codes 95782 and 95783 for CY 2013 to describe 

the physician work involved in pediatric polysomnography for children 5 years of age or 

younger. 

 We reviewed CPT codes 95782 and 95783 and determined that the specialty society 

survey 25th percentile work RVUs of 2.60 for CPT code 95782 (Polysomnography; younger than 

6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) 

and 2.83 for CPT code 95783 (Polysomnography; younger than 6 years, sleep staging with 4 or 

more additional parameters of sleep, with initiation of continuous positive airway pressure 

therapy or bi-level ventilation, attended by a technologist) appropriately reflect the work 

involved in furnishing these services. CPT codes 95782 and 95783 were previously reported 
551 

under CPT codes 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more 

additional parameters of sleep, attended by a technologist) and 95811 (Polysomnography; age 6 

years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of 

continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist). 

These CPT codes (95810 and 95811) have revised descriptors for CY 2013 indicating age 6 

years and older. CPT code 95810 has a CY 2012 work RVU of 2.50, and CPT code 95811 has a 

CY 2012 work RVU of 2.60. We believe the increase from these current work RVUs to the CY 

2013 work RVUs of 2.60 for CPT code 95782 and 2.83 for CPT code 95783 reflect the 

incremental difference in work between the existing services for ages 6 years and older and new 

services for younger than 6 years. The AMA RUC recommended the specialty society survey 

median work RVUs of 3.00 for CPT code 95782 and 3.20 for CPT code 95783. We are 

assigning a work RVU of 2.60 to CPT code 95782 and a work RVU of 2.83 to CPT code 95783 

on an interim final basis for CY 2013. 

(34) Neurology and Neuromuscular Procedures: Electromyography and Nerve Conduction Tests 

TABLE 65: Neurology and Neuromuscular Procedures: Electromyography and Nerve 

Conduction Tests 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

95860 Muscle test one limb 0.96 0.96 0.96 Agree No 

95861 Muscle test 2 limbs 1.54 1.54 1.54 Agree No 

95863 Muscle test 3 limbs 1.87 1.87 1.87 Agree No 

95864 Muscle test 4 limbs 1.99 1.99 1.99 Agree No 

95865 Muscle test larynx 1.57 1.57 1.57 Agree No 

95866 

Muscle test 

hemidiaphragm 1.25 1.25 1.25 Agree No 

95867 

Muscle test cran nerv 

unilat 0.79 0.79 0.79 Agree No 

95868 

Muscle test cran nerve 

bilat 1.18 1.18 1.18 Agree No 

95869 Muscle test thor paraspinal 0.37 0.37 0.37 Agree No 

95870 Muscle test nonparaspinal 0.37 0.37 0.37 Agree No 

95885 

Musc tst done w/nerv tst 

lim 0.35 0.35 0.35 Agree No 

95886 Musc test done w/n test 0.92 0.92 0.70 Disagree No 
552 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

comp 

95887 

Musc tst done w/n tst 

nonext 0.73 0.73 0.47 Disagree No 

95905 

Motor &/ sens nrve cndj 

test 0.05 0.05 0.05 Agree No 

95907 

Motor&/sens 1-2 nrv cndj 

tst New 1.00 1.00 Agree No 

95908 

Motor&/sens 3-4 nrv cndj 

tst New 1.37 1.25 Disagree Yes 

95909 

Motor&/sens 5-6 nrv cndj 

tst New 1.77 1.50 Disagree Yes 

95910 

Motor&sens 7-8 nrv cndj 

test New 2.80 2.00 Disagree No 

95911 

Motor&sen 9-10 nrv cndj 

test New 3.34 2.50 Disagree No 

95912 

Motor&sen 11-12 nrv cnd 

test New 4.00 3.00 Disagree No 

95913 

Motor&sens 13/> nrv cnd 

test New 4.20 3.56 Disagree No 

 CPT codes 95860, 95861, 95863, and 95864 were identified as potentially misvalued 

through the Codes Reported Together 75 percent or More screen. The related specialty societies 

submitted a code change proposal to the CPT Editorial Panel to bundle the services commonly 

reported together. In response, for CY 2012, the CPT Panel created three add-on codes (CPT 

codes 95885 through 95887), and for CY 2013, the Panel created seven new codes (CPT codes 

95907 through 95913) that bundle the work of multiple nerve conduction studies into each 

individual code. 

 We first reviewed CPT codes 95885 (Needle electromyography, each extremity, with 

related paraspinal areas, when performed, done with nerve conduction, amplitude and 

latency/velocity study; limited (list separately in addition to code for primary procedure)), 95886 

(Needle electromyography, each extremity, with related paraspinal areas, when performed, done 

with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 

studied, innervated by three or more nerves or four or more spinal levels (list separately in 
553 

addition to code for primary procedure)), and 95887 (Needle electromyography, non-extremity 

(cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and 

latency/velocity study (list separately in addition to code for primary procedure)) for the CY 

2012 PFS final rule with comment period. We stated that we were accepting the AMA RUCrecommended work RVUs and times on an interim basis, pending review of the other 

electromyography services (76 FR 73207). For CY 2013 we were able to review these services 

alongside the related electromyography services and nerve conduction tests. After reviewing 

these services, we agree with the AMA RUC-recommended times and RVUs for needle 

electromyography CPT codes 95860 through 95870 (all listed in the table above). We also agree 

with the AMA RUC-recommendations for the CY 2012 needle electromyography add-on CPT 

code 95885, however we do not agree with the AMA RUC recommendations for the other two 

CY 2012 needle electromyography add-on CPT codes 95886 and 95887. 

 After review, we determined that the AMA RUC-recommended work RVU of 0.35 for 

CPT code 95885 was appropriate and was well-aligned with CPT code 95870 (Needle 

electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles 

(unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or 

sphincters), to which we are assigning a work RVU of 0.37; the services involve similar work 

and both include 15 minutes of intra-service time. We believe that CPT codes 95886 and 95887 

involve the same level of work intensity as CPT code 95885. To determine the appropriate RVU 

for CPT codes 95886 and 95887 relative to 95885, we increased the work RVU in proportion to 

the increase in time for the services. Under this methodology, because we are assigning a work 

RVU of 0.35 and 15 minutes of intra-service time to CPT code 95885, we believe it is 

appropriate to assign a work RVU of 0.70 to CPT code 95886, which has an intra-service time of 

30 minutes; and a work RVU of 0.47 to CPT code 95887, which has an intra-service time of 20 
554 

minutes. The AMA RUC recommended a work RVU of 0.92 for CPT code 95886 and a work 

RVU of 0.73 for CPT code 95887. We are assigning a work RVU of 0.70 to CPT code 95886 

and a work RVU of 0.47 to CPT code 95887 on an interim final basis for CY 2013. 

 We reviewed new CPT codes 95907 (Nerve conduction studies; 1-2 studies), 95908 

(Nerve conduction studies; 3-4 studies), 95909 (Nerve conduction studies; 5-6 studies), 95910 

(Nerve conduction studies; 7-8 studies), 95911 (Nerve conduction studies; 9-10 studies), 95912 

(Nerve conduction studies; 11-12 studies), and 95913 (Nerve conduction studies; 13 or more 

studies) and found that the progression of the survey 25th percentile work RVUs and survey 

median times appropriately reflect the relativity of these services. The two CPT codes in the 

nerve conduction studies series that describe the fewest nerve conduction studies, 95907 and 

95908, are the exception to this trend, as the survey 25th percentile work RVUs are too low 

relative to other fee schedule services. For CPT code 95907, the survey 25th percentile work 

RVU is 0.48, but we believe that the survey median and AMA RUC recommended work RVU of 

1.00 is more appropriate for this service. For CPT code 95908, the survey 25th percentile work 

RVU is 1.00, however CPT code 95908 should be valued between CPT code 95907 and 95909, 

which has a survey 25th percentile work RVU of 1.50. We believe a work RVU of 1.25, halfway between the work RVU of CPT codes 95907 and 95909, accurately reflects the work of this 

service relative to other services in this series. The AMA RUC recommended the survey median 

values for most of the services in the series, and used a crosswalk methodology to develop a 

work RVU recommendation for CPT codes 95908 and 95909. In sum, on an interim final basis 

for CY 2013, we are assigning a work RVU of 1.00 to CPT code 95907; a work RVU of 1.25 to 

CPT code 95908; a work RVU of 1.50 to CPT codes 95909; a work RVU of 2.00 to CPT codes 

95910; a work RVU of 2.50 to CPT code 95911; a work RVU of 3.00 to CPT code 95912; and a 

work RVU of 3.56 to CPT code 95913. We are refining the AMA RUC-recommended intra-
555 

service time for CPT code 95908 from 25 minutes to the survey median time of 22 minutes, and 

for CPT code 95909 from 35 minutes to the survey median time of 30 minutes, so that all the 

CPT codes in this series are valued using the survey median intra-service time. A complete list 

of the interim final times assigned to these procedures is available on the CMS website at 

www.cms.gov/physicianfeesched/. 

(35) Neurology and Neuromuscular Procedures: Evoked Potentials and Reflex Tests 

TABLE 66: Neurology and Neuromuscular Procedures: Evoked Potentials and Reflex 

Tests 

HCPCS 

Code Short Descriptor 

CY 

2012 

Work 

RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

95925 Somatosensory testing 0.54 N/A 0.54 Interim N/A 

95926 Somatosensory testing 0.54 N/A 0.54 Interim N/A 

95928 

C motor evoked uppr 

limbs 1.50 N/A 1.50 Interim N/A 

95929 C motor evoked lwr limbs 1.50 N/A 1.50 Interim N/A 

95938 Somatosensory testing 0.86 0.86 0.86 Interim No 

95939 

C motor evoked upr&lwr 

limbs 2.25 2.25 2.25 Interim No 

 

CPT code pairs 95925 with 95926, and 95928 with 95929, were identified as potentially 

misvalued through the Codes Reported Together 75 percent or More screen. For CY 2012, the 

CPT Editorial Panel created CPT code 95938 to capture the reporting of CPT codes 95925 and 

95926 together, and CPT codes 95939 to capture the reporting of CPT codes 95928 with 95929. 

The related specialty societies surveyed CPT codes 95938 and 95939 and the AMA RUC sent us 

recommendations on those services for the CY 2012 PFS final rule with comment period. 

We reviewed CPT codes 95938 (Short-latency somatosensory evoked potential study, 

stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; 

in upper and lower limbs) and 95939 (Central motor evoked potential study (transcranial motor 

stimulation); in upper and lower limbs) for the CY 2012 PFS final rule with comment period. In 

that rule, we stated that we were accepting the AMA RUC-recommended values on an interim 
556 

basis, and requested that the AMA RUC review the component CPT codes 95925 (Short-latency 

somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 

recording from the central nervous system; in upper limbs), 95926 (Short-latency somatosensory 

evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the 

central nervous system; in lower limbs), 95928 (Central motor evoked potential study 

(transcranial motor stimulation); upper limbs), and 95929 (Central motor evoked potential study 

(transcranial motor stimulation); lower limbs) (76 FR 73207 through 73208). 

In response to this request, the AMA RUC Relativity Assessment Workgroup referred 

component CPT codes 95925, 95926, 95928, and 95929 to the PE Subcommittee of the AMA 

RUC to review the direct practice expense inputs, but the AMA RUC decided not to review the 

physician work or time. 

When reviewing the physician work and time for the two new bundled CPT codes and 

their component codes, we saw unlikely relationships between the physician times assigned to 

these services, especially CPT codes 95928, 95929, and 95939. Given these time anomalies, we 

are also concerned the current (CY 2012) work RVUs do not reflect the appropriate relativity of 

the services. CPT code 95939 describes an evoked potential study in both the upper and lower 

limbs together, and is assigned 30 minutes of intra-service time. CPT code 95928 describes an 

evoked potential study in the upper limbs only, and is assigned 60 minutes of intra-service time. 

CPT code 95929 describes an evoked potential study in the lower limbs, and is assigned 55 

minutes of intra-service time. We do not believe that an evoked potential study on the upper or 

lower limbs alone takes twice as long as an evoked potential study on both the upper and lower 

limbs. 

Additionally, CPT code 95938 describes an evoked potential study in both the upper and 

lower limbs together, and is assigned 30 minutes of intra-service time. CPT code 95925 
557 

describes an evoked potential study in the upper limbs only and is assigned 15 minutes of intraservice time. CPT code 95926 describes an evoked potential study in the lower limbs and is 

assigned 15 minutes of intra-service time. We note that the intra-service times of CPT codes 

95925 and 95926 are significantly different from the intra-service times of CPT codes 95928 and 

95929 for very similar procedures, but somehow the new bundled procedure codes for both have 

30 minutes of intra-service time. We conclude that there are valuation and time inaccuracies, 

both across the evoked potential study codes and relative to the new bundled codes. For 

example, for CPT codes 95925 and 95926, we do not believe that the correct intra-service time 

for CPT code 95938 can be the sum of the intra-service times of CPT codes 95925 and 95926, as 

we are confident that there efficiencies to be recognized when performing these services 

together. 

Given these anomalous relationships, we request public comments on the appropriate 

work and time values for these services. We are maintaining the current (CY 2012) work RVUs 

and times for CPT codes 95925, 95926, 95928, 95929, 95938, and 95939 on an interim basis for 

CY 2013, and anticipate re-reviewing these services for CY 2014. 

(36) Neurology and Neuromuscular Procedures: Intraoperative Neurophysiology 

TABLE 67: Neurology and Neuromuscular Procedures: Intraoperative Neurophysiology 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

95940 

Ionm in operatng room 15 

min New 0.60 0.60 Agree No 

95941 

Ionm remote/>1 pt or per 

hr New 2.00 Invalid N/A N/A 

G0453 

Cont intraop neuro 

monitor New N/A 0.50 N/A N/A 

Effective January 1, 2013, the CPT Editorial Panel is deleting CPT code 95920 

(Intraoperative neurophysiology testing, per hour (List separately in addition to code for primary 
558 

procedure)), and is replacing it with CPT codes 95940 (Continuous intraoperative 

neurophysiology monitoring in the operating room, one on one monitoring requiring personal 

attendance, each 15 minutes) and CPT code 95941 (Continuous intraoperative neurophysiology 

monitoring, from outside the operating room (remote or nearby) or for monitoring of more than 

one case while in the operating room, per hour). Currently remote monitoring is billed under the 

PFS using CPT code 95920, though the code does not specify whether the physician is present in 

the same room with a patient or monitoring from a remote location, nor does the code descriptor 

indicate whether the code may be billed for the monitoring of one patient or more than one 

simultaneously. Some carriers have established local coverage determinations (LCDs) to address 

these issues and more tightly define the circumstances under which CPT code 95920 may be 

billed. 

The CPT prefatory language for CPT code 95941 states: “... One or more simultaneous 

cases may be reported...Report 95941 for all remote or non-one on one monitoring time 

connected to each case regardless of overlap with other cases.” Given this language, we are 

concerned that CPT code 95941 allows a practitioner to bill individual beneficiaries for 

monitoring more than one beneficiary for the same work during the same time interval. To 

resolve this concern, we have created HCPCS code G0453 (Continuous intraoperative 

neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, 

(attention directed exclusively to one patient) each 15 minutes (list in addition to primary 

procedure)), effective January 1, 2013. HCPCS code G0453 may be billed only for undivided 

attention by the monitoring physician to a single beneficiary, not for simultaneous attention by 

the monitoring physician to more than one patient. HCPCS code G0453 may be billed in 

multiple units to account for the cumulative time spent monitoring, that is, 15 minutes of 

continuous attendance followed by another 15 minutes later in the procedure would constitute 
559 

one half hour of monitoring, and CPT code G0453 would be billed with a unit of 2. HCPCS 

code G0453 will replace CPT code 95941, which will have a PFS procedure status indicator of I 

(Not valid for Medicare purposes. Medicare uses another code for the reporting of and the 

payment for these services) for CY 2013. CPT code 95940, which describes continuous 

intraoperative neurophysiology monitoring in the operating room for one patient at a time, will 

be payable on the PFS for CY 2013, with a PFS procedure status indicator of A (Active). 

After reviewing CPT code 95940, we agree with the AMA RUC that a work RVU of 0.60 

accurately accounts for the work involved in furnishing this procedure. We are assigning a work 

RVU of 0.60 to CPT code 95940 on an interim final basis for CY 2013. Also, we agree with the 

AMA RUC that a work RVU of 2.00 accurately accounts for the work for involved in furnishing 

60 minutes of continuous intraoperative neurophysiology monitoring from outside the operating 

room. Accordingly, we are assigning a work RVU of 0.50 to HCPCS code G0453, which 

describes 15 minutes of monitoring from outside the operating room, on an interim final basis for 

CY 2013. 

(37) Physical Medicine and Rehabilitation: Active Wound Care Management 

TABLE 68: Physical Medicine and Rehabilitation: Active Wound Care Management 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

G0456 

Neg pre wound <=50 sq 

cm New N/A 

Contractor 

Priced N/A N/A 

G0457 

Neg pres wound >50 sq 

cm New N/A 

Contractor 

Priced N/A N/A 

For CY 2013, we are creating two HCPCS codes in order to provide a payment 

mechanism for negative pressure wound therapy services furnished to beneficiaries through 

means unrelated to the durable medical equipment benefit: G0456 (Negative pressure wound 

therapy,(eg vacuum assisted drainage collection) using a mechanically-powered device, not 
560 

durable medical equipment, including provision of cartridge and dressing(s), topical 

application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) 

surface area less than or equal to 50 square centimeters) and G0457 (Negative pressure wound 

therapy,(eg vacuum assisted drainage collection) using a mechanically-powered device, not 

durable medical equipment, including provision of cartridge and dressing(s), topical 

application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) 

surface area greater than 50 sq cm). The two new codes will be contractor priced on an interim 

basis for CY 2013. We request comments on the appropriate value for this service. 

(38) Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care 

Services: Pediatric Critical Care Patient Transport 

TABLE 69: Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal 

Critical Care Services: Pediatric Critical Care Patient Transport 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

99485 

Suprv interfacilty 

transport New 1.50 Bundled N/A N/A 

99486 

Suprv interfac trnsport 

addl New 1.30 Bundled N/A N/A 

The CPT editorial panel created CPT codes 99485 and 99486 for CY 2013, to describe 

the non-face-to-face services provided by physician to supervise interfacility care of critically ill 

or critically injured pediatric patients. 

We reviewed CPT codes 99485 (Supervision by a control physician of interfacility 

transport care of the critically ill or critically injured pediatric patient, 24 months of age or 

younger, includes two-way communication with transport team before transport, at the referring 

facility and during the transport, including data interpretation and report; first 30 minutes) and 

99486 (Supervision by a control physician of interfacility transport care of the critically ill or 

critically injured pediatric patient, 24 months of age or younger, includes two-way 
561 

communication with transport team before transport, at the referring facility and during the 

transport, including data interpretation and report; each additional 30 minutes (list separately in 

addition to code for primary procedure)), and we believe these services are bundled into other 

services and are not separately payable. We believe these services are similar to CPT codes 

99288 (Physician or other qualified health care professional direction of emergency medical 

systems (ems) emergency care, advanced life support), which is also bundled on the PFS. The 

AMA RUC recommended a work RVU of 1.50 for CPT code 99485 and a work RVU of 1.30 for 

CPT code 99486. On an interim final basis for CY 2013, we are assigning CPT codes 99485 and 

99486 a PFS procedure status indicator of B (Payments for covered services are always bundled 

into payment for other services, which are not specified. If RVUs are shown, they are not used 

for Medicare payment. If these services are covered, payment for them is subsumed by the 

payment for the services to which they are bundled. 

(39) Complex Chronic Care Coordination Services 

TABLE 70: Complex Chronic Care Coordination Services 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

99487 

Cmplx chron care w/o pt 

vsit New 1.00 Bundled N/A N/A 

99488 

Cmplx chron care w/ pt 

vsit New 2.50 Bundled N/A N/A 

99489 

Complx chron care addl30 

min New 0.50 Bundled N/A N/A 

The CPT Editorial Panel created CPT codes 99487, 99488, and 99489 for CY 2013 to 

describe complex chronic care coordination services that are patient-centered management and 

support services. 

In section II.H. of this CY 2013 PFS final rule with comment period, we discuss our 

broader HHS and CMS multi-year strategy to recognize and support primary care and care 
562 

management under the PFS and commitment to exploring payment approaches and developing 

proposals to promote primary care within a fee-for-service payment structure. We intend to 

consider CPT codes 99487 (Complex chronic care coordination services; first hour of clinical 

staff time directed by a physician or other qualified health care professional with no face-to-face 

visit, per calendar month), 99488 (Complex chronic care coordination services; first hour of 

clinical staff time directed by a physician or other qualified health care professional with one 

face-to-face visit, per calendar month), and 99489 (Complex chronic care coordination services; 

each additional 30 minutes of clinical staff time directed by a physician or other qualified health 

care professional, per calendar month (list separately in addition to code for primary procedure)) 

as part of that larger discussion. At this time, we believe these services are bundled into the 

services to which they are incident and are not separately payable. The AMA RUC 

recommended a work RVU of 1.00 for CPT code 99487, a work RVU of 2.50 for CPT code 

99488, and a work RVU of 0.50 for CPT code 99489. On an interim final basis for CY 2013, we 

are assigning CPT codes 99487, 99488, and 99489 a PFS procedure status indicator of B 

(Payments for covered services are always bundled into payment for other services, which are 

not specified. If RVUs are shown, they are not used for Medicare payment. If these services are 

covered, payment for them is subsumed by the payment for the services to which they are 

bundled). 

(40) Transitional Care Management Services 

TABLE 71: Transitional Care Management Services 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

99495 

Trans care mgmt 14 day 

disch New 2.11 2.11 Agree No 

99496 

Trans care mgmt 7 day 

disch New 3.05 3.05 Agree Yes 
563 

The CPT Editorial Panel created CPT codes 99495 and 99496 for CY 2013 to describe 

transitional care provided to patients from an inpatient setting to a home setting over a 30-day 

period. 

CPT codes 99495 (Transitional care management services with the following required 

elements: communication (direct contact, telephone, electronic) with the patient and/or caregiver 

within 2 business days of discharge medical decision making of at least moderate complexity 

during the service period face-to-face visit, within 14 calendar days of discharge) and 99496 

(Transitional care management services with the following required elements: communication 

(direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of 

discharge medical decision making of high complexity during the service period face-to-face 

visit, within 7 calendar days of discharge) are discussed in detail in section III.H of this CY 2013 

PFS final rule with comment period. In sum, after clinical review, we are assigning a work RVU 

of 2.11 with 40 minutes of intra-service time to CPT code 99495, and a work RVU of 3.05 with 

50 minutes of intra-service time to CPT codes 99496 on an interim final basis for CY 2013. 

(41) Physician Documentation of Face-to-Face visit for Durable Medical Equipment (DME) 

TABLE 72: Physician Documentation of Face-to-Face visit for Durable Medical 

Equipment (DME) 

HCPCS 

Code Short Descriptor 

CY 2012 

Work RVU 

AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CY 2013 

Interim/Interim 

Final Work 

RVU 

Agree/Disagree 

with AMA 

RUC/HCPAC 

Recommended 

Work RVU 

CMS 

Refinement to 

AMA/HCPAC 

Recommended 

Time 

G0454 

MD document visit by 

NPP New N/A 0.18 N/A N/A 

Effective January 1, 2013, we have created HCPCS code G0454 (Physician 

documentation of face-to-face visit for Durable Medical Equipment determination performed by 

Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist) for payment to a physician 

who documents that a PA, NP, or CNS practitioner has performed a face-to-face encounter for 
564 

the list of specified DME covered items. As discussed in section IV.C. of this CY 2013 PFS 

final rule with comment period, for HCPCS code G0454, we are finalizing a work RVU of 0.18, 

with 5 minutes of intra-service time and 2 minutes of post-service time, which is a crosswalk to 

CPT code 99211 (Level 1 office or other outpatient visit, established patient). We believe these 

values appropriately capture the work and time involved in furnishing this service. 

(42) Other CY 2013 New, Revised, and Potentially Misvalued CPT Codes Not Specifically 

Discussed Previously 

 For all other CY 2013 new, revised and potentially misvalued CPT codes not specifically 

discussed previously, we agree with the AMA RUC/HCPAC recommended work RVUs and 

times and are setting as interim final the work RVUs listed in Table 30. 

3. Establishing Interim and Interim Final Direct PE RVUs for CY 2013 

b. Establishing Interim Final Direct PE RVUs for CY 2013 

i. Background 

The AMA RUC provides CMS with recommendations regarding direct PE inputs, 

including clinical labor, supplies, and equipment, for new, revised, and potentially misvalued 

codes. We review the AMA RUC-recommended direct PE inputs on a code-by-code basis, 

including the recommended facility PE inputs and/or nonfacility PE inputs, as clinically 

appropriate for the code. We determine whether we agree with the AMA RUC's recommended 

direct PE inputs for a service or, if we disagree, we refine the PE inputs to represent inputs that 

better reflect our estimate of the PE resources required to furnish the service in the facility and/or 

nonfacility settings. We also confirm that CPT codes should have facility and/or nonfacility 

direct PE inputs and make changes based on our clinical judgment and any PFS payment policies 

that would apply to the code. 

ii. Methodology 
565 

We have accepted for CY 2013, as interim and without refinement, the direct PE inputs 

based on the recommendations submitted by the AMA RUC for the codes listed in Table KK6. 

For the remainder of the AMA RUC's direct PE recommendations, we have accepted the PE 

recommendations submitted by the AMA RUC as interim, but with refinements. These codes 

and the refinements to their direct PE inputs are listed in Table KK7. In some cases, we have 

maintained the interim status of direct PE inputs for certain code beyond the year of the initial 

recommendation. In those cases, we address the associated direct PE inputs in this section, along 

with the interim direct PE inputs, established through our review of AMA RUC 

recommendations. 

We note that the final CY 2013 PFS direct PE input database reflects the refined direct 

PE inputs that we are adopting on an interim basis for CY 2013. That database is available under 

downloads for the CY 2013 PFS final rule with comment period on the CMS Web site at: 

http://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage. We also note that the PE 

RVUs displayed in Addenda B and C reflect the interim values and policies described in this 

section. All codes adopted on an interim basis are included in Addenda C and are open for 

comment.

iii. Common and Code-Specific Refinements

 While Table KK7 details the CY 2013 refinements of the AMA RUC's direct PE 

recommendations at the code-specific level, we discuss the general nature of some common 

refinements and the reasons for particular refinements in the following section. 

(a) Changes in Physician Time 

Some direct PE inputs are directly affected by revisions in physician time described in 

section III.B.3. and III.M.3.a. of this final rule with comment period. Specifically, changes in the 

intra-service portions of the physician time and changes in the number or level of postoperative 
566 

visits associated with the global periods result in corresponding changes to direct PE inputs. 

Changes in Intra-service Physician Time in the Nonfacility Setting. For most codes 

valued in the nonfacility setting, a portion of the clinical labor time allocated to the intra-service 

period reflects minutes assigned for assisting the physician with the procedure. To the extent 

that we are refining the times associated with the intra-service portion of such procedures, we 

have adjusted the corresponding intra-service clinical labor minutes in the nonfacility setting. 

 For equipment associated with the intra-service period in the nonfacility setting, we 

generally allocate time based on the typical number of minutes a piece of equipment is being 

used and, therefore, not available for use with another patient during that period. In general, we 

allocate these minutes based on the description of typical clinical labor activities. To the extent 

that we are making changes in the clinical labor times associated with the intra-service portion of 

procedures, we have adjusted the corresponding equipment minutes associated with the codes. 

Changes in the Number or Level of Postoperative Office Visits in the Global Period. For 

codes valued with post-service physician office visits during a global period, most of the clinical 

labor time allocated to the post-service period reflects a standard number of minutes allocated for 

each of those visits. To the extent that we are refining the number or level of postoperative 

visits, we have modified the clinical staff time in the post-service period to reflect the change. 

For codes valued with post-service physician office visits during a global period, we allocate 

standard equipment for each of those visits. To the extent that we are making a change in the 

number or level of postoperative visits associated with a code, we have adjusted the 

corresponding equipment minutes. For codes valued with post-service physician office visits 

during a global period, a certain number of supply items are allocated for each of those office 

visits. To the extent that we are making a change in the number of postoperative visits, we have 

adjusted the corresponding supply item quantities associated with the codes. We note that many 
567 

supply items associated with post-service physician office visits are allocated for each office visit 

(for example, a minimum multi-specialty visit pack (SA048) in the CY 2012 direct PE database). 

For these supply items, the quantities in the direct PE database should reflect the number of 

office visits associated with the code's global period. However, some supply items are 

associated with post-service physician office visits but are only allocated once during the global 

period because they are typically used during only one of the post-service office visits (for 

example, pack, post-op incision care (suture) (SA054) in the direct PE database). For these 

supply items, the quantities in the proposed notice direct PE database reflect that single quantity. 

 These refinements are reflected in the final CY 2013 PFS direct PE input database and 

detailed in Table 73. 

(b) Equipment Minutes

 In general, the equipment time inputs reflect the sum of the times within the intra-service 

period when a clinician is using the piece of equipment, plus any additional time the piece of 

equipment is not available for use for another patient due to its use during the designated 

procedure. While some services include equipment that is typically unavailable during the entire 

clinical labor service period, certain highly technical pieces of equipment and equipment rooms 

are less likely to be used by a clinician for all tasks associated with a service and therefore are 

typically available for other patients during the pre-service and post-service components of the 

service period. We adjust those equipment times accordingly. We refer interested stakeholders 

to our extensive discussion of these policies in the CY 2012 PFS final rule (76 FR 73182-73183).

We are refining the CY 2013 AMA RUC direct PE recommendations to conform to these 

equipment time policies. These refinements are reflected in the final CY 2013 PFS direct PE 

database and detailed in Table 73. 

(c) Moderate Sedation Inputs 
568 

In the CY 2012 PFS final rule (76 FR 73043-73049), we finalized a standard package of 

direct PE inputs for services where moderate sedation is considered inherent in the procedure. 

We are refining the CY 2013 AMA RUC direct PE recommendations to conform to these 

policies. These refinements are reflected in the final CY 2013 PFS direct PE database and 

detailed in Table73. 

(d) Standard Minutes for Clinical Labor Tasks 

In general, the minutes associated with certain clinical labor tasks are standardized 

depending on the type of procedure, its typical setting, its global period, and the other procedures 

with which it is typically reported. In the case of some services, the RUC has recommended a 

numbers of minutes either greater or less than time typically allotted for certain tasks. In those 

cases, CMS clinical staff has reviewed the deviations from the standards to determine their 

clinical appropriateness. Where CMS clinical judgment considers that the standard number of 

minutes generally accommodates the range of minutes likely to be typical for such activities, the 

recommended exceptions have not been accepted, and we have refined the interim final direct PE 

inputs to match the standard times for those tasks. Each of those refinements appears in Table 

73. 

(e) Digestive System (CPT code 44705 and HCPCS Code G0455) 

The CPT Editorial Panel created CPT code 44705 (Preparation of fecal microbiota for 

instillation, including assessment of donor specimen) and the AMA RUC recommended 

nonfacility direct PE inputs for this service for CY 2013. As discussed in section III.M.3.a. of 

this final rule, Medicare payment for the preparation of the donor specimen would only be made 

if the specimen is ultimately used for the treatment of a beneficiary. Because of this policy, we 

believe it is appropriate to bundle the preparation and instillation into one payable HCPCS code. 

For CY 2013, we have created HCPCS code G0455 (Preparation with instillation of fecal 
569 

microbiota by any method, including assessment of donor specimen). HCPCS code G0455 will 

replace new CPT code 44705 (Preparation of fecal microbiota for instillation, including 

assessment of donor specimen) which will have a PFS procedure status indicator of I (Not valid 

for Medicare purposes), and includes both the work of preparation and instillation of the 

microbiota. 

In order to establish direct PE inputs for this service that includes both the preparation 

and instillation, we examined the AMA RUC recommendations for CPT code 44705 and 

incorporated an additional 17 minutes of clinical labor time in the service period to account for 

pre-service activities like greeting and gowning the beneficiary, obtaining the vital signs, 

providing pre-education/obtaining consent, preparing the room and equipment, and preparing the 

patient and post-service activities like cleaning the room and providing home care instructions to 

the beneficiary, based on the amount of time allocated for those services in the direct PE inputs 

for evaluation and management services . We note that we have also included a minimum multispecialty visit pack (SA048) as a supply input for the code and otherwise crosswalked the AMA 

RUC-recommended supply and equipment inputs from CPT code 44705. 

(f) Diagnostic Radiology: Abdomen (CPT Codes 72191, 72192, 72193, 72194, 74150, 74160, 

74170, 74174, 74175, 74176, 74177, 74178) 

Generally, we only establish interim final direct PE inputs for services when the RUC has 

provided a new recommendation. However, in some cases, we believe it is necessary to establish 

new interim final direct PE inputs for codes not recently reviewed by the RUC in order to 

maintain appropriate relativity between the PE and work components of PFS payment or among 

those codes and other related codes. For example, this situation can occur when either the 

physician work of particular codes has been reviewed without parallel review of the direct PE 

inputs or when the direct PE inputs of certain codes have been reviewed without parallel review 
570 

of the direct PE inputs of closely related codes. We addressed the issue in detail in the CY 2012 

PFS final rule (76 FR 73212). 

Over the past several years, AMA CPT has created codes for diagnostic radiology 

services that describe CT and computed tomographic angiography (CTA) of the abdomen and 

pelvis combined while maintaining the current component codes that describe CT and CTA of 

each region separately. In reviewing both the physician work and the direct PE inputs for these 

services, we have consistently requested that recommendations for appropriate valuation of these 

services consider the whole code set at once. 

In response to this request, commenters contended that the AMA RUC operates under the 

premise that the values of all the services paid on the PFS are assumed to be accurate and 

therefore, our request to review component codes is unnecessary and that reviewing and possibly 

revaluing individual codes solely because they are bundled to create a new code, risks rank-order 

anomalies within families, which could threaten the relativity of the values of the PFS services. 

One commenter suggested that our requests would create an endless cycle of review. 

 We continue to believe that code sets that include component and combined codes should 

be reviewed for appropriate revaluing as whole sets instead of in fragments. In fact, we believe 

that disjointed review, as opposed to comprehensive review, is itself the most likely cause of 

rank order anomalies and “endless cycles of review.” The Act requires CMS to conduct periodic 

reviews of PFS services [1848(c)(2)(B)] and make appropriate adjustments to misvalued codes 

[1848(c)(2)(K)]. In consideration of these obligations, we believe that the relative values for 

these codes must be considered as a whole set instead of in fragments. In the interest of 

examining the direct PE inputs of these services as a comprehensive set, we have reviewed the 

direct PE inputs for all of the abdomen and pelvis CT codes and all of the abdomen and pelvis 

CTA codes as two individual sets. We have started from the basis that the most recently 
571 

developed AMA RUC recommendation represents the most current information regarding 

typical medical practice. For each set of codes, we have established a common set of disposable 

supplies and medical equipment. We established clinical labor minutes that reflect the 

fundamental assumption that the component codes should include a base number of minutes for 

particular tasks and that the number of minutes in the combined codes should reflect efficiencies 

that occur when the regions are examined together. 

 We are establishing the direct PE input for each of these services on an interim basis for 

CY 2013, and we have displayed particular refinements to the most recent AMA RUC 

recommendations or current direct PE inputs for the codes in Table 73. 

 Regarding the supply item called “computer media, optical disk 2.6gb” (SK016), we note 

that the most recent AMA RUC recommendation included the item with a quantity of 1 as a 

disposable supply. When reviewing the item in the direct PE input database, we noted that its 

quantity for other similar codes is 0.1. We believe that quantity better reflects the resource costs 

of storing digital images for these services. We also note that the item is currently priced at 

$68.75 in the direct PE input database, and we believe that price may be significantly higher than 

typical prices. Therefore, we are seeking comment on the appropriate quantity and price for the 

item, which will be set at a quantity of 0.1 for these services on an interim basis for CY 2013. 

 Finally, we note that the direct PE inputs for these services will not be finalized until the 

associated work RVUs are finalized, consistent with our established policies regarding the 

concurrent review of work and direct practice expense inputs. 

(g) Nuclear Medicine: Diagnostic (CPT Code 78072) 

When clinically appropriate, the AMA RUC generally recommends the use of supply and 

equipment items that already exist in the direct PE database for new, revised, and potentially 

misvalued codes. Some recommendations include supply or equipment items that are not 
572 

currently in the direct PE database. In these cases, the AMA RUC has historically recommended 

a new item be created and has facilitated CMS' pricing of that item by working with the specialty 

societies to provide sales invoices to us. We appreciate the contributions of the AMA RUC in 

that process. 

We received invoices for several new supply and equipment items for CY 2013. We 

have accepted the majority of these items and added them to the direct PE database. For CY 

2013, we could not price the new equipment for CPT code 78072 (Parathyroid planar imaging 

(including subtraction, when performed); with tomographic (SPECT), and concurrently acquired 

computed tomography (CT) for anatomical localization). We received a recommendation to 

create a new equipment item in the direct PE database called “gamma camera system, singledual head SPECT/CT” for use in furnishing this service in the nonfacility setting. In order to 

facilitate pricing the new item, the AMA RUC forwarded information from the specialty society, 

but that information only included a letter from the device manufacturer that offered a price 

quote. While we recognize that the resource costs for the equipment is significant, we do not 

believe that a letter from the manufacturer is adequate documentation for establishing a price for 

a new equipment item. In many cases when we cannot adequately price a newly recommended 

item, we have included the item in the direct PE input database without an associated price. 

While doing so means that the item does not contribute to the calculation of the PE RVU for 

particular services, it facilitates our ability to incorporate a price once we are able to do so. 

However, in the case of this new CPT code, because the cost of the item we cannot currently 

price is disproportionately large relative to the costs reflected by remainder of the recommended 

direct PE inputs, we are contractor pricing the technical component of the code for CY 2013, on 

an interim basis, until the newly recommended equipment item can be appropriately priced. 

(h) Pathology and Laboratory: Chemistry (CPT Code 86153) 
573 

The AMA RUC submitted direct PE input recommendations for CPT code 86153 (Cell 

enumeration using immunologic selection and identification in fluid specimen (eg, circulating 

tumor cells in blood); physician interpretation and report, when required) that describes a 

laboratory physician interpretation code. As we discuss in section III.M.3.a. of this final rule 

with comment period, CPT code 86153 is a professional component-only CPT code that will be 

considered a “clinical laboratory interpretation service,” which is one of the current categories of 

PFS pathology services under the definition of physician pathology services at §415.130(b)(4). 

This code must be billed with the “26” modifier to be paid under the PFS. Therefore, CPT code 

86153 -26 should be valued exclusively without direct practice expense inputs. Therefore, we 

are not accepting the recommended direct PE inputs for CPT code 86153. 

(i) Pathology and Laboratory: Surgical Pathology (CPT Codes 88300, 88302, 88304, 88305, 

88307, 88309) 

For surgical pathology CPT codes 88300, 88302, 88304, 88305, 88307, 88309 (Surgical 

Pathology, Levels I through VI), the AMA RUC recommended creating several new supply and 

equipment items in direct PE input database that we will not incorporate for CY 2013 in addition 

to several new direct PE inputs that we are adopting on an interim basis. The new supply items 

that we will not incorporate were called “specimen, solvent, and formalin disposal cost,” and 

“courier transportation costs.” We do not believe that specimen and supply disposal or courier 

costs for transporting specimens are appropriately considered as disposable medical supplies. 

Instead, we believe the costs described by these recommendations are incorporated into the PE 

RVUs for these services through the indirect PE allocation. We note that the current direct PE 

inputs for these and similar services across the PFS do not include these kinds of costs as 

disposable supplies. 

In addition to the recommendation to include these new supply items, the AMA RUC 
574 

recommended that we create new equipment items called “equipment maintenance cost,” 

“Copath System with maintenance contract,” and “Copath software” as direct PE inputs for these 

codes. Our standard equipment cost per minute calculation includes a maintenance factor to 

incorporate costs related to maintenance in amortizing the cost of the equipment itself. 

Therefore, we will not incorporate separate maintenance costs for particular items. Regarding 

the “Copath” system and software equipment, the AMA RUC forwarded materials from a 

manufacturer that included a description of a computer system that is used to interface with other 

data systems to provide inbound demographic information and export laboratory results and 

billing information. Based on the way those functionalities were presented in this information, 

we believe that this computer system and associated software reflects an indirect practice 

expense since the clerical and other administrative functionality seem central to its purpose. We 

note that no similar equipment is currently included as a direct PE input for these services. All 

direct PE inputs for these services are interim for CY 2013 and open to comment. We would 

consider additional information regarding whether this computer system and associated software 

might be considered a direct cost as medical equipment associated with furnishing the technical 

component of these surgical pathology services for CY 2014 rulemaking. We are especially 

interested in understanding the clinical functionality of the equipment in relation to the services 

being furnished. 

 In addition to this information, we are also seeking additional public comment regarding 

the appropriate assumptions regarding the direct PE inputs for these services. We note that the 

AMA RUC recommendations for these potentially misvalued codes were developed based on an 

underlying assumption regarding the typical number of blocks used each time a service is 

reported. The number of blocks assumed to be used has significant impact on the quantity of 

other supplies and the number of clinical labor and equipment minutes assigned as direct PE 
575 

inputs to each code. After conducting an initial clinical review of these direct PE inputs, we are 

concerned that the number of blocks assumed for each code may be inaccurate. For 88300, no 

blocks are assumed. For 88302, one block is assumed. For 88304 and 88305, the assumed 

number of blocks typically used is 2. For 88307, the assumed number of blocks is 12 and for 

88309, the typical number of blocks is assumed to be 18. We are accepting the AMA RUC’s 

recommended direct PE inputs that derive from these assumptions on an interim basis for CY 

2013, but we are seeking independent evidence regarding the appropriate number of blocks to 

assume as typical for each of these services. We are requesting public comment regarding the 

appropriate number of blocks and urge the AMA RUC and interested medical specialty societies 

to provide corroborating, independent evidence that the number of blocks assumed in the current 

direct PE input recommendations is typical prior to finalizing the direct PE inputs for these 

services. 

(j) Pathology and Laboratory: Cytopathology (CPT Codes 88120 and 88121) 

 The CPT Editorial Panel created CPT codes 88120 (Cytopathology, in situ hybridization 

(eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each 

specimen; manual) and 88121 (Cytopathology, in situ hybridization (eg, FISH), urinary tract 

specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computerassisted technology) to describe in situ hybridization testing using urine samples, effective for 

CY 2011. 

As we explain in section III.M.3.a. of this final rule with comment period, we believe that 

the work and direct PE inputs for existing CPT codes 88365, 88367, and 88368 should be 

reviewed alongside CPT codes 88120 and 88121 to ensure the appropriate relativity between 

these two sets of services (76 FR 73153 through 73154). The AMA RUC has stated that it 

intends to do so after CY 2012 utilization data are available to assess how these services are 
576 

being billed. We agree with this approach, and are maintaining the interim status for the direct 

PE inputs for CPT code 88120 and 88121 until we review CPT codes 88120 and 88121 

alongside CPT codes 88365, 88367, and 88368 for CY 2014. 

 Distinct from that forthcoming review, stakeholders have informed us of two separate 

issues related to the interim direct PE inputs for these services. Two stakeholders have examined 

the AMA RUC recommendations and found miscalculations in the recommended equipment 

minutes. The information we reviewed suggested that that the recommended times of 107 

minutes for the ThemoBrite equipment (EP088) for 88120 and 26.75 minutes for 88121 were 

derived in error because the division for the typical batch sizes of 3 and 6, respectively, occurred 

twice. The stakeholders also presented information that the recommended minutes for the 

Olympus BX41 Fluorescent Microscope (without filters or camera) (EP092) as a direct PE input 

for CPT code 88120 ought to have been 73 minutes, instead of 1.33 minutes. Finally, the 

stakeholders provided information suggesting the minutes for the IkoniScope (EP090) and 

IkoniLan software (EP091) included as direct PE inputs for CPT code 88121 were intended to be 

29.7 minutes, instead of 2.97. Upon clinical review of this information, we agree with the 

stakeholders regarding the intention of these recommendations, and have refined the CY 2013 

direct PE input database accordingly. 

 These stakeholders also suggested that CMS should increase the price of the supply 

“UroVysion test kit” (SA105) by building in an “efficiency factor” to account for the kits that are 

purchased by practitioners and used in tests that fail. The stakeholders provided documentation 

suggesting that a certain failure rate is inherent in the procedure. 

 The prices associated with supply inputs in the direct PE input database reflect the price 

per unit of each supply. Since the current PE methodology relies on the inputs for each service 

reflecting the typical direct practice expense costs for each service, and the supply costs for the 
577 

failed tests are not used in furnishing PFS services, we do not believe that the methodology 

accommodates a failure rate in allocating the cost of disposable medical supplies. Therefore, we 

are not adjusting the price input for “UroVysion test kit” (SA105) in the direct PE input 

database. 

(j) Psychiatry (CPT Codes 90791, 90832, 90834, 90837) 

For CY 2013, the CPT Editorial Panel has replaced the current psychiatry/psychotherapy 

CPT codes with a new structure that allows for the separate reporting of E/M codes, eliminates 

the site-of-service differential, establishes CPT codes for crisis, and creates a series of add-on 

CPT codes to psychotherapy to describe interactive complexity and medication management. As 

we note in section III.M.3.a. of this final rule with commenter period, because related specialty 

societies have not yet surveyed some of the new CPT codes, namely, the new CPT codes for 

psychotherapy for crisis, interactive complexity, and pharmacologic management, we anticipate 

re-reviewing the values for all the codes in the family in the near future. For CY 2013, our 

general approach is to maintain the current values, or as close to the current values as possible, 

given the consolidation of multiple CY 2012 CPT codes into a single CY 2013 CPT code, for 

these service on an interim basis, pending re-review. 

The AMA RUC submitted direct PE input recommendations for codes in this family that 

included significant reductions in the direct PE costs associated with the predecessor codes. For 

most of the new codes, we believe that accepting these recommended reductions in direct 

practice expense conforms to our general approach of maintaining the current values for these 

services since many practitioners who furnish these services will now report concurrent medical 

evaluation and management services with PE values that will offset the differences in total PE 

values between the new and old psychotherapy codes. However, for practitioners who do not 

furnish medical evaluation and management services, there are no corresponding PE value 
578 

increases to offset the recommended reductions in the direct PE inputs for these codes. 

Therefore, instead of accepting the recommended direct PE inputs for the new CPT codes that 

describe services primarily furnished by practitioners who do not also report medical evaluation 

and management services, we will crosswalk the PE RVUs from the CY 2012 codes that 

describe the same services. We believe this crosswalk will effectively maintain the total value of 

the services, pending a comprehensive review of the code family. The CPT codes with CY 2013 

PE RVU crosswalks are: 90791 (Psychiatric diagnostic evaluation), 90832 (Psychotherapy, 30 

minutes with patient and/or family member), 90834 (Psychotherapy, 45 minutes with patient 

and/or family member), and 90837 (Psychotherapy, 60 minutes with patient and/or family 

member). For CY 2013, we are crosswalking the PE RVUs developed for the predecessor codes 

for CY 2012. We note that the PE RVUs used for these services will correspond with the CY 

2013 fully implemented values instead of the transition values since this interim policy is to 

maintain the current values relative to the new coding structure for the services, not exempt the 

services from the final year of the PPIS transition, as described in section III.A. of this final rule 

with comment period. The values in Addendum C reflect the interim PE RVUs for these codes. 

(k) Medicine: Gastroenterology (CPT Code 91112) 

 The AMA RUC submitted direct PE input recommendations for CPT code 91112 

(Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, 

with interpretation and report). The recommendations reflect an assumption that the patient data 

receiver would be typically used for 7200 minutes, or 5 days, for each service. However, 

product information available on the device manufacturer’s website specifies a 24 to 48 hour 

capsular passage time. Based on this information and CMS clinical review, we believe that 

assigning 2880 minutes to the data receiver is appropriate based on the assumption that 2 days 

reflects the maximum typical time for passage of the capsule. We also note that while the AMA 
579 

RUC’s recommendation included the capsule and standardized meal as separate disposable 

items, the submitted invoice priced the items together, so the new supply item created in the 

direct PE input database reflects the combined items as a single disposable supply. 

(l) Neurology and Neuromuscular Procedures: Intraoperative Neurophysiology (CPT Codes 

95940, 95941 and HCPCS Code G0453) 

Effective January 1, 2013, the CPT Editorial Panel is deleting CPT code 95920 

(Intraoperative neurophysiology testing, per hour (List separately in addition to code for primary 

procedure)), and is replacing it with CPT codes 95940 (Continuous intraoperative 

neurophysiology monitoring in the operating room, one on one monitoring requiring personal 

attendance, each 15 minutes) and CPT code 95941 (Continuous intraoperative neurophysiology 

monitoring, from outside the operating room (remote or nearby) or for monitoring of more than 

one case while in the operating room, per hour). 

As we note in section III.M.3.a. of this final rule with comment period, we have created 

HCPCS code G0453 (Continuous intraoperative neurophysiology monitoring, from outside the 

operating room (remote or nearby), per patient, (attention directed exclusively to one patient) 

each 15 minutes (list in addition to primary procedure)), effective January 1, 2013 to replace 

CPT code 95941 for Medicare purposes. CPT code 95941 will have a PFS procedure status 

indicator of I (Not valid for Medicare purposes. Medicare uses another code for the reporting of 

and the payment for these services) for CY 2013. CPT code 95940, which describes continuous 

intraoperative neurophysiology monitoring in the operating room for one patient at a time, will 

be payable on the PFS for CY 2013. 

The AMA RUC provided direct PE input recommendations for CPT codes 95940 and 

95941. However, we do not believe that these services are furnished to patients outside of 

facility settings. Medicare makes payment for technical inputs (labor, supplies, equipment, 
580 

capital, and overhead) to the facility when services are performed in a facility setting. For these 

services, the patient would receive this service in the ASC or hospital setting and payment for 

any technical services, including those for remote monitoring, should be included in the facility 

payment. We do not believe it would be appropriate to incorporate nonfacility direct PE inputs or 

develop nonfacility PE RVUs for CPT code 95940 and newly created HCPCS code G0453 for 

CY 2013. We do not believe that these services incur PFS direct practice expense costs when 

furnished to patients in the facility setting. Therefore, we are developing facility PE RVUs for 

this service based on no direct PE inputs. 

(m) Neurology and Neuromuscular Procedures: Sleep Medicine Testing CPT Codes 95782, 

95783) 

 The AMA RUC submitted direct PE input recommendations for new CPT codes 

describing pediatric polysomonography: 95782 (Polysomnography, younger than 6 years, 4 or 

more) and 95783 (Polysomnography, younger than 6 years, w/cpap). We note that in addition to 

refining minutes assigned to certain labor tasks based on CMS clinical judgment, we have not 

accepted the AMA RUC’s recommendation to create a new equipment item ‘crib’ for use in 

these services. We do not believe that a crib would typically be used in this service, and we have 

incorporated the bedroom furniture including a hospital bed and a reclining chair as typical 

equipment for this service. 

(n) Special Dermatological Procedures (CPT Codes 96920, 96921, 96922) 

The AMA RUC provided new direct PE input recommendations for CPT codes 

96920(Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm), 

96921 (Laser treatment for inflammatory skin disease, (psoriasis); between 250 sq cm to 500 sq 

cm), and 96922 (Laser treatment for inflammatory skin disease, (psoriasis); over 500 sq cm).

 Included in the new direct PE inputs for these services was a disposable laser tip (SF028). 
581 

This disposable item, priced at $290 in the direct PE input database, was not previously included 

as a direct PE input for these services. The recommendation did not provide a rationale as to 

why this highly priced disposable should be included as a direct PE input for these existing 

services when the codes have not previously included this item or any similarly priced disposable 

supply. Therefore, we are refining the RUC recommendation by removing the supply item 

SF028 from 96920, 96921, and 96922. We note that the direct PE inputs for these codes are 

interim for CY 2013, and we will consider any additional information and public comments 

regarding the typical use of this supply in furnishing these services prior to finalizing the direct 

PE inputs for CY 2014. 

(o) Transitional Care Management Services (CPT Codes 99495, 99496) 

 The CPT Editorial Panel created CPT codes 99495 and 99496 for CY 2013 to describe 

transitional care provided to patients from an inpatient setting to a home setting over a 30-day 

period. The AMA RUC submitted direct PE input recommendations for these services that we 

are accepting with the following refinements. 

As discussed in detail in section III.H of this CY 2013 PFS final rule with comment, we 

agree with the AMA RUC recommendation to include 45 minutes of RN/LPN time for CPT code 

99495 for dedicated to non-face-to-face care management activities. However, for CPT code 

99496, we are refining the 60 minutes of recommended clinical labor time for a RN/LPN nurse 

blend dedicated to non-face-to-face care management activities from 60 minutes to 70 minutes. 

We believe that the total clinical labor staff time and physician intra-service work time that the 

AMA RUC-recommended for non-face-to-face care management activities was accurate for both 

codes, but that the proportionality between physician work and clinical staff time should be 

refined to reflect greater clinical staff time in 99496. 

We also note that we are refining the AMA RUC recommendation by incorporating the clinical 
582 

labor inputs for dedicated to non-face-to-face care management activities as facility inputs. 

TABLE 73: CPT Codes with Accepted Direct PE Recommendations for CY 2013 Interim 

Codes 

CPT Code CPT Code Description 

20985 Cptr-asst dir ms px 

24160 Remove elbow joint implant 

24371 Revise reconst elbow joint 

29828 Arthroscopy biceps tenodesis 

31648 Bronchial valve addl insert 

31649 Bronchial valve remov init 

31651 Bronchial valve remov addl 

31660 Bronch thermoplsty 1 lobe 

31661 Bronch thermoplsty 2/> lobes 

33430 Replacement of mitral valve 

33533 Cabg arterial single 

36227 Place cath xtrnl carotid 

37211 Thrombolytic art therapy 

37212 Thrombolytic venous therapy 

37213 Thromblytic art/ven therapy 

37214 Cessj therapy cath removal 

66982 Cataract surgery complex 

66984 Cataract surg w/iol 1 stage 

77082 Dxa bone density vert fx 

90792 Psych diag eval w/med srvcs 

90833 Psytx pt&/fam w/e&m 30 min 

90837 Psytx pt&/family 60 minutes 

90838 Psytx pt&/fam w/e&m 60 min 

90845 Psychoanalysis 

90846 Family psytx w/o patient 

90847 Family psytx w/patient 

90853 Group psychotherapy 

92286 Internal eye photography 

93016 Cardiovascular stress test 

93018 Cardiovascular stress test 

95017 Perq & icut allg test venoms 

95018 Perq&ic allg test drugs/biol 

95079 Ingest challenge addl 60 min 

95860 Muscle test one limb 

95866 Muscle test hemidiaphragm 

95867 Muscle test cran nerv unilat 
583 

CPT Code CPT Code Description 

95869 Muscle test thor paraspinal 

95870 Muscle test nonparaspinal 

95925 Somatosensory testing 

95926 Somatosensory testing 

95928 C motor evoked uppr limbs 

95929 C motor evoked lwr limbs 

95938 Somatosensory testing 

95939 C motor evoked upr&lwr limbs 

TABLE 74: CPT Codes with Refined Direct PE Recommendations for CY 2013 Interim 

Codes 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ED0

04 

camera, digital (6 

mexapixel) NF 29 14 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

4 light, surgical NF 29 14 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 29 14 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

11300 

Shave skin 

lesion 0.5 

cm/< 

EF03

1 table, power NF 29 14 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
584 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 29 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 29 24 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 29 14 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicative 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

11301 

Shave skin 

lesion 0.6-

1.0 cm 

ED0

04 

camera, digital (6 

mexapixel) NF 32 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
585 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 32 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 32 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 32 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 32 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 32 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 32 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
586 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

ED0

04 

camera, digital (6 

mexapixel) NF 37 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

4 light, surgical NF 37 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 37 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

11302 

Shave skin 

lesion 1.1-

2.0 cm 

EF03

1 table, power NF 37 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
587 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 37 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 37 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 37 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicative 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

11303 

Shave skin 

lesion >2.0 

cm 

ED0

04 

camera, digital (6 

mexapixel) NF 41 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
588 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 41 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 41 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 41 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 41 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 41 32 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 41 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
589 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

ED0

04 

camera, digital (6 

mexapixel) NF 29 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

4 light, surgical NF 29 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 29 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

11305 

Shave skin 

lesion 0.5 

cm/< 

EF03

1 table, power NF 29 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
590 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 29 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 29 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 29 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicative 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

11306 

Shave skin 

lesion 0.6-

1.0 cm 

ED0

04 

camera, digital (6 

mexapixel) NF 31 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
591 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 31 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 31 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 31 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 31 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 31 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 31 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
592 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Assist physician 

in performing 

procedure 

10 18 

Conformi

ng to 

physician 

time 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

ED0

04 

camera, digital (6 

mexapixel) NF 37 21 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

4 light, surgical NF 37 21 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 37 21 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

11307 

Shave skin 

lesion 1.1-

2.0 cm 

EF03

1 table, power NF 37 21 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
593 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 37 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 37 31 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 37 21 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicative 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

11308 

Shave skin 

lesion >2.0 

cm 

ED0

04 

camera, digital (6 

mexapixel) NF 42 24 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
594 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 42 24 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 42 24 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 42 24 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 42 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 42 34 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 42 24 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
595 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

ED0

04 

camera, digital (6 

mexapixel) NF 34 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

4 light, surgical NF 34 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 34 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

11310 

Shave skin 

lesion 0.5 

cm/< 

EF03

1 table, power NF 34 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
596 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 34 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 34 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 34 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicative 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

11311 

Shave skin 

lesion 0.6-

1.0 cm 

ED0

04 

camera, digital (6 

mexapixel) NF 34 18 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
597 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 34 18 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 34 18 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 34 18 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 34 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 34 28 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 34 18 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
598 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Assist physician 

in performing 

procedure 

11 17 

Conformi

ng to 

physician 

time 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

ED0

04 

camera, digital (6 

mexapixel) NF 43 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

4 light, surgical NF 43 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 43 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

11312 

Shave skin 

lesion 1.1-

2.0 cm 

EF03

1 table, power NF 43 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
599 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 43 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 43 37 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 43 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicative 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

11313 

Shave skin 

lesion >2.0 

cm 

ED0

04 

camera, digital (6 

mexapixel) NF 43 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
600 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 43 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 43 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 43 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 43 0 

CMS 

clinical 

review; 

not 

described 

as typical 

in work 

vignette 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 43 40 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 43 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
601 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

1 10 

Standardi

zed time 

input 

SB00

3 

cover, probe 

(cryosurgery) NF 1 0 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicativ

e 

SB03

3 mask, surgical NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

3 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Provide preservice 

education/obtai

n consent 

2 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Prepare room, 

equipment, 

supplies 

2 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Clean 

room/equipment 

by physician 

staff 

3 1 

CMS 

clinical 

review 

SJ02

8 

hydrogen 

peroxide NF 10 0 

CMS 

clinical 

review 

11719 Trim nail(s) 

any number 

SJ05

3 swab-pad, alcohol NF 10 0 

CMS 

clinical 

review 

13100 

Cmplx rpr 

trunk 1.1-

2.5 cm 

EF01

4 light, surgical NF 32 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
602 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

5 mayo stand NF 32 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 32 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 32 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 32 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 32 46 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 32 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
603 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicativ

e 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicative 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 

EF01

4 light, surgical NF 45 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 45 47 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 45 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13101 

Cmplx rpr 

trunk 2.6-

7.5 cm 

EF03

1 table, power NF 45 47 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
604 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 45 47 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 45 54 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 45 47 

CMS 

clinical 

review 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicative 

SB02

7 

gown, staff, 

impervious F 2 0 

CMS 

clinical 

review 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicativ

e 

SB03

4 

mask, surgical, 

with face shield F 2 1 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 10 0 Duplicativ

e 

13102 

Cmplx rpr 

trunk addl 

5cm/< 

EF01

5 mayo stand NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
605 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF03

1 table, power NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 

13120 

Cmplx rpr 

s/a/l 1.1-2.5 

cm 

EF01

4 light, surgical NF 86 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
606 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

5 mayo stand NF 86 41 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 86 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 86 41 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 86 41 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 86 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 86 41 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
607 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicativ

e 

SB02

7 

gown, staff, 

impervious F 2 0 

CMS 

clinical 

review 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicativ

e 

SB03

4 

mask, surgical, 

with face shield F 2 1 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 

EF01

4 light, surgical NF 129 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 129 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13121 

Cmplx rpr 

s/a/l 2.6-7.5 

cm 

EF02

3 table, exam NF 129 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
608 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF03

1 table, power NF 129 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 129 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 129 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 129 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

15 10 

Standardi

zed time 

input 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicativ

e 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 
609 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SJ04

1 

povidone soln 

(Betadine) NF 10 0 Duplicative 

EF01

5 mayo stand NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 30 20 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

13122 

Cmplx rpr 

s/a/l addl 5 

cm/> 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 
610 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 45 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 45 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13131 

Cmplx rpr 

f/c/c/m/n/ax

/g/h/f 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 45 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
611 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicative 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 

EF01

4 light, surgical NF 50 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13132 

Cmplx rpr 

f/c/c/m/n/ax

/g/h/f 

EF02

3 table, exam NF 50 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
612 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF03

1 table, power NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 50 58 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicativ

e 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 10 0 Duplicative 
613 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

5 mayo stand NF 35 23 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 35 23 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 35 23 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 35 23 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 35 23 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

13133 

Cmplx rpr 

f/c/c/m/n/ax

/g/h/f 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 
614 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF01

4 light, surgical NF 30 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 30 44 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 30 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 30 44 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 30 44 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13150 

Cmplx rpr 

e/n/e/l 1.0 

cm/< 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 30 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
615 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 30 44 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Assist physician 

in performing 

procedure 

20 26 

Conformi

ng to 

physician 

time 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicative 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicativ

e 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicative 

EF01

4 light, surgical NF 45 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13151 

Cmplx rpr 

e/n/e/l 1.1-

2.5 cm 

EF01

5 mayo stand NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
616 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF02

3 table, exam NF 45 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 45 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 45 48 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicativ

e 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicativ

e 
617 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 

EF01

4 light, surgical NF 50 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

5 mayo stand NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 50 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13152 

Cmplx rpr 

e/n/e/l 2.6-

7.5 cm 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
618 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 50 58 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 50 51 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 15 10 

Standardi

zed time 

input 

SB01

6 

drape-cover, 

sterile, OR light 

handle 

NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 2 0 Duplicativ

e 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicative 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 10 0 Duplicativ

e 

EF01

5 mayo stand NF 45 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

13153 

Cmplx rpr 

e/n/e/l addl 

5cm/< 

EF03

1 table, power NF 45 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
619 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

14 

electrosurgical 

generator, up to 

120 watts 

NF 45 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 45 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

51 

Smoke 

Evacuator(tubing, 

covering, etc.) 

with stand 

NF 45 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SC02

9 needle, 18-27g NF 2 0 

CMS 

clinical 

review 

SF01

6 

cautery, 

monopolar, 

electrode tip 

NF 1 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 5 0 Duplicativ

e 

EF02

3 table, exam NF 19 16 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

20600 Drain/inject 

joint/bursa 

EQ1

68 light, exam NF 19 16 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
620 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA F Discharge day management 6 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA F 

Conduct phone 

calls/call in 

prescriptions 

0 3 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 4 2 

CMS 

clinical 

review 

SC05

5 syringe 3ml NF 2 1 

CMS 

clinical 

review 

EF02

3 table, exam NF 19 16 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 19 16 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA F Discharge day 

management 6 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA F 

Conduct phone 

calls/call in 

prescriptions 

0 3 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 4 2 

CMS 

clinical 

review 

20605 Drain/inject 

joint/bursa 

SC05

5 syringe 3ml NF 2 1 

CMS 

clinical 

review 

20610 Drain/inject 

joint/bursa 

EF02

3 table, exam NF 19 16 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
621 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

68 light, exam NF 19 16 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA F Discharge day management 6 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA F 

Conduct phone 

calls/call in 

prescriptions 

0 3 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 4 2 

CMS 

clinical 

review 

SC05

7 syringe 5-6ml NF 2 1 

CMS 

clinical 

review 

SA05

2 

pack, post-op 

incision care 

(staple) 

F 0 1 

CMS 

clinical 

review 23472 

Reconstruct 

shoulder 

joint SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 

SA05

2 

pack, post-op 

incision care 

(staple) 

F 0 1 

CMS 

clinical 

review 23473 

Revis 

reconst 

shoulder 

joint SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 

SA05

2 

pack, post-op 

incision care 

(staple) 

F 0 1 

CMS 

clinical 

review 23474 

Revis 

reconst 

shoulder 

joint SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 

SA05

2 

pack, post-op 

incision care 

(staple) 

F 0 1 

CMS 

clinical 

review 24363 Replace 

elbow joint SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 

24370 

Revise 

reconst 

elbow joint 

SA05

2 

pack, post-op 

incision care 

(staple) 

F 0 1 

CMS 

clinical 

review 
622 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SA05

2 

pack, post-op 

incision care 

(staple) 

F 0 1 

CMS 

clinical 

review 

SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 

SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 

EF00

8 

chair with 

headrest, exam, 

reclining 

NF 43 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

38 

instrument pack, 

medium ($1500 

and up) 

NF 0 47 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

67 

light source, 

xenon 

NF 43 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

70 

light, fiberoptic 

headlight wsource NF 43 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

31231 

Nasal 

endoscopy 

dx 

EQ2

34 

suction and 

pressure cabinet, 

ENT (SMR) 

NF 43 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
623 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ES01

3 

endoscope, rigid, 

sinoscopy NF 63 42 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES01

3 

endoscope, rigid, 

sinoscopy NF 63 0 

CMS 

clinical 

review 

ES03

1 

video system, 

endoscopy 

(processor, digital 

capture, monitor, 

printer, cart) 

NF 43 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES03

2 

video system, 

stroboscopy 

(strobing 

platform, camera, 

digital recorder, 

monitor, printer, 

cart) 

NF 43 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES03

6 

Nasal Endoscopy 

Instrument 

Package 

NF 63 0 

Nonstandard 

direct 

practice 

expense 

input 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

2 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Obtain vital signs 1 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Clean Surgical 

Instrument 

Package 

10 15 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF 

Review/read Xray, lab, and 

pathology 

reports 

5 0 

CMS 

clinical 

review 
624 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SB02

7 

gown, staff, 

impervious NF 2 1 Duplicative 

SB03

4 

mask, surgical, 

with face shield NF 2 1 Duplicative 

L047

C 

RN/Respiratory 

Therapist F 

Complete preservice 

diagnostic & 

referral forms 

3 5 

CMS 

clinical 

review 31647 

Bronchial 

valve init 

insert L047

C 

RN/Respiratory 

Therapist F Coordinate presurgery services 5 3 

CMS 

clinical 

review 

EF02

3 table, exam NF 56 52 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 0 52 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Complete preservice 

diagnostic & 

referral forms 

5 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Coordinate presurgery services 3 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

5 10 

CMS 

clinical 

review 

SA04

8 

pack, minimum 

multi-specialty 

visit 

NF 0 1 

CMS 

clinical 

review 

SA06

7 tray, shave prep NF 0 1 

CMS 

clinical 

review 

32554 

Aspirate 

pleura w/o 

imaging 

SA07

7 

kit, pleural 

catheter insertion NF 0 1 

CMS 

clinical 

review 
625 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SB00

1 cap, surgical NF 0 2 

CMS 

clinical 

review 

SB00

6 

drape, non-sterile, 

sheet 40in x 60in NF 1 0 

CMS 

clinical 

review 

SB02

4 gloves, sterile NF 1 2 

CMS 

clinical 

review 

SB03

4 

mask, surgical, 

with face shield NF 0 2 

CMS 

clinical 

review 

SB03

9 

shoe covers, 

surgical NF 0 2 

CMS 

clinical 

review 

SB04

4 

underpad 2ft x 3ft 

(Chux) NF 0 1 

CMS 

clinical 

review 

SG05

6 

gauze, sterile 4in 

x 4in (10 pack 

uou) 

NF 0 1 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 58 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

9 stretcher chair NF 15 10 

CMS 

clinical 

review 

EL01

5 

room, ultrasound, 

general NF 33 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

32555 

Aspirate 

pleura w/ 

imaging 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 58 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
626 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Complete preservice 

diagnostic & 

referral forms 

5 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Coordinate presurgery services 3 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

15 10 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Process images, 

complete data 

sheet, present 

images and data 

to the 

interpreting 

physician 

5 2 

CMS 

clinical 

review 

SA02

7 

kit, scissors and 

clamp NF 0 1 

CMS 

clinical 

review 

SA07

7 

kit, pleural 

catheter insertion NF 0 1 

CMS 

clinical 

review 

SB00

1 cap, surgical NF 0 3 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 0 1 

CMS 

clinical 

review 

SB03

9 

shoe covers, 

surgical NF 0 3 

CMS 

clinical 

review 

SB04

4 

underpad 2ft x 3ft 

(Chux) NF 0 1 

CMS 

clinical 

review 

SG07

8 

tape, surgical 

occlusive 1in 

(Blenderm) 

NF 0 15 

CMS 

clinical 

review 

SM0

12 

disinfectant spray 

(Transeptic) NF 10 0 

CMS 

clinical 

review 

SM0

21 

sanitizing clothwipe (patient) NF 2 0 

CMS 

clinical 

review 
627 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

68 light, exam NF 0 76 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Complete preservice 

diagnostic & 

referral forms 

5 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Coordinate presurgery services 3 1 

CMS 

clinical 

review 

SA04

4 

pack, moderate 

sedation NF 0 1 

CMS 

clinical 

review 

SA04

8 

pack, minimum 

multi-specialty 

visit 

NF 0 1 

CMS 

clinical 

review 

SA06

7 tray, shave prep NF 0 1 

CMS 

clinical 

review 

SB00

1 cap, surgical NF 0 2 

CMS 

clinical 

review 

SB00

6 

drape, non-sterile, 

sheet 40in x 60in NF 1 0 

CMS 

clinical 

review 

SB03

4 

mask, surgical, 

with face shield NF 0 2 

CMS 

clinical 

review 

SB03

9 

shoe covers, 

surgical NF 0 2 

CMS 

clinical 

review 

SB04

4 

underpad 2ft x 3ft 

(Chux) NF 0 1 

CMS 

clinical 

review 

SC01

0 

closed flush 

system, 

angiography 

NF 0 1 

CMS 

clinical 

review 

SG05

6 

gauze, sterile 4in 

x 4in (10 pack 

uou) 

NF 1 0 

CMS 

clinical 

review 

32556 

Insert cath 

pleura w/o 

image 

SH06

5 

sodium chloride 

0.9% flush 

syringe 

NF 0 1 

CMS 

clinical 

review 
628 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SH06

9 

sodium chloride 

0.9% irrigation 

(500-1000ml uou) 

NF 0 1 

CMS 

clinical 

review 

SL15

7 cup, sterile, 8 oz NF 0 1 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 58 7 

CMS 

clinical 

review 

EF01

9 stretcher chair NF 15 10 

CMS 

clinical 

review 

EL00

7 room, CT NF 43 40 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 60 40 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 58 7 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Complete preservice 

diagnostic & 

referral forms 

5 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Coordinate presurgery services 3 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Check dressings 

& wound/ home 

care instructions 

/coordinate 

office visits 

/prescriptions 

3 5 

CMS 

clinical 

review 

32557 

Insert cath 

pleura w/ 

image 

L046

A CT Technologist NF 

Assist physician 

in performing 

procedure 

28 30 

Conformi

ng to 

physician 

time 
629 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SA04

4 

pack, moderate 

sedation NF 0 1 

CMS 

clinical 

review 

SA07

1 

kit, AccuStick II 

Introducer System 

with RO Marker 

NF 1 0 

CMS 

clinical 

review 

SA07

7 

kit, pleural 

catheter insertion NF 0 1 

CMS 

clinical 

review 

SB00

1 cap, surgical NF 2 3 

CMS 

clinical 

review 

SB01

1 

drape, sterile, 

fenestrated 16in x 

29in 

NF 1 0 

CMS 

clinical 

review 

SB01

4 

drape, sterile, 

three-quarter sheet NF 1 0 

CMS 

clinical 

review 

SB01

9 

drape-towel, 

sterile 18in x 26in NF 4 0 

CMS 

clinical 

review 

SB02

4 gloves, sterile NF 2 1 

CMS 

clinical 

review 

SB02

7 

gown, staff, 

impervious NF 0 1 

CMS 

clinical 

review 

SB03

9 

shoe covers, 

surgical NF 2 3 

CMS 

clinical 

review 

SC04

9 stop cock, 3-way NF 1 0 

CMS 

clinical 

review 

SC05

6 syringe 50-60ml NF 2 0 

CMS 

clinical 

review 

SC05

8 

syringe w-needle, 

OSHA compliant 

(SafetyGlide) 

NF 1 0 

CMS 

clinical 

review 

SD04

3 

dilator, vessel, 

angiographic NF 1 0 

CMS 

clinical 

review 

SD08

8 guidewire NF 1 0 

CMS 

clinical 

review 
630 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SD14

6 

catheter 

percutaneous 

fastener (PercuStay) 

NF 1 0 

CMS 

clinical 

review 

SD16

1 

drainage catheter, 

all purpose NF 1 0 

CMS 

clinical 

review 

SD16

3 

drainage pouch, 

nephrostomybiliary NF 1 0 

CMS 

clinical 

review 

SF00

7 

blade, surgical 

(Bard-Parker) NF 1 0 

CMS 

clinical 

review 

SG00

9 

applicator, 

sponge-tipped NF 4 0 

CMS 

clinical 

review 

SG07

8 

tape, surgical 

occlusive 1in 

(Blenderm) 

NF 0 25 

CMS 

clinical 

review 

SH04

7 

lidocaine 1%-2% 

inj (Xylocaine) NF 10 0 

CMS 

clinical 

review 

SJ04

1 

povidone soln 

(Betadine) NF 60 0 

CMS 

clinical 

review 

SL03

6 

cup, biopsyspecimen sterile 

4oz 

NF 1 0 

CMS 

clinical 

review 

SL15

6 

cup, sterile, 12-16 

oz 

NF 1 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA F Coordinate presurgery services 40 10 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Schedule space 

and equipment 

in facility 

8 5 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Provide preservice 

education/obtai

n consent 

20 7 

Standardi

zed time 

input 

33361 

Replace 

aortic valve 

perq 

L037

D RN/LPN/MTA F 

Follow-up 

phone calls & 

prescriptions 

7 3 

Standardi

zed time 

input 

33362 

Replace 

aortic valve 

open 

L037

D RN/LPN/MTA F Coordinate presurgery services 40 10 

Standardi

zed time 

input 
631 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA F 

Schedule space 

and equipment 

in facility 

8 5 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Provide preservice 

education/obtai

n consent 

20 7 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Follow-up 

phone calls & 

prescriptions 

7 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F Coordinate presurgery services 40 10 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Schedule space 

and equipment 

in facility 

8 5 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Provide preservice 

education/obtai

n consent 

20 7 

Standardi

zed time 

input 

33363 

Replace 

aortic valve 

open 

L037

D RN/LPN/MTA F 

Follow-up 

phone calls & 

prescriptions 

7 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F Coordinate presurgery services 40 10 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Schedule space 

and equipment 

in facility 

8 5 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Provide preservice 

education/obtai

n consent 

20 7 

Standardi

zed time 

input 

33364 

Replace 

aortic valve 

open 

L037

D RN/LPN/MTA F 

Follow-up 

phone calls & 

prescriptions 

7 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F Coordinate presurgery services 40 10 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Schedule space 

and equipment 

in facility 

8 5 

Standardi

zed time 

input 

L037

D RN/LPN/MTA F 

Provide preservice 

education/obtai

n consent 

20 7 

Standardi

zed time 

input 

33365 

Replace 

aortic valve 

open 

L037

D RN/LPN/MTA F 

Follow-up 

phone calls & 

prescriptions 

7 3 

Standardi

zed time 

input 
632 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L051

A RN F 

Other Clinical 

Activity - 

specify: for 

reference code 

33406 and 

codes 33405 

and 33430: 

Additional 

coordination 

between 

multiple 

specialties for 

complex 

procedures 

(tests, meds, 

scheduling, etc) 

prior to patient 

arrival at site of 

service. 

15 0 

CMS 

clinical 

review 

33405 

Replacemen

t of aortic 

valve 

L051

A RN F 

Other Clinical 

Activity - 

specify: for 

reference code 

33406 and 

codes 33405 

and 33430: 

Additional 

coordination 

between 

multiple 

specialties for 

complex 

procedures 

(tests, meds, 

scheduling, etc) 

prior to patient 

arrival at site of 

service. 

15 0 

CMS 

clinical 

review 

35475 

Repair 

arterial 

blockage 

EL01

1 

room, 

angiography NF 51 52 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
633 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ0

11 

ECG, 3-channel 

(with SpO2, 

NIBP, temp, resp) 

NF 212 285 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 

EQ0

32 IV infusion pump NF 212 285 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 

EQ1

68 light, exam NF 120 52 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA F 

Complete preservice 

diagnostic & 

referral forms 

5 3 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Obtain vital 

signs 5 3 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Prepare room, 

equipment, 

supplies 

4 2 

Standardi

zed time 

input 

SB01

9 

drape-towel, 

sterile 18in x 26in NF 4 2 

CMS 

clinical 

review 
634 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

Ef02

7 

table, instrument, 

mobile NF 302 277 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 

EL01

1 

room, 

angiography NF 43 44 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

11 

ECG, 3-channel 

(with SpO2, 

NIBP, temp, resp) 

NF 137 277 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 

35476 

Repair 

venous 

blockage 

EQ0

32 IV infusion pump NF 137 277 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 
635 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

68 light, exam NF 120 44 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA F 

Schedule space 

and equipment 

in facility 

3 5 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Obtain vital signs 5 3 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Prepare room, 

equipment, 

supplies 

4 2 

Standardi

zed time 

input 

SB01

9 

drape-towel, 

sterile 18in x 26in NF 4 2 

CMS 

clinical 

review 

EF01

8 stretcher NF 272 0 

CMS 

Code 

correction 

EF02

7 

table, instrument, 

mobile NF 0 272 

CMS 

Code 

correction 

EL01

1 

room, 

angiography NF 49 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

36221 

Place cath 

thoracic 

aorta 

EQ0

88 

contrast media 

warmer 

NF 49 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
636 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 49 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

5 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF Obtain vital signs 5 3 

CMS 

clinical 

review 

L041

A Angio Technician NF Image Post 

Processing 5 0 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Prepare room, 

equipment, 

supplies 

2 7 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

2 7 

CMS 

clinical 

review 

SD24

9 

Sterile Radioopaque ruler (le 

Maitre, 

documentation 

available) 

NF 1 0 

CMS 

clinical 

review 

EF01

8 stretcher NF 282 0 

CMS 

Code 

correction 

EF02

7 

table, instrument, 

mobile NF 0 282 

CMS 

Code 

correction 

36222 

Place cath 

carotid/ino

m art 

EL01

1 

room, 

angiography NF 59 49 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
637 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ0

88 

contrast media 

warmer 

NF 59 49 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 59 49 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

5 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF Obtain vital 

signs 5 3 

CMS 

clinical 

review 

SD14

7 catheter, (Glide) NF 1 0 

CMS 

clinical 

review 

SD24

9 

Sterile Radioopaque ruler (le 

Maitre, 

documentation 

available) 

NF 1 0 

CMS 

clinical 

review 

EF01

8 stretcher NF 287 0 

CMS 

Code 

correction 

EF02

7 

table, instrument, 

mobile NF 0 287 

CMS 

Code 

correction 

36223 

Place cath 

carotid/ino

m art 

EL01

1 

room, 

angiography NF 64 54 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
638 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ0

88 

contrast media 

warmer 

NF 64 54 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 64 54 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

5 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF Obtain vital 

signs 5 3 

CMS 

clinical 

review 

SD24

9 

Sterile Radioopaque ruler (le 

Maitre, 

documentation 

available) 

NF 1 0 

CMS 

clinical 

review 

EF01

8 stretcher NF 292 0 

CMS 

Code 

correction 

EF02

7 

table, instrument, 

mobile NF 0 292 

CMS 

Code 

correction 

36224 Place cath 

carotd art 

EL01

1 

room, 

angiography NF 69 59 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
639 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ0

88 

contrast media 

warmer 

NF 69 59 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 69 59 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

5 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF Obtain vital 

signs 5 3 

CMS 

clinical 

review 

EF01

8 stretcher NF 287 0 

CMS 

Code 

correction 

EF02

7 

table, instrument, 

mobile NF 0 287 

CMS 

Code 

correction 

EL01

1 

room, 

angiography NF 64 54 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

36225 

Place cath 

subclavian 

art 

EQ0

88 

contrast media 

warmer 

NF 64 54 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
640 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 64 54 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

5 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF Obtain vital signs 5 3 

CMS 

clinical 

review 

EF01

8 stretcher NF 292 0 

CMS 

Code 

correction 

EF02

7 

table, instrument, 

mobile NF 0 292 

CMS 

Code 

correction 

EL01

1 

room, 

angiography NF 69 59 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

88 

contrast media 

warmer 

NF 69 59 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

36226 Place cath 

vertebral art 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 69 59 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
641 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

5 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF Obtain vital signs 5 3 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Prepare room, 

equipment, 

supplies 

1 0 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Assisting with 

flouroscopy/ima

ge acquisition 

(75%) 

23 22 

CMS 

clinical 

review 

36228 

Place cath 

intracranial 

art 

SC05

7 syringe 5-6ml NF 4 0 

CMS 

clinical 

review 

EF02

7 

table, instrument, 

mobile NF 305 302 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 

37197 

Remove 

intrvas 

foreign 

body 

EL01

1 

room, 

angiography NF 77 72 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
642 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ0

11 

ECG, 3-channel 

(with SpO2, 

NIBP, temp, resp) 

NF 305 302 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 

EQ0

32 IV infusion pump NF 305 302 

Moderate 

Sedation 

equipment 

- Time 

includes 

administer

ing 

anesthesia

, 

procedure 

time, and 

monitorin

g patient 

EQ0

88 

contrast media 

warmer 

NF 77 0 

CMS 

clinical 

review 

EQ2

50 

ultrasound unit, 

portable NF 77 0 

CMS 

clinical 

review 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 77 72 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

5 3 

Standardi

zed time 

input 

L037

D RN/LPN/MTA NF Obtain vital signs 5 3 

CMS 

clinical 

review 
643 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L041

B 

Radiologic 

Technologist NF 

Prepare room, 

equipment, 

supplies 

(including 

imaging 

equipment) 

7 5 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

5 2 

Standardi

zed time 

input 

SB04

8 

sheath-cover, 

sterile, 96in x 6in 

(transducer) 

NF 1 0 

CMS 

clinical 

review 

SB04

8 

sheath-cover, 

sterile, 96in x 6in 

(transducer) 

NF 1 0 

CMS 

clinical 

review 

SD14

7 catheter, (Glide) NF 1 0 

CMS 

clinical 

review 

SD25

2 

guidewire, 

Amplatz wire 260 

cm 

NF 1 0 

CMS 

clinical 

review 

SH06

5 

sodium chloride 

0.9% flush 

syringe 

NF 2 0 

CMS 

clinical 

review 

SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 47600 Removal of 

gallbladder SA05

4 

pack, post-op 

incision care 

(suture) 

F 0 1 

CMS 

clinical 

review 

SA05

3 

pack, post-op 

incision care 

(suture & staple) 

F 1 0 

CMS 

clinical 

review 47605 Removal of 

gallbladder SA05

4 

pack, post-op 

incision care 

(suture) 

F 0 1 

CMS 

clinical 

review 

50590 

Fragmentin

g of kidney 

stone 

EL01

4 

room, 

radiographicfluoroscopic NF 86 0 

Consistent 

with the 

AMA 

RUC's 

CY2011 

recommen

dation 
644 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

75 

lithotriptor, with 

C-arm (ESWL) NF 86 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

7 

table, instrument, 

mobile NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

53 

laser (gs, uro, obg, 

ge) (Indigo 

Optima) 

NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

52214 

Cystoscopy 

and 

treatment 

EQ1

67 

light source, 

xenon 

NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
645 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ES00

6 

endoscope 

forceps, biopsy NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES00

7 

endoscope 

forceps, grasping NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES01

8 

fiberscope, 

flexible, 

cystoscopy 

NF 100 92 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES03

1 

video system, 

endoscopy 

(processor, digital 

capture, monitor, 

printer, cart) 

NF 100 65 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF Review Chart 3 0 

CMS 

clinical 

review 

SB01

9 

drape-towel, 

sterile 18in x 26in NF 1 0 Duplicative 

SB02

4 gloves, sterile NF 0 1 

CMS 

clinical 

review 

SD27

0 Penis clamp NF 1 0 

Not a 

disposable 

supply 

SH04

7 

lidocaine 1%-2% 

inj (Xylocaine) NF 50 0 Duplicative 
646 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF02

7 

table, instrument, 

mobile NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

53 

laser (gs, uro, obg, 

ge) (Indigo 

Optima) 

NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

67 

light source, 

xenon 

NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

52224 

Cystoscopy 

and 

treatment 

ES00

6 

endoscope 

forceps, biopsy NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
647 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ES00

7 

endoscope 

forceps, grasping NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES01

8 

fiberscope, 

flexible, 

cystoscopy 

NF 105 94 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES03

1 

video system, 

endoscopy 

(processor, digital 

capture, monitor, 

printer, cart) 

NF 105 67 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF Review Chart 3 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Prepare biopsy Specimen 5 2 

CMS 

clinical 

review 

SB01

9 

drape-towel, 

sterile 18in x 26in NF 1 0 Duplicativ

e 

SB02

4 gloves, sterile NF 3 1 

CMS 

clinical 

review 

SD27

0 Penis clamp NF 1 0 

Not a 

disposable 

according 

to 

submitted 

invoice 

SH04

7 

lidocaine 1%-2% 

inj (Xylocaine) NF 50 0 Duplicative 

SL03

6 

cup, biopsyspecimen sterile 

4oz 

NF 6 3 

CMS 

clinical 

review 
648 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF02

7 

table, instrument, 

mobile NF 78 49 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 78 49 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

70 

light, fiberoptic 

headlight wsource 

NF 78 49 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES01

8 

fiberscope, 

flexible, 

cystoscopy 

NF 78 76 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ES03

1 

video system, 

endoscopy 

(processor, digital 

capture, monitor, 

printer, cart) 

NF 78 49 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Assist physician 

in performing 

procedure 

20 21 

Conformi

ng to 

physician 

time 

52287 

Cystoscopy 

chemodener

vation 

SH04

8 

lidocaine 2% 

jelly, topical 

(Xylocaine) 

NF 10 0 Duplicativ

e 
649 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF02

0 

stretcher, 

endoscopy NF 99 85 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

7 

table, instrument, 

mobile NF 99 85 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 169 152 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

37 

TUMT system 

control unit NF 99 85 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 169 152 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

53850 

Prostatic 

microwave 

thermotx 

EQ1

68 light, exam F 169 152 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
650 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ2

50 

ultrasound unit, 

portable NF 99 85 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Prepare room, 

equipment, 

supplies 

2 4 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Setup 

ultrasound 

probe 

5 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Setup TUMT 

machine 5 0 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Clean TUMT machine 3 0 

CMS 

clinical 

review 

SB02

2 gloves, non-sterile NF 3 2 

CMS 

clinical 

review 

SB02

4 gloves, sterile NF 3 2 

CMS 

clinical 

review 

SH04

7 

lidocaine 1%-2% 

inj (Xylocaine) NF 3 30 

CMS 

clinical 

review 

EL00

6 

lane, screening 

(oph) F 39 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL00

6 

lane, screening 

(oph) NF 48 45 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

64612 

Destroy 

nerve face 

muscle 

SC03

1 needle, 30g F 0 1 

CMS 

clinical 

review 
651 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

64615 

Chemodene

rv musc 

migraine 

EF02

3 table, exam NF 24 18 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

E711

1 Lane, Screening NF 21 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 65800 Drainage of 

eye 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 21 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF01

4 light, surgical NF 20 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

1 table, power NF 20 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

67810 

Biopsy 

eyelid & lid 

margin 

EQ1

10 

electrocauteryhyfrecator, up to 

45 watts 

NF 1 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
652 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ1

37 

instrument pack, 

basic ($500-

$1499) 

NF 1 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SB01

1 

drape, sterile, 

fenestrated 16in x 

29in 

NF 0 1 

CMS 

clinical 

review 

SB01

9 

drape-towel, 

sterile 18in x 26in NF 4 1 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 1 0 

Standardi

zed time 

input 

ED0

25 

film processor, 

wet NF 20 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL01

2 

room, basic 

radiology NF 20 13 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 20 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

72040 

X-ray exam 

neck spine 

3/<vws 

 Film jacket or 

jacket insert NF 1 0 

Nonstandard 

direct 

practice 

expense 

input 
653 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ED0

25 

film processor, 

wet NF 28 6 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL01

2 

room, basic 

radiology NF 28 19 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 28 6 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

72050 

X-ray exam 

neck spine 

4/5vws 

 Film jacket or 

jacket insert NF 1 0 

Nonstandard 

direct 

practice 

expense 

input 

ED0

25 

film processor, 

wet NF 36 8 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

72052 

X-ray exam 

neck spine 

6/>vws 

EL01

2 

room, basic 

radiology NF 36 25 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
654 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 36 8 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

 Film jacket or 

jacket insert NF 1 0 

Nonstandard 

direct 

practice 

expense 

input 

EL00

7 room, CT NF 101 40 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L041

B 

Radiologic 

Technologist NF 

 - Retrieve 

prior 

appropriate 

imaging exams 

and hang for 

MD review, 

verify orders, 

review the chart 

to incorporate 

relevant clinical 

information 

0 5 

CMS 

Clinical 

Review 

L041

B 

Radiologic 

Technologist NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

0 3 

CMS 

Clinical 

Review 

L041

B 

Radiologic 

Technologist NF 

Education/instru

ction/counseling

/obtain consent 

0 2 

CMS 

Clinical 

Review 

L041

B 

Radiologic 

Technologist NF 

Prepare room, 

equipment, 

supplies 

0 2 

Standardi

zed time 

input 

72191 

Ct 

angiograph 

pelv 

w/o&w/dye 

L041

B 

Radiologic 

Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

0 7 

CMS 

Clinical 

Review 
655 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L041

B 

Radiologic 

Technologist NF Aquire images 0 28 

CMS 

Clinical 

Review 

L041

B 

Radiologic 

Technologist NF 

Clean 

room/equipment 

by physician 

staff 

0 3 

CMS 

Clinical 

Review 

L046

A CT Technologist NF 

 - Retrieve 

prior 

appropriate 

imaging exams 

and hang for 

MD review, 

verify orders, 

review the chart 

to incorporate 

relevant clinical 

information 

5 0 

CMS 

Clinical 

Review 

L046

A CT Technologist NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

3 0 

CMS 

Clinical 

Review 

L046

A CT Technologist NF 

Education/instru

ction/counseling

/obtain consent 

2 0 

CMS 

Clinical 

Review 

L046

A CT Technologist NF 

Prepare room, 

equipment, 

supplies 

5 0 

CMS 

Clinical 

Review 

L046

A CT Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

7 0 

CMS 

Clinical 

Review 

L046

A CT Technologist NF Aquire images 28 0 

CMS 

Clinical 

Review 

L046

A CT Technologist NF 

Clean 

room/equipment 

by physician 

staff 

3 0 

CMS 

Clinical 

Review 

SK01

6 

computer media, 

optical disk 2.6gb NF 1 0.1 

CMS 

clinical 

review 

72192 Ct pelvis 

w/o dye 

ED0

24 

film processor, 

dry, laser NF 5 0 

CMS 

clinical 

review 
656 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ED0

32 

printer, laser, 

paper 

NF 0 5 

CMS 

clinical 

review 

EL00

7 room, CT NF 45 22 

CMS 

clinical 

review 

L046

A CT Technologist NF Pre-Service Period 6 4 

CMS 

clinical 

review 

SK01

3 

computer media, 

dvd NF 1 0 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

SK09

1 x-ray envelope NF 1 0 

CMS 

clinical 

review 

SK09

8 

film, x-ray, laser 

print NF 4 8 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 5 0 

CMS 

clinical 

review 

ED0

32 

printer, laser, 

paper 

NF 0 5 

CMS 

clinical 

review 

EL00

7 room, CT NF 40 32 

CMS 

clinical 

review 

L046

A CT Technologist NF Pre-Service 

Period 7 4 

CMS 

clinical 

review 

L046

A CT Technologist NF Service Period 40 43 

CMS 

clinical 

review 

SB00

6 

drape, non-sterile, 

sheet 40in x 60in NF 1 0 

CMS 

clinical 

review 

SB01

4 

drape, sterile, 

three-quarter sheet NF 0 1 

CMS 

clinical 

review 

72193 Ct pelvis 

w/dye 

SC00

1 

angiocatheter 14g24g NF 1 0 

CMS 

clinical 

review 
657 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SC00

2 angiocatheter set NF 0 1 

CMS 

clinical 

review 

SC02

5 

needle, 14-20g, 

biopsy NF 0 1 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SC05

9 

syringe, 25ml 

(MRI power 

injector) 

NF 0 1 

CMS 

clinical 

review 

SG05

9 oto-wick NF 0 6 

CMS 

clinical 

review 

SG06

8 

plaster bandage 

(4in x 5yd uou) NF 1 0 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 6 0 

CMS 

clinical 

review 

SH06

5 

sodium chloride 

0.9% flush 

syringe 

NF 0 15 

CMS 

clinical 

review 

SK01

3 

computer media, 

dvd NF 1 0 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

SK09

1 x-ray envelope NF 1 0 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 10 7 

CMS 

clinical 

review 

EL00

7 room, CT NF 54 39 

CMS 

clinical 

review 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 10 7 

CMS 

clinical 

review 

72194 

Ct pelvis 

w/o & 

w/dye 

L046

A CT Technologist NF Pre-Service 

Period 7 4 

CMS 

clinical 

review 
658 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L046

A CT Technologist NF Service Period 54 52 

CMS 

clinical 

review 

SC02

5 

needle, 14-20g, 

biopsy NF 0 1 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SK01

3 

computer media, 

dvd NF 1 0 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

SK09

1 x-ray envelope NF 1 0 

CMS 

clinical 

review 

SK09

8 

film, x-ray, laser 

print NF 0 8 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 63 33 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL00

8 room, MR NF 63 33 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

73221 

Mri joint 

upr extrem 

w/o dye 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 63 33 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
659 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L047

A MRI Technologist NF 

Prepare room, 

equipment, 

supplies 

5 3 

CMS 

clinical 

review 

L047

A MRI Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

3 2 

Standardi

zed time 

input 

L047

A MRI Technologist NF 

Escort patient 

from exam 

room due to 

magnetic 

sensitivity 

2 0 

Nonstandard 

direct 

practice 

expense 

input 

 Insert folder NF 1 0 

Nonstandard 

direct 

practice 

expense 

input 

ED0

24 

film processor, 

dry, laser NF 63 33 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL00

8 room, MR NF 63 33 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 63 33 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

73721 

Mri jnt of 

lwr extre 

w/o dye 

L047

A MRI Technologist NF 

Prepare room, 

equipment, 

supplies 

5 3 

CMS 

clinical 

review 
660 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L047

A MRI Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

3 2 

Standardi

zed time 

input 

L047

A MRI Technologist NF 

Escort patient 

from exam 

room due to 

magnetic 

sensitivity 

2 0 

Nonstandard 

direct 

practice 

expense 

input 

 Insert folder NF 1 0 

Nonstandard 

direct 

practice 

expense 

input 

ED0

24 

film processor, 

dry, laser NF 5 0 

CMS 

clinical 

review 

ED0

32 

printer, laser, 

paper 

NF 0 5 

CMS 

clinical 

review 

EL00

7 room, CT NF 32 22 

CMS 

clinical 

review 

L046

A CT Technologist NF Pre-Service 

Period 6 4 

CMS 

clinical 

review 

SK01

3 

computer media, 

dvd NF 1 0 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

SK09

1 x-ray envelope NF 1 0 

CMS 

clinical 

review 

74150 Ct abdomen 

w/o dye 

SK09

8 

film, x-ray, laser 

print NF 4 8 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 7 0 

CMS 

clinical 

review 

74160 Ct abdomen 

w/dye 

ED0

32 

printer, laser, 

paper 

NF 0 5 

CMS 

clinical 

review 
661 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EL00

7 room, CT NF 47 32 

CMS 

clinical 

review 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 7 5 

CMS 

clinical 

review 

L046

A CT Technologist NF Pre-Service Period 7 4 

CMS 

clinical 

review 

L046

A CT Technologist NF Service Period 47 43 

CMS 

clinical 

review 

SB00

6 

drape, non-sterile, 

sheet 40in x 60in NF 1 0 

CMS 

clinical 

review 

SB01

4 

drape, sterile, 

three-quarter sheet NF 0 1 

CMS 

clinical 

review 

SC00

1 

angiocatheter 14g24g NF 1 0 

CMS 

clinical 

review 

SC00

2 angiocatheter set NF 0 1 

CMS 

clinical 

review 

SC02

5 

needle, 14-20g, 

biopsy NF 0 1 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SC05

9 

syringe, 25ml 

(MRI power 

injector) 

NF 0 1 

CMS 

clinical 

review 

SG05

9 oto-wick NF 0 1 

CMS 

clinical 

review 

SG07

5 

tape, elastic, 1in 

(Elastoplast, 

Elasticon) (5yd 

uou) 

NF 0 6 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 6 0 

CMS 

clinical 

review 

SH06

5 

sodium chloride 

0.9% flush 

syringe 

NF 0 15 

CMS 

clinical 

review 
662 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SH06

8 

sodium chloride 

0.9% inj 

bacteriostatic 

(30ml uou) 

NF 1 0 

CMS 

clinical 

review 

SK01

3 

computer media, 

dvd NF 1 0 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

SK09

1 x-ray envelope NF 1 0 

CMS 

clinical 

review 

SK09

8 

film, x-ray, laser 

print NF 6 4 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 15 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL00

7 room, CT NF 65 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

74170 

Ct abdomen 

w/o & 

w/dye 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 15 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
663 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L046

A CT Technologist NF 

 - Retrieve 

prior 

appropriate 

imaging exams 

and hang for 

MD review, 

verify orders, 

review the chart 

to incorporate 

relevant clinical 

information and 

confirm contrast 

protocol with 

interpreting MD 

7 4 

CMS 

clinical 

review 

L046

A CT Technologist NF 

Assist physician 

in performing 

procedure 

32 27 

CMS 

clinical 

review 

L046

A CT Technologist NF Image Post Processing 15 7 

CMS 

clinical 

review 

SB00

6 

drape, non-sterile, 

sheet 40in x 60in NF 1 0 

CMS 

clinical 

review 

SB01

4 

drape, sterile, 

three-quarter sheet NF 0 1 

CMS 

clinical 

review 

SC00

1 

angiocatheter 14g24g NF 1 0 

CMS 

clinical 

review 

SC00

2 angiocatheter set NF 0 1 

CMS 

clinical 

review 

SC02

5 

needle, 14-20g, 

biopsy NF 0 1 

CMS 

clinical 

review 

SC02

9 needle, 18-27g NF 1 0 

CMS 

clinical 

review 

SC05

9 

syringe, 25ml 

(MRI power 

injector) 

NF 0 1 

CMS 

clinical 

review 

SG07

5 

tape, elastic, 1in 

(Elastoplast, 

Elasticon) (5yd 

uou) 

NF 0 6 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 6 0 

CMS 

clinical 

review 
664 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SH01

6 

barium suspension 

(Polibar) NF 900 0 

CMS 

clinical 

review 

SH06

5 

sodium chloride 

0.9% flush 

syringe 

NF 0 15 

CMS 

clinical 

review 

SH06

8 

sodium chloride 

0.9% inj 

bacteriostatic 

(30ml uou) 

NF 1 0 

CMS 

clinical 

review 

SK01

3 

computer media, 

dvd NF 1 0 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

SK05

0 

neurobehavioral 

status forms, 

average 

NF 0 1 

CMS 

clinical 

review 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

SK09

1 x-ray envelope NF 1 0 

CMS 

clinical 

review 

SK09

8 

film, x-ray, laser 

print NF 14 8 

CMS 

clinical 

review 

EL00

7 room, CT NF 101 40 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

74175 

Ct angio 

abdom w/o 

& w/dye 

L041

B 

Radiologic 

Technologist NF 

 - Retrieve 

prior 

appropriate 

imaging exams 

and hang for 

MD review, 

verify orders, 

review the chart 

to incorporate 

relevant clinical 

information 

0 5 

CMS 

clinical 

review 
665 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L041

B 

Radiologic 

Technologist NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

0 3 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Education/instru

ction/counseling

/obtain consent 

0 2 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Prepare room, 

equipment, 

supplies 

0 2 

Standardi

zed time 

input 

L041

B 

Radiologic 

Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

0 7 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF Aquire images 0 28 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Clean 

room/equipment 

by physician 

staff 

0 3 

CMS 

clinical 

review 

L046

A CT Technologist NF 

 - Retrieve 

prior 

appropriate 

imaging exams 

and hang for 

MD review, 

verify orders, 

review the chart 

to incorporate 

relevant clinical 

information 

5 0 

CMS 

clinical 

review 

L046

A CT Technologist NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

3 0 

CMS 

clinical 

review 

L046

A CT Technologist NF 

Education/instru

ction/counseling

/obtain consent 

2 0 

CMS 

clinical 

review 

L046

A CT Technologist NF 

Prepare room, 

equipment, 

supplies 

5 0 

CMS 

clinical 

review 
666 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L046

A CT Technologist NF 

Prepare and 

position patient/ 

monitor patient/ 

set up IV 

7 0 

CMS 

clinical 

review 

L046

A CT Technologist NF Aquire images 28 0 

CMS 

clinical 

review 

L046

A CT Technologist NF 

Clean 

room/equipment 

by physician 

staff 

3 0 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 1 0.1 

CMS 

clinical 

review 

ED0

32 

printer, laser, 

paper 

NF 8 7 

CMS 

clinical 

review 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 27 7 

CMS 

clinical 

review 

L046

A CT Technologist NF Service Period 40 39 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

74176 Ct abd & 

pelvis 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

ED0

32 

printer, laser, 

paper 

NF 10 7 

CMS 

clinical 

review 

EL00

7 room, CT NF 42 39 

CMS 

clinical 

review 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 42 7 

CMS 

clinical 

review 

L046

A CT Technologist NF Pre-Service Period 7 6 

CMS 

clinical 

review 

L046

A CT Technologist NF Service Period 58 52 

CMS 

clinical 

review 

74177 

Ct abd & 

pelv 

w/contrast 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 
667 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

SK09

8 

film, x-ray, laser 

print NF 10 8 

CMS 

clinical 

review 

ED0

32 

printer, laser, 

paper 

NF 20 10 

CMS 

clinical 

review 

EL00

7 room, CT NF 57 48 

CMS 

clinical 

review 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 57 10 

CMS 

clinical 

review 

L046

A CT Technologist NF Pre-Service Period 7 6 

CMS 

clinical 

review 

L046

A CT Technologist NF Service Period 83 64 

CMS 

clinical 

review 

SK01

6 

computer media, 

optical disk 2.6gb NF 0 0.1 

CMS 

clinical 

review 

SK07

6 

slide sleeve 

(photo slides) NF 0 1 

CMS 

clinical 

review 

74178 

Ct abd & 

pelv 1/> 

regns 

SK09

8 

film, x-ray, laser 

print NF 23 16 

CMS 

clinical 

review 

ED0

24 

film processor, 

dry, laser NF 5 0 

CMS 

clinical 

review 

ED0

32 

printer, laser, 

paper 

NF 1 0 

CMS 

clinical 

review 

76830 Transvagina

l us non-ob 

EF02

7 

table, instrument, 

mobile NF 0 36 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
668 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF03

4 table, ultrasound NF 0 36 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL01

5 

room, ultrasound, 

general NF 37 0 

CMS 

clinical 

review 

EQ2

50 

ultrasound unit, 

portable NF 0 36 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 10 0 

CMS 

clinical 

review 

ER08

6 ultrasound probe NF 0 37 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF 

Clean 

room/equipment 

by physician 

staff 

3 2 

CMS 

clinical 

review 

SB02

6 gown, patient NF 0 1 

CMS 

clinical 

review 

SJ03

3 

lubricating jelly 

(Surgilube) NF 1 0 

CMS 

clinical 

review 

76872 Us 

transrectal 

EF02

7 

table, instrument, 

mobile NF 68 34 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
669 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF03

4 table, ultrasound NF 68 34 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ2

50 

ultrasound unit, 

portable NF 68 34 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER08

6 ultrasound probe NF 68 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF 

Retrieve prior 

images for 

comparison: 

0 3 

CMS 

clinical 

review 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF Review Chart 3 0 

CMS 

clinical 

review 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF Obtain vital 

signs 3 0 

CMS 

clinical 

review 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF 

Prepare room, 

equipment, 

supplies 

2 3 

CMS 

clinical 

review 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF 

Prepare 

ultrasound 

probe 

5 0 

CMS 

clinical 

review 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF Obtain vital 

signs 3 0 

CMS 

clinical 

review 

L051

B 

RN/Diagnostic 

Medical 

Sonographer 

NF 

Clean 

room/equipment 

by physician 

staff 

3 2 

CMS 

clinical 

review 

SB01

2 

drape, sterile, for 

Mayo stand NF 1 0 

CMS 

clinical 

review 
670 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SC01

9 

iv tubing 

(extension) NF 1 0 

CMS 

clinical 

review 

SH04

8 

lidocaine 2% 

jelly, topical 

(Xylocaine) 

NF 10 0 

CMS 

clinical 

review 

SJ00

1 

alcohol isopropyl 

70% NF 5 0 

CMS 

clinical 

review 

SJ03

2 

lubricating jelly 

(K-Y) (5gm uou) NF 2 0 

CMS 

clinical 

review 

SM0

18 

glutaraldehyde 

3.4% (Cidex, 

Maxicide, 

Wavicide) 

NF 32 0 

CMS 

clinical 

review 

SM0

19 

glutaraldehyde 

test strips (Cidex, 

Metrex) 

NF 1 0 

CMS 

clinical 

review 

SM0

22 

sanitizing clothwipe (surface, 

instruments, 

equipment) 

NF 2 0 

CMS 

clinical 

review 

ED0

25 

film processor, 

wet NF 3 2 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL01

4 

room, 

radiographicfluoroscopic NF 9 18 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

77003 

Fluoroguide 

for spine 

inject 

ER02

9 

film alternator 

(motorized film 

viewbox) 

NF 3 2 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
671 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L041

B 

Radiologic 

Technologist NF 

Clean 

room/equipment 

by physician 

staff 

2 1 

CMS 

clinical 

review 

L041

B 

Radiologic 

Technologist NF 

Process films, 

hang films and 

review study 

with 

interpreting MD 

prior to patient 

discharge 

3 2 

CMS 

clinical 

review 

77080 

Dxa bone 

density 

axial 

ER07

8 

phantom, spine, 

DXA calibration 

check 

NF 1 2 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ED0

11 

computer system, 

record and verify NF 20 0 

CMS 

clinical 

review 

ED0

33 

treatment 

planning system, 

IMRT (Corvus wPeregrine 3D 

Monte Carlo) 

NF 376 330 

CMS 

clinical 

review 

ER00

5 

IMRT CT-based 

simulator NF 58 47 

CMS 

clinical 

review 

ER01

4 

chamber, Farmertype NF 45 47 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

77301 

Radiotherap

y dose plan 

imrt 

ER02

8 

electrometer, PCbased, dual 

channel 

NF 45 47 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
672 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ER05

0 

phantom, solid 

water calibration 

check 

NF 45 47 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER08

9 IMRT accelerator NF 45 47 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF Obtain vital signs 3 0 

CMS 

clinical 

review 

EF01

0 

chair, thyroid 

imaging NF 40 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 78012 

Thyroid 

uptake 

measureme

nt 

ER06

3 

thyroid uptake 

system NF 40 30 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

78013 

Thyroid 

imaging 

w/blood 

flow 

ER03

2 

gamma camera 

system, singledual head 

NF 48 38 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

78014 

Thyroid 

imaging 

w/blood 

flow 

EF01

0 

chair, thyroid 

imaging NF 65 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
673 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ER03

2 

gamma camera 

system, singledual head 

NF 65 50 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER06

3 

thyroid uptake 

system NF 65 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

78070 

Parathyroid 

planar 

imaging 

ER03

2 

gamma camera 

system, singledual head 

NF 73 68 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

78071 

Parathyrd 

planar w/wo 

subtrj 

ER03

2 

gamma camera 

system, singledual head NF 86 81 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EP10

6 

CELLSEARCH 

system NF 16 0 

Laborator

y 

Physician 

Interpretat

ion Code 

EP10

7 

Laboratory 

Information 

System 

NF 4 0 

Laborator

y 

Physician 

Interpretat

ion Code 

86153 

Cell 

enumeratio

n phys 

interp 

L045

A Cytotechnologist NF 

Collate images 

and review with 

Pathologist 

5 0 

Laborator

y 

Physician 

Interpretat

ion Code 
674 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EP08

8 ThermoBrite NF 107 321 

CMS 

clinical 

review 

88120 

Cytp urne 

3-5 probes 

ea spec EP09

2 

Olympus BX41 

Fluorescent 

Microscope 

(without filters or 

camera) 

NF 1.33 73 

CMS 

clinical 

review 

EP08

8 ThermoBrite NF 26.75 160.5 

CMS 

clinical 

review 

EP09

0 IkoniScope NF 2.97 29.7 

CMS 

clinical 

review 

88121 

Cytp urine 

3-5 probes 

cmptr 

EP09

1 IkoniLan software NF 2.97 29.7 

CMS 

clinical 

review 

 courier 

transportation cost NF 2.02 0 

Indirect 

Practice 

Expense 

 

Copath System 

with maintenance 

contract 

NF 3 0 

Indirect 

Practice 

Expense 

88300 Surgical 

path gross 

 Copath software NF 3 0 

Indirect 

Practice 

Expense 

 

specimen, solvent, 

and formalin 

disposal cost 

NF 0.18 0 

Indirect 

Practice 

Expense 

 courier 

transportation cost NF 2.02 0 

Indirect 

Practice 

Expense 

 equipment 

maintenance cost NF 0.61 0 

Included 

in 

equipment 

cost per 

minute 

calculatio

n 

 

Copath System 

with maintenance 

contract 

NF 3 0 

Indirect 

Practice 

Expense 

88302 

Tissue 

exam by 

pathologist 

 Copath software NF 3 0 

Indirect 

Practice 

Expense 
675 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

 

specimen, solvent, 

and formalin 

disposal cost 

NF 0.35 0 

Indirect 

Practice 

Expense 

 courier 

transportation cost NF 2.02 0 

Indirect 

Practice 

Expense 

 equipment 

maintenance cost NF 0.61 0 

Included 

in 

equipment 

cost per 

minute 

calculatio

n 

 

Copath System 

with maintenance 

contract 

NF 5 0 

Indirect 

Practice 

Expense 

88304 

Tissue 

exam by 

pathologist 

 Copath software NF 5 0 

Indirect 

Practice 

Expense 

 

specimen, solvent, 

and formalin 

disposal cost 

NF 0.35 0 

Indirect 

Practice 

Expense 

 courier 

transportation cost NF 2.02 0 

Indirect 

Practice 

Expense 

 equipment 

maintenance cost NF 0.61 0 

Included 

in 

equipment 

cost per 

minute 

calculatio

n 

 

Copath System 

with maintenance 

contract 

NF 4 0 

Indirect 

Practice 

Expense 

88305 

Tissue 

exam by 

pathologist 

 Copath software NF 4 0 

Indirect 

Practice 

Expense 

 

specimen, solvent, 

and formalin 

disposal cost 

NF 1.85 0 

Indirect 

Practice 

Expense 

88307 

Tissue 

exam by 

pathologist 

 courier 

transportation cost NF 2.02 0 

Indirect 

Practice 

Expense 
676 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

 equipment 

maintenance cost NF 0.61 0 

Included 

in 

equipment 

cost per 

minute 

calculatio

n 

 

Copath System 

with maintenance 

contract 

NF 10 0 

Indirect 

Practice 

Expense 

 Copath software NF 10 0 

Indirect 

Practice 

Expense 

 

specimen, solvent, 

and formalin 

disposal cost 

NF 1.85 0 

Indirect 

Practice 

Expense 

 courier 

transportation cost NF 2.02 0 

Indirect 

Practice 

Expense 

 equipment 

maintenance cost NF 0.61 0 

Included 

in 

equipment 

cost per 

minute 

calculatio

n 

 

Copath System 

with maintenance 

contract 

NF 12 0 

Indirect 

Practice 

Expense 

88309 

Tissue 

exam by 

pathologist 

 Copath software NF 12 0 

Indirect 

Practice 

Expense 

90791 

Psych 

diagnostic 

evaluation 

 NF 

2012 

Fully 

Implemen

ted PE 

RVUs 

maintaine

d 

90832 

Psytx 

pt&/family 

30 minutes 

 NF 

2012 

Fully 

Implemen

ted PE 

RVUs 

maintaine

d 
677 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

90834 

Psytx 

pt&/family 

45 minutes 

 NF 

2012 

Fully 

Implemen

ted PE 

RVUs 

maintaine

d 

90836 

Psytx 

pt&/fam 

w/e&m 45 

min 

 NF 

2012 

Fully 

Implemen

ted PE 

RVUs 

maintaine

d 

EQ3

52 Data receiver NF 7220 2880 

CMS 

clinical 

review 

SA04

8 

pack, minimum 

multi-specialty 

visit 

NF 1 0 

CMS 

clinical 

review 

91112 

Gi wireless 

capsule 

measure 

SK11

6 SmartBar NF 1 0 

CMS 

clinical 

review 

92081 

Visual field 

examination

(s) 

EL00

6 

lane, screening 

(oph) NF 12 17 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

92082 

Visual field 

examination

(s) 

EL00

6 

lane, screening 

(oph) NF 22 27 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

92083 

Visual field 

examination

(s) 

EL00

6 

lane, screening 

(oph) NF 32 37 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
678 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ED0

08 

camera, retinal 

(TRC 50IX, wICG, filters, motor 

drives) 

NF 60 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF03

0 

table, motorized 

(for instrumentsequipment) NF 60 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EL00

5 lane, exam (oph) NF 60 35 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L038

A 

COMT/COT/RN/

CST NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

5 2 

CMS 

clinical 

review 

92235 Eye exam 

with photos 

L039

A 

Certified Retinal 

Angio NF 

Assist physician 

in performing 

procedure 

40 20 

CMS 

clinical 

review 

EF02

3 table, exam NF 58 46 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

93015 

Cardiovasc

ular stress 

test 

EQ0

78 

cardiac monitor 

w-treadmill (12-

lead PC-based 

ECG) 

NF 58 46 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
679 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L051

A RN NF 

Assist physician 

in performing 

procedure 

20 14 

CMS 

clinical 

review 

EF02

3 table, exam NF 58 46 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

78 

cardiac monitor 

w-treadmill (12-

lead PC-based 

ECG) 

NF 58 46 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L051

A RN NF 

Assist physician 

in performing 

procedure 

20 14 

CMS 

clinical 

review 

93017 

Cardiovasc

ular stress 

test 

L051

A RN NF 

Complete 

diagnostic 

forms, lab & Xray requisitions 

0 4 

CMS 

clinical 

review 

ED0

11 

computer system, 

record and verify NF 10 0 

CMS 

clinical 

review 

ED0

21 

computer, 

desktop, wmonitor NF 95 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ED0

25 

film processor, 

wet NF 10 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

93925 

Lower 

extremity 

study 

ED0

34 

video SVHS VCR 

(medical grade) NF 95 0 

CMS 

clinical 

review 
680 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EL01

6 

room, ultrasound, 

vascular NF 95 76 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER06

7 

x-ray view box, 4 

panel NF 10 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L054

A 

Vascular 

Technologist NF 

Provide preservice 

education/obtai

n consent 

3 2 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Prepare room, 

equipment, 

supplies 

3 2 

Standardi

zed time 

input 

L054

A 

Vascular 

Technologist NF Prepare and position patient 3 2 

Standardi

zed time 

input 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Collate 

preliminary 

data, arrange 

images, archive 

10 7 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Record patient 

history 

1 0 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: QA 

documentation 

4 0 

CMS 

clinical 

review 

SK08

6 video tape, VHS NF 1 0 

CMS 

clinical 

review 

93926 

Lower 

extremity 

study 

ED0

11 

computer system, 

record and verify NF 10 0 

CMS 

clinical 

review 
681 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ED0

21 

computer, 

desktop, wmonitor 

NF 59 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ED0

25 

film processor, 

wet NF 10 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ED0

34 

video SVHS VCR 

(medical grade) NF 59 0 

CMS 

clinical 

review 

EL01

6 

room, ultrasound, 

vascular NF 59 42 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ER06

7 

x-ray view box, 4 

panel NF 10 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L054

A 

Vascular 

Technologist NF 

Provide preservice 

education/obtai

n consent 

3 2 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Prepare room, 

equipment, 

supplies 

3 2 

Standardi

zed time 

input 

L054

A 

Vascular 

Technologist NF Prepare and position patient 3 2 

Standardi

zed time 

input 
682 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Collate 

preliminary 

data, arrange 

images, archive 

8 4 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Record patient 

history 

1 0 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: QA 

documentation 

4 0 

CMS 

clinical 

review 

SK08

6 video tape, VHS NF 1 0 

CMS 

clinical 

review 

ED0

11 

computer system, 

record and verify NF 10 0 

CMS 

clinical 

review 

ED0

21 

computer, 

desktop, wmonitor 

NF 71 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ED0

25 

film processor, 

wet NF 10 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ED0

34 

video SVHS VCR 

(medical grade) NF 71 0 

CMS 

clinical 

review 

93970 Extremity 

study 

EL01

6 

room, ultrasound, 

vascular NF 71 52 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
683 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ER06

7 

x-ray view box, 4 

panel NF 10 7 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L054

A 

Vascular 

Technologist NF 

Provide preservice 

education/obtai

n consent 

3 2 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Prepare room, 

equipment, 

supplies 

3 2 

Standardi

zed time 

input 

L054

A 

Vascular 

Technologist NF Prepare and position patient 3 2 

Standardi

zed time 

input 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Collate 

preliminary 

data, arrange 

images, archive 

10 7 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Record patient 

history 

1 0 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: QA 

documentation 

4 0 

CMS 

clinical 

review 

SK08

6 video tape, VHS NF 1 0 

CMS 

clinical 

review 

ED0

11 

computer system, 

record and verify NF 10 0 

CMS 

clinical 

review 

93971 Extremity 

study 

ED0

21 

computer, 

desktop, wmonitor 

NF 45 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
684 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

ED0

25 

film processor, 

wet NF 10 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

ED0

34 

video SVHS VCR 

(medical grade) NF 45 0 

CMS 

clinical 

review 

EL01

6 

room, ultrasound, 

vascular NF 45 30 

CMS 

clinical 

review 

ER06

7 

x-ray view box, 4 

panel NF 10 4 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L054

A 

Vascular 

Technologist NF 

Provide preservice 

education/obtai

n consent 

3 2 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Prepare room, 

equipment, 

supplies 

3 2 

Standardi

zed time 

input 

L054

A 

Vascular 

Technologist NF Prepare and position patient 3 2 

Standardi

zed time 

input 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Collate 

preliminary 

data, arrange 

images, archive 

6 4 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: 

Record patient 

history 

1 0 

CMS 

clinical 

review 

L054

A 

Vascular 

Technologist NF 

Other Clinical 

Activity: QA 

documentation 

4 0 

CMS 

clinical 

review 

SB00

6 

drape, non-sterile, 

sheet 40in x 60in NF 2 1 

CMS 

clinical 

review 
685 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SK08

6 video tape, VHS NF 1 0 

CMS 

clinical 

review 

EF02

3 table, exam NF 141 133 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 141 133 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

95076 

Ingest 

challenge 

ini 120 min 

L037

D RN/LPN/MTA NF Prepare testing doses 15 7 

CMS 

clinical 

review 

95115 

Immunother

apy one 

injection 

EF04

0 

refrigerator, 

vaccine, 

commercial grade, 

w-alarm lock 

NF 15 0 

CMS 

clinical 

review 

95117 

Immunother

apy 

injections 

EF04

1 

x-ray machine, 

portable NF 17 0 

CMS 

clinical 

review 

EF00

3 

bedroom furniture 

(hospital bed, 

table, reclining 

chair) 

NF 660 602 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF04

4 Crib NF 660 0 

CMS 

clinical 

review 

95782 

Polysom <6 

yrs 4/> 

paramtrs 

EQ1

34 

impedance meter, 

32-channel NF 660 602 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
686 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ2

72 

sleep diagnostic 

system, attended 

(w-acquisition 

station, review 

master, computer) 

NF 660 662 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

48 Capnograph NF 660 0 

CMS 

clinical 

review 

ER08

8 

Infrared 

illuminator NF 660 602 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L047

B REEGT NF 

Provide preservice 

education/obtai

n consent 

5 3 

CMS 

clinical 

review 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: Set up 

and calibrate all 

monitoring and 

recording 

equipment 

(initial), 

including 

capnograph (for 

child) 

6 5 

CMS 

clinical 

review 
687 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: 

Measure and 

mark head and 

face. Apply and 

secure 

electrodes to 

head and face. 

Check 

impedances. 

Reapply 

electrodes as 

needed. (1.5 

min per 

electrode for 

child, 1 min per 

electrode for 

adult) 

30 20 

CMS 

clinical 

review 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: Apply 

recording 

devices for 

cardiorespiratory, leg 

movements, 

body 

positioning and 

snoring 

0 15 

CMS 

clinical 

review 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: Apply 

recording 

devices for 

cardiorespiratory, leg 

movements, 

body 

positioning, 

snoring and 

capnography 

20 0 

CMS 

clinical 

review 
688 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: 

Daytime tech 

reviews and 

edits recording, 

marks artifacts, 

scores sleep 

stages, performs 

evaluation of 

physiological 

changes 

100 97 

CMS 

clinical 

review 

EF00

3 

bedroom furniture 

(hospital bed, 

table, reclining 

chair) 

NF 660 647 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF04

4 Crib NF 660 0 

CMS 

clinical 

review 

EQ1

34 

impedance meter, 

32-channel NF 660 647 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ2

72 

sleep diagnostic 

system, attended 

(w-acquisition 

station, review 

master, computer) 

NF 660 707 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ3

48 Capnograph NF 660 0 

CMS 

clinical 

review 

95783 

Polysom <6 

yrs 

cpap/bilvl 

ER08

8 

Infrared 

illuminator NF 660 647 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
689 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L047

B REEGT NF 

Provide preservice 

education/obtai

n consent 

5 3 

CMS 

clinical 

review 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: Set up 

and calibrate all 

monitoring and 

recording 

equipment 

(initial), 

including 

capnograph (for 

child) 

6 5 

CMS 

clinical 

review 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: 

Measure and 

mark head and 

face. Apply and 

secure 

electrodes to 

head and face. 

Check 

impedances. 

Reapply 

electrodes as 

needed. (1.5 

min per 

electrode for 

child, 1 min per 

electrode for 

adult) 

30 20 

CMS 

clinical 

review 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: Apply 

recording 

devices for 

cardiorespiratory, leg 

movements, 

body 

positioning and 

snoring 

0 15 

CMS 

clinical 

review 
690 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: Apply 

recording 

devices for 

cardiorespiratory, leg 

movements, 

body 

positioning, 

snoring and 

capnography 

20 0 

CMS 

clinical 

review 

L047

B REEGT NF 

Other Clinical 

Activity - 

specify: 

Daytime tech 

reviews and 

edits recording, 

marks artifacts, 

scores sleep 

stages, performs 

evaluation of 

physiological 

changes 

100 97 

CMS 

clinical 

review 

EF02

3 table, exam NF 44 41 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

24 

EMG-NCV-EP 

system, 8 channel NF 44 41 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

95861 Muscle test 

2 limbs 

L037

D RN/LPN/MTA NF 

Assist physician 

in performing 

procedure 

19 29 

Conformi

ng to 

physician 

time 
691 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF02

3 table, exam NF 58 52 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 95863 Muscle test 

3 limbs 

EQ0

24 

EMG-NCV-EP 

system, 8 channel NF 58 52 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 71 62 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 95864 Muscle test 

4 limbs 

EQ0

24 

EMG-NCV-EP 

system, 8 channel NF 71 62 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EF02

3 table, exam NF 27 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 95865 Muscle test 

larynx 

EQ0

24 

EMG-NCV-EP 

system, 8 channel NF 27 22 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
692 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF02

3 table, exam NF 35 32 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 95868 

Muscle test 

cran nerve 

bilat 

EQ0

24 

EMG-NCV-EP 

system, 8 channel NF 35 32 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

SG05

1 

gauze, non-sterile 

4in x 4in NF 0 4 

CMS 

clinical 

review 

SG05

5 

gauze, sterile 4in 

x 4in NF 4 0 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 12 0 

CMS 

clinical 

review 

95907 

Motor&/sen

s 1-2 nrv 

cndj tst 

SJ02

2 

electrode skin 

prep gel (NuPrep) NF 100 0 

CMS 

clinical 

review 

SG05

1 

gauze, non-sterile 

4in x 4in NF 0 8 

CMS 

clinical 

review 

SG05

5 

gauze, sterile 4in 

x 4in NF 8 0 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 24 0 

CMS 

clinical 

review 

95908 

Motor&/sen

s 3-4 nrv 

cndj tst 

SJ02

2 

electrode skin 

prep gel (NuPrep) NF 100 0 

CMS 

clinical 

review 

SG05

1 

gauze, non-sterile 

4in x 4in NF 0 12 

CMS 

clinical 

review 

SG05

5 

gauze, sterile 4in 

x 4in NF 12 0 

CMS 

clinical 

review 

95909 

Motor&/sen

s 5-6 nrv 

cndj tst 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 36 0 

CMS 

clinical 

review 
693 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SJ02

2 

electrode skin 

prep gel (NuPrep) NF 100 0 

CMS 

clinical 

review 

L037

A 

Electrodiagnostic 

Technologist NF 50 40 

Conformi

ng to 

physician 

time 

SG05

1 

gauze, non-sterile 

4in x 4in NF 0 16 

CMS 

clinical 

review 

SG05

5 

gauze, sterile 4in 

x 4in NF 16 0 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 48 0 

CMS 

clinical 

review 

95910 

Motor&sen

s 7-8 nrv 

cndj test 

SJ02

2 

electrode skin 

prep gel (NuPrep) NF 100 0 

CMS 

clinical 

review 

L037

A 

Electrodiagnostic 

Technologist NF 64 50 

Conformi

ng to 

physician 

time 

SG05

1 

gauze, non-sterile 

4in x 4in NF 0 20 

CMS 

clinical 

review 

SG05

5 

gauze, sterile 4in 

x 4in NF 20 0 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 60 0 

CMS 

clinical 

review 

95911 

Motor&sen 

9-10 nrv 

cndj test 

SJ02

2 

electrode skin 

prep gel (NuPrep) NF 100 0 

CMS 

clinical 

review 

L037

A 

Electrodiagnostic 

Technologist NF 77 60 

Conformi

ng to 

physician 

time 

SG05

1 

gauze, non-sterile 

4in x 4in NF 0 24 

CMS 

clinical 

review 

SG05

5 

gauze, sterile 4in 

x 4in NF 24 0 

CMS 

clinical 

review 

95912 

Motor&sen 

11-12 nrv 

cnd test 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 72 0 

CMS 

clinical 

review 
694 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SJ02

2 

electrode skin 

prep gel (NuPrep) NF 100 0 

CMS 

clinical 

review 

L037

A 

Electrodiagnostic 

Technologist NF 87 70 

Conformi

ng to 

physician 

time 

SG05

1 

gauze, non-sterile 

4in x 4in NF 0 26 

CMS 

clinical 

review 

SG05

5 

gauze, sterile 4in 

x 4in NF 26 0 

CMS 

clinical 

review 

SG07

9 

tape, surgical 

paper 1in 

(Micropore) 

NF 78 0 

CMS 

clinical 

review 

95913 

Motor&sen

s 13/> nrv 

cnd test 

SJ02

2 

electrode skin 

prep gel (NuPrep) NF 100 0 

CMS 

clinical 

review 

EF03

2 

table, tilt (wtrendelenberg) NF 64 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

51 

arterial tonometry 

acquisition system 

(WR Testworks) 

NF 64 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

52 

arterial tonometry 

monitor (Colin 

Pilot) 

NF 64 55 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

95921 

Autonomic 

nrv parasym 

inervj 

L037

A 

Electrodiagnostic 

Technologist NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

3 0 

CMS 

clinical 

review 
695 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

A 

Electrodiagnostic 

Technologist NF Obtain vital signs 3 0 

CMS 

clinical 

review 

L037

A 

Electrodiagnostic 

Technologist NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

5 2 

CMS 

clinical 

review 

EF03

2 

table, tilt (wtrendelenberg) NF 79 70 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

51 

arterial tonometry 

acquisition system 

(WR Testworks) 

NF 79 70 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

52 

arterial tonometry 

monitor (Colin 

Pilot) 

NF 79 70 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

A 

Electrodiagnostic 

Technologist NF 

Greet patient, 

provide 

gowning, assure 

appropriate 

medical records 

are available 

3 0 

CMS 

clinical 

review 

L037

A 

Electrodiagnostic 

Technologist NF Obtain vital signs 3 0 

CMS 

clinical 

review 

95922 

Autonomic 

nrv adrenrg 

inervj 

L037

A 

Electrodiagnostic 

Technologist NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

5 2 

CMS 

clinical 

review 
696 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ0

35 

QSART 

acquisition system 

(Q-Sweat) 

NF 74 61 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

24 

stimulator, 

constant current, 

w-stimulating and 

grounding 

electrodes (Grass 

Telefactor) 

NF 74 61 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

71 

light, infra-red, 

ceiling mount NF 74 61 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

A 

Electrodiagnostic 

Technologist NF 

Assist physician 

in performing 

procedure 

55 45 

CMS 

clinical 

review 

L037

A 

Electrodiagnostic 

Technologist NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

5 2 

CMS 

clinical 

review 

95923 

Autonomic 

nrv syst 

funj test 

SJ02

0 

electrode 

conductive gel NF 5 0 

CMS 

clinical 

review 

95924 

Ans 

parasymp & 

symp w/tilt 

EF03

2 

table, tilt (wtrendelenberg) NF 79 76 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 
697 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EQ0

51 

arterial tonometry 

acquisition system 

(WR Testworks) 

NF 79 76 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ0

52 

arterial tonometry 

monitor (Colin 

Pilot) 

NF 79 76 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

A 

Electrodiagnostic 

Technologist NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

5 2 

CMS 

clinical 

review 

EF03

1 table, power NF 20 26 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

61 laser, excimer NF 20 26 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 17 26 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

96920 

Laser tx 

skin < 250 

sq cm 

L037

D RN/LPN/MTA NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

3 1 

CMS 

clinical 

review 
698 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

L037

D RN/LPN/MTA NF 

Clean 

room/equipment 

by physician 

staff 

3 2 

CMS 

clinical 

review 

SF02

8 

laser tip (single 

use) NF 1 0 

CMS 

clinical 

review 

SJ02

9 ice pack, instant NF 4 1 

CMS 

Code 

correction 

EF03

1 table, power NF 23 29 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

61 laser, excimer NF 23 29 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 23 29 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

3 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Clean 

room/equipment 

by physician 

staff 

3 2 

CMS 

clinical 

review 

SF02

8 

laser tip (single 

use) NF 1 0 

CMS 

clinical 

review 

96921 

Laser tx 

skin 250-

500 sq cm 

SJ02

9 ice pack, instant NF 4 2 

CMS 

Code 

correction 
699 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

EF03

1 table, power NF 33 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

61 laser, excimer NF 33 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

EQ1

68 light, exam NF 30 39 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

L037

D RN/LPN/MTA NF 

Monitor pt. 

following 

service/check 

tubes, monitors, 

drains 

3 1 

CMS 

clinical 

review 

L037

D RN/LPN/MTA NF 

Clean 

room/equipment 

by physician 

staff 

3 2 

CMS 

clinical 

review 

96922 

Laser tx 

skin >500 

sq cm 

SF02

8 

laser tip (single 

use) NF 1 0 

CMS 

clinical 

review 

EQ2

48 

ultrasonic 

biometry, 

pachymeter 

NF 10 5 

Refined 

equipment 

time to 

reflect 

typical 

use 

exclusive 

to patient 

97150 

Group 

therapeutic 

procedures 

EQ2

69 

blood pressure 

monitor, 

ambulatory, wbattery charger 

NF 1 0 

CMS 

clinical 

review 
700 

CPT 

Code 

CPT Code 

Description 

CMS 

Code 

CMS Code 

Description 

NonFac

/ Fac 

Labor Activity 

(if applicable) 

AMA 

RUC 

Recomme

ndation or 

Current 

Value 

(min or 

qty) 

CMS 

Refine

ment 

(min 

or qty) 

Comment 

SA00

7 

kit, cooking 

activity 

ingredients (maccheese) 

NF 1 0 

CMS 

clinical 

review 

99495 

Trans care 

mgmt 14 

day disch 

L042

A RN/LPN F 

communication 

(with patient, 

family 

members, 

guardian or 

caretaker, 

surrogate 

decision 

makers, and/or 

other 

professionals) 

regarding 

aspects of care, 

etc. 

0 45 

CMS 

clinical 

review 

NF 60 70 

CMS 

clinical 

review 

99496 

Trans care 

mgmt 7 day 

disch 

L042

A RN/LPN 

F 

communication 

(with patient, 

family 

members, 

guardian or 

caretaker, 

surrogate 

decision 

makers, and/or 

other 

professionals) 

regarding 

aspects of care, 

etc. 

0 70 

CMS 

clinical 

review 
701 

c. Establishing CY 2013 Interim Final Malpractice Crosswalks 

 According to our malpractice methodology discussed in section III.C.1 of this CY 2013 

PFS final rule with comment period, we have assigned malpractice RVUs for CY 2013 new and 

revised codes by utilizing a crosswalk to a source code with a similar malpractice risk-of-service. 

We have reviewed the AMA RUC-recommended malpractice source code crosswalks for CY 

2013 new and revised codes, and we are accepting all of them on an interim final basis for CY 

2013. 

 For CY 2013, we created several HCPCS G-codes. HCPCS code G0452 (Molecular 

pathology procedure; physician interpretation and report) was created to replace CPT code 83912 

(Molecular diagnostics; interpretation and report), which is deleted effective January 1, 2013. 

We believe CPT code 83912 has a similar malpractice risk-of-service as HCPCS code G0452. 

Therefore, we are assigning an interim final malpractice crosswalk of CPT code 83912 to 

HCPCS code G0452 on an interim final basis for CY 2013. 

 For CY 2013, we created HCPCS code G0453 (Continuous intraoperative 

neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, 

(attention directed exclusively to one patient), each 15 minutes) to replace new CPT code 95941 

(Continuous intraoperative neurophysiology monitoring, from outside the operating room 

(remote or nearby) or for monitoring of more than one case while in the operating room, per 

hour) which will have a PFS procedure status indicator of I (Not valid for Medicare purposes. 

Medicare uses another code for the reporting of and the payment for these services) for CY 2013, 

as discussed in section III.M.3.a. of this CY 2013 PFS final rule with comment period. The 

AMA RUC recommended a malpractice crosswalk of CPT code 95920 (Intraoperative 

neurophysiology testing, per hour (List separately in addition to code for primary procedure)) for 

CPT code 95941. We believe CPT code 95920 has a similar malpractice risk-of-service as 
702 

HCPCS code G0453. Therefore, we are assigning an interim final malpractice crosswalk of CPT 

code 95920 to HCPCS code G0453 for CY 2013. 

 For CY 2013, we created HCPCS code G0454 (Physician documentation of face-to- face 

visit for Durable Medical Equipment determination performed by Nurse Practitioner, Physician 

Assistant or Clinical Nurse Specialist) for payment to a physician who documents that a PA, NP, 

or CNS practitioner has performed a face-to-face encounter for the list of specified DME covered 

items. As discussed in section IV.C. of this CY 2013 PFS final rule with comment period, we 

have assigned HCPCS code G0454 a work RVU of 0.18, which is a crosswalk to CPT code 

99211 (Level 1 office or other outpatient visit, established patient). We believe CPT code 99211 

has a similar malpractice risk-of-service as HCPCS code G0454. Therefore, we are assigning an 

interim final malpractice crosswalk of CPT code 99211 to HCPCS code G0454 for CY 2013. 

 For CY 2013, we created HCPCS code G0455 (Preparation with instillation of fecal 

microbiota by any method, including assessment of donor specimen) to replace new CPT code 

44705 (Preparation of fecal microbiota for instillation, including assessment of donor specimen) 

which will have a PFS procedure status indicator of I (Not valid for Medicare purposes. 

Medicare uses another code for the reporting of and the payment for these services) for CY 2013, 

as discussed in section III.M.3.a. of this CY 2013 PFS final rule with comment period. The 

AMA RUC recommended a malpractice crosswalk of CPT code 91065 (Breath hydrogen test 

(eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal 

gastrointestinal transit) for CPT code 44705. We believe CPT code 91065 has a similar 

malpractice risk-of-service as HCPCS code G0455. Therefore, we are assigning an interim final 

malpractice crosswalk of CPT code 91065 to HCPCS code G0455 for CY 2013. 

 In accordance with our malpractice methodology, we have adjusted the malpractice 

RVUs of the CY 2013 new/revised codes for the difference in work RVUs (or, if greater, the 
703 

clinical labor portion of the fully implemented PE RVUs) between the source code and the 

new/revised codes to reflect the specific risk-of-service for the new/revised codes. Table 75 lists 

the CY 2012 new/revised HCPCS codes and their respective source codes used to set the interim 

final CY 2013 malpractice RVUs. Revised CPT codes that are crosswalked to themselves (that 

is, CPT code 11300 to 11300) are not listed. The malpractice RVUs for these services are 

reflected in Addendum B of this CY 2013 PFS final rule with comment period. 

TABLE 75: Malpractice Crosswalks for CY 2013 New/Revised Codes Used to Establish 

Malpractice RVUs 

CY 2013 New, Revised, or Potentially Misvalued 

HCPCS Code 

Malpractice Risk Factor Crosswalk HCPCS 

Code 

22586 Prescrl fuse w/ instr l5/s1 22558 Lumbar spine fusion 

23473 Revis reconst shoulder joint 23472 Reconstruct shoulder joint 

23474 Revis reconst shoulder joint 23210 Resect scapula tumor 

24370 Revise reconst elbow joint 24363 Replace elbow joint 

24371 Revise reconst elbow joint 24363 Replace elbow joint 

31647 Bronchial valve init insert 31636 Bronchoscopy bronch stents 

31648 Bronchial valve addl insert 31638 Bronchoscopy revise stent 

31649 Bronchial valve remov init 31637 Bronchoscopy stent add-on 

31651 Bronchial valve remov addl 31637 Bronchoscopy stent add-on 

31660 Bronch thermoplsty 1 lobe 31636 Bronchoscopy bronch stents 

31661 Bronch thermoplsty 2/> lobes 31638 Bronchoscopy revise stent 

32551 Insertion of chest tube 19260 Removal of chest wall lesion 

32554 Aspirate pleura w/o imaging 32421 Thoracentesis for aspiration 

32555 Aspirate pleura w/ imaging 32422 Thoracentesis w/tube insert 

32556 Insert cath pleura w/o image 32422 Thoracentesis w/tube insert 

32557 Insert cath pleura w/ image 32551 Insertion of chest tube 

32701 Thorax stereo rad targetw/tx 33468 Revision of tricuspid valve 

33361 Replace aortic valve perq 33880 Endovasc taa repr incl subcl 

33362 Replace aortic valve open 33880 Endovasc taa repr incl subcl 

33363 Replace aortic valve open 33880 Endovasc taa repr incl subcl 

33364 Replace aortic valve open 33880 Endovasc taa repr incl subcl 

33365 Replace aortic valve open 33979 Insert intracorporeal device 

33367 Replace aortic valve w/byp 33979 Insert intracorporeal device 

33368 Replace aortic valve w/byp 33979 Insert intracorporeal device 

33369 Replace aortic valve w/byp 33305 Repair of heart wound 

33990 Insert vad artery access 33240 Insrt pulse gen w/singl lead 

33991 Insert vad art&vein access 33240 Insrt pulse gen w/singl lead 

33992 Remove vad different session 33240 Insrt pulse gen w/singl lead 

33993 Reposition vad diff session 33240 Insrt pulse gen w/singl lead 

36221 Place cath thoracic aorta 36200 Place catheter in aorta 

36222 Place cath carotid/inom art 36216 Place catheter in artery 

36223 Place cath carotid/inom art 36216 Place catheter in artery 

36224 Place cath carotd art 36217 Place catheter in artery 

36225 Place cath subclavian art 36215 Place catheter in artery 
704 

CY 2013 New, Revised, or Potentially Misvalued 

HCPCS Code 

Malpractice Risk Factor Crosswalk HCPCS 

Code 

36226 Place cath vertebral art 36217 Place catheter in artery 

36227 Place cath xtrnl carotid 36218 Place catheter in artery 

36228 Place cath intracranial art 36218 Place catheter in artery 

37197 Remove intrvas foreign body 37183 Remove hepatic shunt (tips) 

37211 Thrombolytic art therapy 37184 Prim art mech thrombectomy 

37212 Thrombolytic venous therapy 37184 Prim art mech thrombectomy 

37213 Thromblytic art/ven therapy 37184 Prim art mech thrombectomy 

37214 Cessj therapy cath removal 37184 Prim art mech thrombectomy 

38243 Transplj hematopoietic boost 38242 Lymphocyte infuse transplant 

52287 Cystoscopy chemodenervation 51715 Endoscopic injection/implant 

64615 Chemodenerv musc migraine 64612 Destroy nerve face muscle 

78012 Thyroid uptake measurement 78000 Thyroid single uptake 

78013 Thyroid imaging w/blood flow 78010 Thyroid imaging 

78014 Thyroid imaging w/blood flow 78007 Thyroid image mult uptakes 

78071 Parathyrd planar w/wo subtrj 78803 Tumor imaging (3D) 

78072 Parathyrd planar w/spect&ct 78452 Ht muscle image spect mult 

86153 Cell enumeration phys interp 88361 Tumor immunohistochem/comput 

90785 Psytx complex interactive 90846 Family psytx w/o patient 

90791 Psych diagnostic evaluation 90846 Family psytx w/o patient 

90792 Psych diag eval w/med srvcs 90846 Family psytx w/o patient 

90832 Psytx pt&/family 30 minutes 90846 Family psytx w/o patient 

90833 Psytx pt&/fam w/e&m 30 min 90846 Family psytx w/o patient 

90834 Psytx pt&/family 45 minutes 90846 Family psytx w/o patient 

90836 Psytx pt&/fam w/e&m 45 min 90846 Family psytx w/o patient 

90837 Psytx pt&/family 60 minutes 90846 Family psytx w/o patient 

90838 Psytx pt&/fam w/e&m 60 min 90846 Family psytx w/o patient 

91112 Gi wireless capsule measure 91110 Gi tract capsule endoscopy 

92920 Prq cardiac angioplast 1 art 92982 Coronary artery dilation 

92921 Prq cardiac angio addl art 92984 Coronary artery dilation 

92924 Prq card angio/athrect 1 art 92995 Coronary atherectomy 

92925 Prq card angio/athrect addl 92995 Coronary atherectomy 

92928 Prq card stent w/angio 1 vsl 92980 Insert intracoronary stent 

92929 Prq card stent w/angio addl 92981 Insert intracoronary stent 

92933 Prq card stent/ath/angio 92980 Insert intracoronary stent 

92934 Prq card stent/ath/angio 92981 Insert intracoronary stent 

92937 Prq revasc byp graft 1 vsl 92980 Insert intracoronary stent 

92938 Prq revasc byp graft addl 92981 Insert intracoronary stent 

92941 Prq card revasc mi 1 vsl 92980 Insert intracoronary stent 

92943 Prq card revasc chronic 1vsl 92980 Insert intracoronary stent 

92944 Prq card revasc chronic addl 92981 Insert intracoronary stent 

93653 Ep & ablate supravent arrhyt 93620 Electrophysiology evaluation 

93654 Ep & ablate ventric tachy 93620 Electrophysiology evaluation 

93655 Ablate arrhythmia add on 93620 Electrophysiology evaluation 

93656 Tx atrial fib pulm vein isol 93620 Electrophysiology evaluation 

93657 Tx l/r atrial fib addl 93620 Electrophysiology evaluation 

95017 Perq & icut allg test venoms 95010 Percut allergy titrate test 

95018 Perq&ic allg test drugs/biol 95010 Percut allergy titrate test 

95076 Ingest challenge ini 120 min 95180 Rapid desensitization 
705 

CY 2013 New, Revised, or Potentially Misvalued 

HCPCS Code 

Malpractice Risk Factor Crosswalk HCPCS 

Code 

95079 Ingest challenge addl 60 min 95180 Rapid desensitization 

95782 Polysom <6 yrs 4/> paramtrs 95810 Polysomnography 4 or more 

95783 Polysom <6 yrs cpap/bilvl 95811 Polysomnography w/cpap 

95907 Motor&/sens 1-2 nrv cndj tst 95904 Sense nerve conduction test 

95908 Motor&/sens 3-4 nrv cndj tst 95904 Sense nerve conduction test 

95909 Motor&/sens 5-6 nrv cndj tst 95904 Sense nerve conduction test 

95910 Motor&sens 7-8 nrv cndj test 95904 Sense nerve conduction test 

95911 Motor&sen 9-10 nrv cndj test 95904 Sense nerve conduction test 

95912 Motor&sen 11-12 nrv cnd test 95904 Sense nerve conduction test 

95913 Motor&sens 13/> nrv cnd test 95904 Sense nerve conduction test 

95921 Autonomic nrv parasym inervj 95923 Autonomic nerv function test 

95922 Autonomic nrv adrenrg inervj 95923 Autonomic nerv function test 

95924 Ans parasymp & symp w/tilt 95923 Autonomic nerv function test 

95940 Ionm in operatng room 15 min 95920 Intraop nerve test add-on 

99485 Suprv interfacilty transport 99471 Ped critical care initial 

99486 Suprv interfac trnsport addl 99472 Ped critical care subsq 

99487 Cmplx chron care w/o pt vsit 99374 Home health care supervision 

99488 Cmplx chron care w/ pt vsit 99215 Office/outpatient visit est 

99489 Complx chron care addl30 min 99374 Home health care supervision 

99495 Trans care mgmt 14 day disch 99214 Office/outpatient visit est 

99496 Trans care mgmt 7 day disch 99215 Office/outpatient visit est 

G0452 Molecular pathology interpr 83912 Genetic examination 

G0453 Cont intraop neuro monitor 95920 Intraop nerve test add-on 

G0454 MD document visit by NPP 99211 Office/outpatient visit est 

G0455 Fecal microbiota prep instil 91065 Breath hydrogen test 
706 

N. Allowed Expenditures for Physicians' Services and the Sustainable Growth Rate 

1. Medicare Sustainable Growth Rate (SGR) 

The SGR is an annual growth rate that applies to physicians’ services paid by Medicare. 

The use of the SGR is intended to control growth in aggregate Medicare expenditures for 

physicians’ services. Payments for services are not withheld if the percentage increase in actual 

expenditures exceeds the SGR. Rather, the PFS update, as specified in section 1848(d)(4) of the 

Act, is adjusted based on a comparison of allowed expenditures (determined using the SGR) and 

actual expenditures. If actual expenditures exceed allowed expenditures, the update is reduced. 

If actual expenditures are less than allowed expenditures, the update is increased. 

Section 1848(f)(2) of the Act specifies that the SGR for a year (beginning with CY 2001) 

is equal to the product of the following four factors: 

(1) The estimated change in fees for physicians' services; 

(2) The estimated change in the average number of Medicare fee-for-service 

beneficiaries; 

(3) The estimated projected growth in real GDP per capita; and 

(4) The estimated change in expenditures due to changes in statute or regulations. 

In general, section 1848(f)(3) of the Act requires us to publish SGRs for 3 different time 

periods, no later than November 1 of each year, using the best data available as of September 1 

of each year. Under section 1848(f)(3)(C)(i) of the Act, the SGR is estimated and subsequently 

revised twice (beginning with the FY and CY 2000 SGRs) based on later data. (The Act also 

provides for adjustments to be made to the SGRs for FY 1998 and FY 1999. See the 

February 28, 2003 Federal Register (68 FR 9567) for a discussion of these SGRs). Under 

section 1848(f)(3)(C)(ii) of the Act, there are no further revisions to the SGR once it has been 

estimated and subsequently revised in each of the 2 years following the preliminary estimate. In 
707 

this final rule with comment, we are making our preliminary estimate of the CY 2013 SGR, a 

revision to the CY 2012 SGR, and our final revision to the CY 2011 SGR. 

a. Physicians’ Services 

Section 1848(f)(4)(A) of the Act defines the scope of physicians’ services covered by the 

SGR. The statute indicates that “the term physicians’ services includes other items and services 

(such as clinical diagnostic laboratory tests and radiology services), specified by the Secretary, 

that are commonly performed or furnished by a physician or in a physician's office, but does not 

include services furnished to a Medicare+Choice plan enrollee.” 

We published a definition of physicians’ services for use in the SGR in the 

November 1, 2001 Federal Register (66 FR 55316). We defined physicians’ services to include 

many of the medical and other health services listed in section 1861(s) of the Act. Since that 

time, the statute has been amended to add new Medicare benefits. As the statute changed, we 

modified the definition of physicians’ services for the SGR to include the additional benefits 

added to the statute that meet the criteria specified in section 1848(f)(4)(A). 

As discussed in the CY 2010 PFS final rule with comment period (74 FR 61961), the 

statute provides the Secretary with clear discretion to decide whether physician-administered 

drugs should be included or excluded from the definition of “physicians’ services.” 

Accordingly, we removed physician-administered drugs from the definition of physicians’ 

services in section 1848(f)(4)(A) of the Act for purposes of computing the SGR and the levels of 

allowed expenditures and actual expenditures beginning with CY 2010, and for all subsequent 

years. Furthermore, in order to effectuate fully the Secretary’s policy decision to remove drugs 

from the definition of physicians’ services, we removed physician-administered drugs from the 

calculation of allowed and actual expenditures for all prior years. 
708 

Thus, for purposes of determining allowed expenditures, actual expenditures for all years, 

and SGRs beginning with CY 2010 and for all subsequent years, we specified that physicians’ 

services include the following medical and other health services if bills for the items and services 

are processed and paid by Medicare carriers (and those paid through intermediaries where 

specified) or the equivalent services processed by the Medicare Administrative Contractors: 

● Physicians’ services. 

● Services and supplies furnished incident to physicians’ services, except for the 

expenditures for drugs and biologicals which are not usually self-administered by the patient. 

● Outpatient physical therapy services and outpatient occupational therapy services. 

● Services of PAs, certified registered nurse anesthetists, certified nurse midwives, 

clinical psychologists, clinical social workers, nurse practitioners, and certified nurse specialists. 

● Screening tests for prostate cancer, colorectal cancer, and glaucoma. 

● Screening mammography, screening pap smears, and screening pelvic exams. 

● Diabetes outpatient self-management training (DSMT) services. 

● MNT services. 

● Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests (including 

outpatient diagnostic laboratory tests paid through intermediaries). 

● X-ray, radium, and radioactive isotope therapy. 

● Surgical dressings, splints, casts, and other devices used for the reduction of fractures 

and dislocations. 

● Bone mass measurements. 

● An initial preventive physical exam. 

● Cardiovascular screening blood tests. 

● Diabetes screening tests. 
709 

● Telehealth services. 

● Physician work and resources to establish and document the need for a power mobility 

device. 

● Additional preventive services. 

● Pulmonary rehabilitation. 

● Cardiac rehabilitation. 

● Intensive cardiac rehabilitation. 

● Kidney disease education services. 

● Personalized prevention plan services. 

b. Preliminary Estimate of the SGR for 2013 

Our preliminary estimate of the CY 2013 SGR is -19.7 percent. We first estimated the 

CY 2013 SGR in March 2012, and we made the estimate available to the MedPAC and on our 

website. Table 76 shows the March 2012 estimate and our current estimates of the factors 

included in the CY 2013 SGR. The majority of the difference between the March estimate and 

our current estimate of the CY 2013 SGR is explained by changes in estimated enrollment after 

our March estimate was prepared. 

TABLE 76: CY 2013 SGR CALCULATION 

Statutory Factors March Estimate Current Estimate 

Fees 0.5 percent (1.005) 0.3 percent (1.003) 

Enrollment 5.1 percent (1.051) 3.6 percent (1.036) 

Real Per Capita GDP 0.7 percent (1.007) 0.7 percent (1.007) 

Law and Regulation -23.6 percent (0.764) -23.3 percent (0.767) 

Total -18.7 percent (0.813) -19.7 percent (0.803) 

 Note: Consistent with section 1848(f)(2) of the Act, the statutory factors are multiplied, not added, to 

produce the total (that is, 1.003_ x 1.036 x 1.007 x 0.767.= 0.803). A more detailed explanation of each 

figure is provided below in this final rule with comment period. 

c. Revised Sustainable Growth Rate for CY 2012 
710 

Our current estimate of the CY 2012 SGR is 5.1 percent. Table 77 shows our preliminary 

estimate of the CY 2012 SGR that was published in the CY 2012 PFS final rule with comment 

period (76 FR 73269) and our current estimate. The majority of the difference between the 

preliminary estimate and our current estimate of the CY 2012 SGR is explained by adjustments 

to reflect intervening legislative changes that have occurred since publication of the CY 2012 

final rule with comment period. 

TABLE 77: CY 2012 SGR CALCULATION 

Statutory Factors Estimate from CY 2012 Final Rule Current Estimate 

Fees 0.6 percent (1.006) 0.6 percent (1.006)

Enrollment 3.5 percent (1.035) 1.6 percent (1.016)

Real Per Capita GDP 0.6 percent (1.006) 0.7 percent (1.007)

Law and Regulation -20.7 percent (0.793) 2.1 percent (1.021)

Total -16.9 percent (0.831) 5.1 percent (1.051)

Note: A more detailed explanation of each figure is provided in below in this final rule with comment period. 

d. Final Sustainable Growth Rate for CY 2011 

The SGR for CY 2011 is 4.7 percent. Table 78 shows our preliminary estimate of the CY 

2011 SGR from the CY 2011 PFS final rule with comment period, our revised estimate from the 

CY 2012 PFS final rule with comment period, and the final figures determined using the best 

available data as of September 1, 2012. 

TABLE 78: CY 2011 SGR CALCULATION 

Statutory Factors 

Estimate from 

CY 2010 

Final Rule 

Estimate from CY 2011 

Final Rule Final 

Fees 0.2 percent (1.002) 0.2 percent (1.002) 0.2 percent (1.002) 

Enrollment 2.4 percent (1.024) 1.8 percent (1.018) 1.0 percent (1.010) 

Real Per Capita GDP 0.7 percent (1.007) 0.6 percent (1.006) 0.6 percent (1.006) 

Law and Regulation -16.2 percent (0.838) 3.3 percent (1.033) 2.8 percent (1.028) 

Total -13.4 percent (0.866) 6.0 percent (1.060) 4.7 percent (1.047) 

Note: A more detailed explanation of each figure is provided below in this final rule with comment period. 

e. Calculation of CYs 2013, 2012, and 2011 Sustainable Growth Rates 
711 

(1) Detail on the CY 2013 SGR 

 All of the figures used to determine the CY 2013 SGR are estimates that will be revised 

based on subsequent data. Any differences between these estimates and the actual measurement 

of these figures will be included in future revisions of the SGR and allowed expenditures and 

incorporated into subsequent PFS updates. 

(a) Factor 1-- Changes in Fees for Physicians’ Services (Before Applying Legislative 

Adjustments) for CY 2013 

 This factor is calculated as a weighted average of the CY 2013 changes in fees for the 

different types of services included in the definition of physicians’ services for the SGR. 

Medical and other health services paid using the PFS are estimated to account for approximately 

87.7 percent of total allowed charges included in the SGR in CY 2013 and are updated using the 

percent change in the MEI. As discussed in section C, the percent change in the MEI for CY 

2013 is 0.8 percent. Diagnostic laboratory tests are estimated to represent approximately 12.3 

percent of Medicare allowed charges included in the SGR for CY 2013. Medicare payments for 

these tests are updated by the Consumer Price Index for Urban Areas (CPI-U), which is 1.7 

percent for CY 2013. Section 1833(h)(2)(A)(iv(l) of the Act requires that the CPI-U update 

applied to clinical laboratory tests be reduced by a multi-factor productivity adjustment (MFP 

adjustment) and, for each of years 2011 through 2015, by 1.75 percentage points (percentage 

adjustment). The MFP adjustment will not apply in a year where the CPI-U is zero or a 

percentage decrease. Further, the application of the MFP adjustment shall not result in an 

adjustment to the fee schedule of less than zero for a year. However, the application of the 

percentage adjustment may result in an adjustment to the fee schedule 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 applicable productivity adjustment for CY 2013 is -0.9 percent. Adjusting 
712 

the CPI-U update by the productivity adjustment results in a 0.8 percent (1.7 percent (CPI-U)– 

0.9 percent (MFP adjustment) update for CY 2013. Additionally, the percentage reduction of 

1.75 percent is applied for CYs 2011 through 2015, as discussed previously, and an additional 

adjustment of -2.0 percent specified in the Middle Class Tax Relief and Job Creation Act. 

Therefore, for CY 2013, diagnostic laboratory tests will receive an update of -3.0 percent 

(rounded). Table 79 shows the weighted average of the MEI and laboratory price changes for 

CY 2013. 

TABLE 79: WEIGHTED-AVERAGE OF THE MEI AND LABORATORY 

PRICE CHANGES FOR CY 2013 

 Weight Update 

Physician 0.877 0.8% 

Laboratory 0.123 -3.0% 

Weighted-average 1.000 0.3% 

 We estimate that the weighted average increase in fees for physicians’ services in CY 

2013 under the SGR (before applying any legislative adjustments) will be 0.3 percent. 

(b) Factor 2-- The Percentage Change in the Average Number of Part B Enrollees from CY 

2012 to CY 2013 

 This factor is our estimate of the percent change in the average number of fee-for-service 

enrollees from CY 2012 to CY 2013. Services furnished to Medicare Advantage (MA) plan 

enrollees are outside the scope of the SGR and are excluded from this estimate. We estimate that 

the average number of Medicare Part B fee-for-service enrollees will increase by 3.6 percent 

from CY 2012 to CY 2013. Table 80 illustrates how this figure was determined. 

TABLE 80: AVERAGE NUMBER OF MEDICARE PART B FEE-FOR-SERVICE 

ENROLLEES FROM CY 2012 TO CY 2013 

(EXCLUDING BENEFICIARIES ENROLLED IN MA PLANS) 

 CY 2012 CY 2013 

Overall 46.560 million 48.136 million 
713 

 CY 2012 CY 2013 

Medicare Advantage (MA) 13.545 million 13.935 million 

Net 33.016 million 34.201 million 

Percent Increase 3.6 percent 

 An important factor affecting fee-for-service enrollment is beneficiary enrollment in MA 

plans. Because it is difficult to estimate the size of the MA enrollee population before the start 

of a CY, at this time we do not know how actual enrollment in MA plans will compare to current 

estimates. For this reason, the estimate may change substantially as actual Medicare fee-forservice enrollment for CY 2013 becomes known. 

(c) Factor 3-- Estimated Real Gross Domestic Product Per Capita Growth in CY 2013 

 We estimate that the growth in real GDP per capita from CY 2012 to CY 2013 will be 0.7 

percent (based on the annual growth in the 10 year moving average of real GDP per capita (2004 

through 2013)). Our past experience indicates that there have also been changes in estimates of 

real GDP per capita growth made before the year begins and the actual change in real GDP per 

capita growth computed after the year is complete. Thus, it is possible that this figure will 

change as actual information on economic performance becomes available to us in CY 2013. 

(d) Factor 4-- Percentage Change in Expenditures for Physicians' Services Resulting From 

Changes in Statute or Regulations in CY 2013 Compared With CY 2012 

 The statutory and regulatory provisions that will affect expenditures in CY 2013 relative 

to CY 2012 are estimated to have an impact on expenditures of -23.3 percent. The impact is 

primarily due to the expiration of the physician fee schedule update specified in statute for CY 

2012 only. 

(2) Detail on the CY 2012 SGR 

 A more detailed discussion of our revised estimates of the four elements of the CY 2012 

SGR follows. 
714 

(a) Factor 1--Changes in Fees for Physicians' Services (Before Applying Legislative 

Adjustments) for CY 2012 

This factor was calculated as a weighted-average of the CY 2012 changes in fees that 

apply for the different types of services included in the definition of physicians' services for the 

SGR in CY 2012. 

We estimate that services paid using the PFS account for approximately 90.3 percent of 

total allowed charges included in the SGR in CY 2012. These services were updated using the 

CY 2012 percent change in the MEI of 0.6 percent. We estimate that diagnostic laboratory tests 

represent approximately 12.3 percent of total allowed charges included in the SGR in CY 2012. 

For CY 2012, diagnostic laboratory tests received an update of 0.7 percent. 

Table 81 shows the weighted-average of the MEI and laboratory price changes for 

CY 2011. 

TABLE 81: WEIGHTED-AVERAGE OF THE MEI, AND LABORATORY 

PRICE CHANGES FOR CY 2012 

 Weight Update 

Physician 0.903 0.6

Laboratory 0.097 0.7

Weighted-average 1.000 0.6

After considering the elements described in Table 81, we estimate that the 

weighted-average increase in fees for physicians' services in CY 2012 under the SGR was 

0.6 percent. Our estimate of this factor in the CY 2012 PFS final rule with comment period was 

0.6 percent. (76 FR 73271). 

(b) Factor 2--The Percentage Change in the Average Number of Part B Enrollees from CY 2011 

to CY 2012 
715 

We estimate that the average number of Medicare Part B fee-for-service enrollees 

(excluding beneficiaries enrolled in Medicare Advantage plans) increased by 1.6 percent in 

CY 2012. Table 82 illustrates how we determined this figure. 

TABLE 82: AVERAGE NUMBER OF MEDICARE PART B FEE-FOR-SERVICE 

ENROLLEES FROM CY 2011 TO CY 2012 

(EXCLUDING BENEFICIARIES ENROLLED IN MA PLANS) 

 2011 2012 

Overall 44.879 million 46.560 million 

Medicare Advantage (MA) 12.382 million 13.545 million 

Net 32.498 million 33.016 million 

Percent Increase 1.6 percent

 

 Our estimate of the 1.6 percent change in the number of fee-for-service enrollees, net of 

Medicare Advantage enrollment for CY 2012 compared to CY 2011, is different than our 

original estimate of an increase of 3.5 percent in the CY 2012 PFS final rule with comment 

period. (76 FR 73271). While our current projection based on data from 8 months of CY 2012 

differs from our original estimate of 3.5 percent when we had no actual data, it is still possible 

that our final estimate of this figure will be different once we have complete information on 

CY 2012 fee-for-service enrollment. 

(c) Factor 3--Estimated Real Gross Domestic Product Per Capita Growth in CY 2012 

We estimate that the growth in real GDP per capita will be 0.7 percent for CY 2012 

(based on the annual growth in the 10-year moving average of real GDP per capita (2003 through 

2012)). Our past experience indicates that there have also been differences between our 

estimates of real per capita GDP growth made prior to the year's end and the actual change in this 

factor. Thus, it is possible that this figure will change further as complete actual information on 

CY 2012 economic performance becomes available to us in CY 2013. 

(d) Factor 4--Percentage Change in Expenditures for Physicians' Services Resulting From 

Changes in Statute or Regulations in CY 2012 Compared With CY 2011 
716 

The statutory and regulatory provisions that affected expenditures in CY 2012 relative to 

CY 2011 are estimated to have an impact on expenditures of 2.8 percent. This is primarily an 

effect of the statutory requirements surrounding the temporary physician fee schedule update in 

CY 2012. 

(3) Detail on the CY 2011 SGR 

A more detailed discussion of our final revised estimates of the four elements of the 

CY 2011 SGR follows. 

(a) Factor 1--Changes in Fees for Physicians' Services for CY 2011 

This factor was calculated as a weighted average of the CY 2011 changes in fees that 

apply for the different types of services included in the definition of physicians' services for the 

SGR in CY 2011. 

We estimate that services paid under the PFS account for approximately 90.7 percent of 

total allowed charges included in the SGR in CY 2011. These services were updated using the 

CY 2011 percent change in the MEI of 0.4 percent. We estimate that diagnostic laboratory tests 

represent approximately 9.3 percent of total allowed charges included in the SGR in CY 2011. 

For CY 2011, diagnostic laboratory tests received an update of -1.8 percent. 

Table 83 shows the weighted-average of the MEI and laboratory price changes for 

CY 2011. 

TABLE 83: WEIGHTED-AVERAGE OF THE MEI, LABORATORY, AND 

DRUG PRICE CHANGES FOR CY 2011 

 Weight Update 

Physician 0.907 0.4 

Laboratory 0.093 -1.8 

 

Weightedaverage 1.00 0.2 
717 

After considering the elements described in Table 83, we estimate that the 

weighted-average increase in fees for physicians' services in CY 2011 under the SGR (before 

applying any legislative adjustments) was 0.2 percent. This figure is a final one based on 

complete data for CY 2011. 

(b) Factor 2--The Percentage Change in the Average Number of Part B Enrollees from CY 2010 

to CY 2011

We estimate the change in the number of fee-for-service enrollees (excluding 

beneficiaries enrolled in MA plans) from CY 2010 to CY 2011 was 1.0 percent. Our calculation 

of this factor is based on complete data from CY 2011. Table 84 illustrates the calculation of 

this factor. 

TABLE 84: AVERAGE NUMBER OF MEDICARE PART B 

FROM CY 2010 TO CY 2011 

(EXCLUDING BENEFICIARIES ENROLLED IN MA PLANS) 

2010 2011 

Overall 43.871 44.879 million 

Medicare Advantage (MA) 11.692 12.382 million 

Net 32.179 32.498 million 

Percent Change 1.0 

(c) Factor 3--Estimated Real Gross Domestic Product Per Capita Growth in CY 2011 

We estimate that the growth in real per capita GDP was 0.6 percent in CY 2011 (based on 

the annual growth in the 10-year moving average of real GDP per capita (2002 through 2011)). 

This figure is a final one based on complete data for CY 2011. 

(4) Factor 4--Percentage Change in Expenditures for Physicians’ Services Resulting From 

Changes in Statute or Regulations in CY 2011 Compared With CY 2010 

Our final estimate for the net impact on expenditures from the statutory and regulatory 

provisions that affect expenditures in CY 2011 relative to CY 2010 is 2.8 percent. This is 
718 

primarily an effect of the statutory requirements surrounding the temporary physician fee 

schedule update in CY 2011. 

2. The Update Adjustment Factor (UAF) 

Section 1848(d) of the Act provides that the PFS update is equal to the product of the 

MEI and the UAF. The UAF is applied to make actual and target expenditures (referred to in the 

statute as “allowed expenditures”) equal. As discussed previously, allowed expenditures are 

equal to actual expenditures in a base period updated each year by the SGR. The SGR sets the 

annual rate of growth in allowed expenditures and is determined by a formula specified in 

section 1848(f) of the Act. 

a. Calculation under Current Law 

Under section 1848(d)(4)(B) of the Act, the UAF for a year beginning with CY 2001 is 

equal to the sum of the following-- 

● Prior Year Adjustment Component. An amount determined by-- 

+ Computing the difference (which may be positive or negative) between the amount of 

the allowed expenditures for physicians’ services for the prior year (the year prior to the year for 

which the update is being determined) and the amount of the actual expenditures for those 

services for that year; 

+ Dividing that difference by the amount of the actual expenditures for those services for 

that year; and 

+ Multiplying that quotient by 0.75. 

● Cumulative Adjustment Component. An amount determined by-- 

+ Computing the difference (which may be positive or negative) between the amount of 

the allowed expenditures for physicians' services from April 1, 1996, through the end of the prior 

year and the amount of the actual expenditures for those services during that period; 
719 

+ Dividing that difference by actual expenditures for those services for the prior year as 

increased by the SGR for the year for which the UAF is to be determined; and 

+ Multiplying that quotient by 0.33. 

Section 1848(d)(4)(E) of the Act requires the Secretary to recalculate allowed 

expenditures consistent with section 1848(f)(3) of the Act. As discussed previously, section 

1848(f)(3) specifies that the SGR (and, in turn, allowed expenditures) for the upcoming CY 

(CY 2013 in this case), the current CY (that is, CY 2012) and the preceding CY (that is, 

CY 2011) are to be determined on the basis of the best data available as of September 1 of the 

current year. Allowed expenditures for a year generally are estimated initially and subsequently 

revised twice. The second revision occurs after the CY has ended (that is, we are making the 

second revision to CY 2011 allowed expenditures in this final rule with comment). 

Table 85 shows the historical SGRs corresponding to each period through CY 2013. 

Note that these figures have been revised to reflect a correction to the historical clinical 

laboratory expenditure data. 

TABLE 85: ANNUAL AND CUMULATIVE ALLOWED AND ACTUAL 

EXPENDITURES FOR PHYSICIANS' SERVICES FROM APRIL 1, 1996 THROUGH 

THE END OF THE CURRENT CALENDAR YEAR 

Period 

Annual Allowed 

Expenditures 

($ in billions) 

Annual Actual 

Expenditures 

($ in billions) 

Cumulative 

Allowed 

Expenditures 

($ in billions) 

Cumulative 

Actual 

Expenditures 

($ in billions) 

FY/CY SGR 

4/1/96-3/31/97 47.0 47.0 47.0 47.0

4/1/97-3/31/98 48.5 47.2 95.6 94.3 3.2%

4/1/98-3/31/99 50.6 48.1 146.2 142.4 4.2%

1/1/99-3/31/99 12.7 12.5 146.2 142.4

4/1/99-12/31/99 40.5 37.2 186.7 179.6 6.9%

1/1/99-12/31/99 53.2 49.7 186.7 179.6

1/1/00-12/31/00 57.1 54.4 243.7 234.0 7.3%

1/1/01-12/31/01 59.7 61.5 303.4 295.5 4.5%

1/1/02-12/31/02 64.6 64.8 368.0 360.3 8.3%

1/1/03-12/31/03 69.3 70.4 437.3 430.7 7.3%

1/1/04-12/31/04 73.9 78.5 511.2 509.1 6.6%

1/1/05-12/31/05 77.0 83.8 588.2 593.0 4.2%

1/1/06-12/31/06 78.2 85.1 666.4 678.1 1.5%

1/1/07-12/31/07 80.9 85.1 747.2 763.1 3.5%

1/1/08-12/31/08 84.5 87.3 831.8 850.4 4.5%

1/1/09-12/31/09 89.9 91.1 921.7 941.5 6.4%
720 

Period 

Annual Allowed 

Expenditures 

($ in billions) 

Annual Actual 

Expenditures 

($ in billions) 

Cumulative 

Allowed 

Expenditures 

($ in billions) 

Cumulative 

Actual 

Expenditures 

($ in billions) 

FY/CY SGR 

1/1/10-12/31/10 97.9 96.0 1,019.6 1,037.4 8.9%

1/1/11-12/31/11 102.5 99.4 1,122.2 1,136.9 4.7%

1/1/12-12/31/12 107.8 102.0 1,230.0 1,238.9 5.1%

(1) Allowed expenditures in the first year (April 1, 1996-March 31, 1997) are equal to actual expenditures. All subsequent figures are equal to 

quarterly allowed expenditure figures increased by the applicable SGR. Cumulative allowed expenditures are equal to the sum of annual allowed 

expenditures. We provide more detailed quarterly allowed and actual expenditure data on our website at the following address: 

http://www.cms.hhs.gov/SustainableGRatesConFact/. We expect to update the website with the most current information later this month. 

(2) Allowed expenditures for the first quarter of 1999 are based on the FY 1999 SGR. 

(3) Allowed expenditures for the last three quarters of 1999 are based on the FY 2000 SGR. 

Consistent with section 1848(d)(4)(E) of the Act, Table 85 includes our second revision 

of allowed expenditures for CY 2011, a recalculation of allowed expenditures for CY 2012, and 

our initial estimate of allowed expenditures for CY 2013. To determine the UAF for CY 2013, 

the statute requires that we use allowed and actual expenditures from April 1, 1996 through 

December 31, 2012 and the CY 2013 SGR. Consistent with section 1848(d)(4)(E) of the Act, we 

will be making further revisions to the CY 2012 and CY 2013 SGRs and CY 2012 and CY 2013 

allowed expenditures. Because we have incomplete actual expenditure data for CY 2012, we are 

using an estimate for this period. Any difference between current estimates and final figures will 

be taken into account in determining the UAF for future years. 

We are using figures from Table 85 in the following statutory formula: 

0.75 0.33

12 13

4 / 96 12 /12 4 / 96 12 /12

12

12 12

13 ×

×

− × + − − − =

Actual SGR

Target Actual

Actual

Target Actual

UAF

UAF13 = Update Adjustment Factor for CY 2013 = 0.6 percent 

Target12 = Allowed Expenditures for CY 2012 = $107.8 billion 

Actual12 = Estimated Actual Expenditures for CY 2012 = $102.0 billion 

Target 4/96-12/12 = Allowed Expenditures from 4/1/1996 - 12/31/2012 = $1230.0 billion 

Actual 4/96-12/12 = Estimated Actual Expenditures from 4/1/1996 - 12/31/2012 = $1238.9 billion 

SGR13 = -19.7 percent (0.803) 
721 

Section 1848(d)(4)(D) of the Act indicates that the UAF determined under section 

1848(d)(4)(B) of the Act for a year may not be less than -0.07 or greater than 0.03. Since 0.006 

(0.6 percent) is between -0.07 and 0.03, the UAF for CY 2013 will be 0.006. 

Section 1848(d)(4)(A)(ii) of the Act indicates that 1.0 should be added to the UAF 

determined under section 1848(d)(4)(B) of the Act. Thus, adding 1.0 to 0.006 yields 1.006. 

3. The Percentage Change in the Medicare Economic Index (MEI) 

The Medicare Economic Index (MEI) is required by section the fourth sentence of 

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 the higher level is justified by year-to-year 

economic changes. The current form of the MEI was detailed in the CY 2011 PFS final rule with 

comment period (75 FR 73262) which updated the cost structure of the index from a base year of 

2000 to 2006. 

The MEI measures the weighted-average annual price change for various inputs needed 

to furnish physicians' services. The MEI is a fixed-weight input price index, with an adjustment 

for the change in economy-wide multifactor productivity. This index, which has CY 2006 base 

year weights, is comprised of two broad categories: (1) physician's own time; and (2) physician's 

practice expense (PE). 

The physician's compensation (own time) component represents the net income portion 

of business receipts and primarily reflects the input of the physician's own time into the 

production of physicians' services in physicians' offices. This category consists of two 

subcomponents: (1) wages and salaries; and (2) fringe benefits. 

0.33 0.6%

$102.0 0.803

$1230.0 $1238.9 0.75

$102.0

$107.8 $102.0

× = ×

− × + −
722 

The physician's practice expense (PE) category represents nonphysician inputs used in 

the production of services in physicians' offices. This category consists of wages and salaries 

and fringe benefits for nonphysician staff and other nonlabor inputs. The physician's PE 

component also includes the following categories of nonlabor inputs: office expenses; medical 

materials and supplies; professional liability insurance; medical equipment; medical materials 

and supplies; and other professional expenses. 

 Table 86 presents a listing of the MEI cost categories with associated weights and percent 

changes for price proxies for the 2013 update. The CY 2013 final MEI update is 1.8 percent and 

reflects a 1.9 percent increase in physician’s own time and a 1.7 percent increase in physician’s 

PE. Within the physician’s PE, the largest increase occurred in chemicals, which increased 

7.1 percent, and rubber and plastic products, which increased 6.1 percent. 

For CY 2013, the increase in the MEI is 0.8 percent, which reflects an increase in the 

non-productivity adjusted MEI of 1.8 percent and a productivity adjustment of 1.0 percent 

(which is based on the 10-year moving average of economy-wide private nonfarm business 

multifactor productivity). The Bureau of Labor Statistics (BLS) is the agency that publishes the 

official measure of private non-farm business multi-factor productivity (MFP). Please see 

http://www.bls.gov/mfp/ , which is the link to the BLS historical published data on the measure 

of MFP. 

TABLE 86: ANNUAL PERCENT CHANGE IN THE REVISED AND REBASED MEI 

CY 2013, ALL CATEGORIES 

Cost Categories 2006 

Weight 2

 

CY 2013 

Percent 

Changes 

MEI Total, productivity adjusted 100.000% 0.8 

Productivity: 10-year moving average of MFP1 N/A 5 1.0 

MEI Total, without productivity adjustment 100.000% 1.8 

 Physician Compensation (Own Time) 3 48.266% 1.9 
723 

Cost Categories 2006 

Weight 2

 

CY 2013 

Percent 

Changes 

 Wages and Salaries 43.880% 1.8 

 Benefits 4.386% 2.9 

 Practice Expenses 51.734% 1.7 

 Nonphysician Compensation 19.153% 1.9 

 Nonphysician Wages 13.\752% 1.7 

 P&T 6.006% 1.6 

 Management 1.446% 1.8 

 Clerical 4.466% 1.8 

 Services 1.834% 1.3 

 Nonphysician Benefits 5.401% 2.6 

 Other Practice Expenses 26.308% 1.6 

 Office Expenses 20.035% 2.0 

 Utilities 1.266% 1.5 

 Chemicals 0.723% 7.1 

 Paper 0.657% 1.9 

 Rubber & Plastics 0.598% 6.1 

 Telephone 1.501% -0.3 

 Postage 0.898% 3.6 

 All Other Services 3.582% 1.5 

 All Other Products 0.500% 2.1 

 Fixed Capital 8.957% 1.8 

 Moveable Capital 1.353% 1.5 

 PLI 4 4.295% 0.5 

 Medical Equipment 1.978% -0.6 

 Medical supplies 1.760% 0.5 

 Other Professional Expenses 4.513% 2.1 

1

 The forecasts are based upon the latest available Bureau of Labor Statistics data on the 10-year average of BLS private nonfarm business 

multifactor productivity published on June 26, 2012. (http://www.bls.gov/news.release/prod3.nr0.htm) 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 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. 

5

 Productivity is factored into the MEI categories as an adjustment; therefore, no explicit weight exists for productivity in the MEI. 

4. Medicare Economic Index Technical Advisory Panel 

From May 2012 through September 2012, the MEI Technical Advisory Panel conducted 

a technical review of the MEI, including analyses of the inputs, input weights, price-
724 

measurement proxies, and productivity adjustment. Details regarding the Panel’s work and 

documents such as transcripts, meeting summaries, and presentations can be found at the 

following website: http://cms.gov/Regulations-and-Guidance/Guidance/FACA/MEITAP.html. 

 The Panel concluded its public work on July 11, 2012 and submitted a final report 

complete with its recommendations to the Secretary of Health and Human Services on August 

27, 2012. 

Comment: We received one comment requesting that CMS engage in dialogue with 

affected parties regarding the analyses and recommendations of the Technical Advisory Panel to 

the MEI prior to proposed rulemaking to implement any such findings. 

Response: The MEI Technical Advisory Panel was chartered according to the Federal 

Advisory Committee Act. As a result, all of the Panel’s meetings were open to the public. In 

each meeting, including the final meeting where the Panel’s findings and recommendations were 

finalized, time was allotted to allow for any public comment. As we find appropriate, any 

recommended changes to the MEI will be proposed via the rulemaking process. Given the time 

made available for public comment during the MEI Technical Advisory Panel’s meetings, as 

well as the opportunity for public comment during rulemaking, we disagree with the 

commenter’s request that we engage in further dialogue prior to proposing possible changes. 

5. Physician and Anesthesia Fee Schedule Conversion Factors for CY 2013 

 The CY 2013 PFS CF is $25.0008. The CY 2012 national average anesthesia CF is 

$15.93. 

a. Physician Fee Schedule Update and Conversion Factor 

(1) CY 2013 PFS Update 

The formula for calculating the PFS update is set forth in section 1848(d)(4)(A) of the 

Act. In general, the PFS update is determined by multiplying the CF for the previous year by the 
725 

percentage increase in the MEI less productivity times the UAF, which is calculated as specified 

under section 1848(d)(4)(B) of the Act. 

(2) CY 2013 PFS Conversion Factor 

Generally, the PFS CF for a year is calculated in accordance with section 1848(d)(1)(A) 

of the Act by multiplying the previous year’s CF by the PFS update. 

We note section 101 of the Medicare Improvements and Extension Act, Division B of the 

Tax Relief and Health Care Act of 2006 (MIEA-TRHCA) provided a 1-year increase in the 

CY 2007 CF and specified that the CF for CY 2008 must be computed as if the 1-year increase 

had never applied. Section 101 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 

(MMSEA) provided a 6-month increase in the CY 2008 CF, from January 1, 2008, through June 

30, 2008, and specified that the CF for the remaining portion of CY 2008 and the CFs for CY 

2009 and subsequent years must be computed as if the 6-month increase had never applied. 

Section 131 of the MIPPA extended the increase in the CY 2008 CF that applied during the first 

half of the year to the entire year, provided for a 1.1 percent increase to the CY 2009 CF, and 

specified that the CFs for CY 2010 and subsequent years must be computed as if the increases 

for CYs 2007, 2008, and 2009 had never applied. Section 1011(a) of the DODAA and section 5 

of the TEA specified a zero percent update for CY 2010, effective January 1, 2010 through 

March 31, 2010. Section 4 of the Continuing Extension Act of 2010 (CEA) extended the zero 

percent update for CY 2010 through May 31, 2010. Subsequently, section 101(a)(2) of the 

PACMBPRA provided for a 2.2 percent update to the CF, effective from June 1, 2010 to 

November 30, 2010. Section 2 of the Physician Payment and Therapy Relief Act of 2010 (Pub. 

L. No. 111-286) extended the 2.2 percent through the end of CY 2010. Section 101 of the 

MMEA provided a zero percent update for CY 2011, effective January 1, 2011 through 

December 31, 2011, and specified that the CFs for CY 2012 and subsequent years must be 
726 

computed as if the increases in previous years had never applied. Section 301 of the Temporary 

Payroll Tax Cut Continuation Act of 2011 (TPTCCA) provided a zero percent update effective 

January 1, 2012 through February 29, 2012, and specified that the CFs for subsequent time 

periods must be computed as if the increases in previous years had never applied. Section 3003 

of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) provided a zero 

percent update for effective March 1, 2012 through December 31, 2012, and specified that the 

CFs for subsequent time periods must be computed as if the increases in previous years had 

never applied. Therefore, under current law, the CF that would be in effect in CY 2012 had the 

prior increases specified above not applied is $24.6712. 

In addition, when calculating the PFS CF for a year, section 1848(c)(2)(B)(ii)(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 it would have been in the absence of these 

changes. If this threshold is exceeded, we must make adjustments to preserve budget neutrality. 

We estimate that CY 2012 RVU changes would result in an increase in Medicare physician 

expenditures of more than $20 million. Accordingly, we are decreasing the CF by -0.1% to 

offset the estimated increase in Medicare physician expenditures due to the CY 2012 RVU 

changes. We calculate the CY 2013 PFS CF to be $25.0008. This final rule with comment 

period announces a reduction to payment rates for physicians' services in CY 2013 under the 

SGR formula. These payment rates are currently scheduled to be reduced under the SGR system 

on January 1, 2013. The total reduction in the conversion factor between CY 2012 and CY 2013 

under the SGR system will be -26.5 percent. By law, we are required to make these reductions 

in accordance with section 1848(d) and (f) of the Act, and these reductions can only be averted 

by an Act of Congress. While Congress has provided temporary relief from these reductions 

every year since 2003, a long-term solution is critical. We will continue to work with Congress 
727 

to fix this untenable situation so doctors and beneficiaries no longer have to worry about the 

stability and adequacy of their payments from Medicare under the Physician Fee Schedule. 

We illustrate the calculation of the CY 2013 PFS CF in Table 87. 

TABLE 87: CALCULATION OF THE CY 2013 PFS CF 

Conversion Factor in effect in CY 2012 $34.0376 

CY 2012 Conversion Factor had statutory 

increases not applied 

 $24.6712 

CY 2013 Medicare Economic Index 0.8 percent (1.008) 

CY 2013 Update Adjustment Factor 0.6 percent (1.006) 

CY 2013 RVU Budget Neutrality Adjustment -0.1 percent (0.99932) 

CY 2013 Conversion Factor $25.0008 

Percent Change from Conversion Factor in 

effect in CY 2012 to CY 2013 Conversion 

Factor 

-26.5% 

We note payment for services under the PFS will be calculated as follows: 

Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU malpractice x 

GPCI malpractice)] x CF. 

b. Anesthesia Conversion Factor 

We calculate the anesthesia CF as indicated in Table 88. Anesthesia services do not have 

RVUs like other PFS services. Therefore, we account for any necessary RVU adjustments 

through an adjustment to the anesthesia CF to simulate changes to RVUs. More specifically, if 

there is an adjustment to the work, PE, or malpractice RVUs, these adjustments are applied to the 

respective shares of the anesthesia CF as these shares are proxies for the work, PE, and 

malpractice RVUs for anesthesia services. Information regarding the anesthesia work, PE, and 

malpractice shares can be found at the following: https://www.cms.gov/center/anesth.asp. 

The anesthesia CF in effect in CY 2012 is $21.52. As explained previously, in order to 

calculate the CY 2013 PFS CF, the statute requires us to calculate the CFs for all previous years 

as if the various legislative changes to the CFs for those years had not occurred. Accordingly, 
728 

under current law, the anesthesia CF in effect in CY 2012 had statutory increases not applied is 

$15.60. The percent change from the anesthesia CF in effect in CY 2012 to the CF for CY 2013 

is –26.0 percent. We illustrate the calculation of the CY 2013 anesthesia CF in Table 88. 

TABLE 88: CALCULATION OF THE CY 2013 ANESTHESIA CF 

2012 National Average Anesthesia Conversion Factor in 

effect in CY 2011 

 $21.52 

2012 National Anesthesia Conversion Factor had Statutory 

Increases Not Applied 

 $15.60 

CY 2013 Medicare Economic Index 0.8 percent 

(1.008) 

CY 2013 Update Adjustment Factor 0.6 percent 

(1.006) 

CY 2013 Budget Neutrality Work and Malpractice 

Adjustment 

-0.1 percent 

(0.99932) 

CY 2013 Anesthesia Fee Schedule change due to Practice 

Expense 

0.8 percent 

(1.008) 

CY 2013 Anesthesia Conversion Factor $15.93 

Percent Change from 2012 to 2013 -26.0% 

III. Other Provisions of the Final Rule with Comment Period 

A. Ambulance Fee Schedule

1. Amendment to section 1834(l) (13) of the Act 

Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 

(Pub. L. 110-275) (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 that 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 that 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 
729 

by 2 percent. 

Sections 3105(a) and 10311(a) of the Affordable Care Act further amended 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 applied to covered ground ambulance transports furnished on or 

after January 1, 2010 and before January 1, 2011. In the CY 2011 PFS final rule (75 FR 73385 

and 73386, 73625), we revised §414.610(c)(1)(ii) to conform the regulations to this statutory 

requirement. 

Section 106(a) of the MMEA again amended 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 applied 

to covered ground ambulance transports furnished on or after January 1, 2011 and before 

January 1, 2012. In the CY 2012 End-Stage Renal Disease Prospective Payment System (ESRD 

PPS) final rule (76 FR 70228, 70284 through 70285, 70315), we revised §414.610(c) (1) (ii) to 

conform the regulations to this statutory requirement. However, in doing so, paragraphs 

(c)(1)(ii)(A) and (B) were inadvertently deleted from the Code of Federal Regulations. Thus, in 

the proposed rule, we proposed to reinstate paragraphs (c)(1)(ii)(A) and (B) as further revised 

below. We did not receive any comments on this proposal. Therefore, we are finalizing our 

proposal to reinstate paragraphs (c)(1)(ii)(A) and (B), as further revised below to conform to 

subsequent legislation. 

Subsequently, section 306 (a) of the Temporary Payroll Tax Cut Continuation Act of 

2011 (Pub. L. 112-78) (TPTCCA) amended section 1834(l)(13)(A) of the Act to extend the 

payment add-ons described above through February 29, 2012; and section 3007(a) of the Middle 

Class Tax Relief and Job Creation Act of 2012 (Pub. L. 112-96) (MCTRJCA) further amended 

section 1834(l)(13)(A) to extend these payment add-ons through December 31, 2012. Thus, 

these payment add-ons also apply to covered ground ambulance transports furnished on or after 
730 

January 1, 2012 and before January 1, 2013. In the proposed rule, we proposed to revise 

§414.610(c)(1)(ii) to conform the regulations to these statutory requirements. We did not receive 

any comments on this proposal. Accordingly, we are finalizing our proposal to revise 

§414.610(c)(1)(ii) to conform to the statutory requirements described above. These statutory 

requirements are self-implementing. 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. 

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. This section originally 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, must 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 Affordable Care Act amended section 146(b)(1) of 

MIPPA to extend this provision for an additional year, through December 31, 2010. In the 

CY 2011 PFS final rule (75 FR 73385 through 86, 73625 through 26), we revised §414.610(h) to 

conform the regulations to this statutory requirement. 

 Section 106(b) of the MMEA amended section 146(b)(1) of MIPPA to extend this 

provision again through December 31, 2011. In the CY 2012 ESRD PPS final rule 

(76 FR 70284 through 70285, 70315), we revised §414.610(h) to conform the regulations to this 

statutory requirement. 

 Subsequently, section 306 (b) of the TPTCCA amended section 146(b)(1) of MIPPA to 

extend this provision through February 29, 2012; and section 3007(b) of the MCTRJCA further 
731 

amended section 146(b)(1) of MIPPA to extend this provision through December 31, 2012. 

Thus, we proposed to revise §414.610(h) to conform the regulations to these statutory 

requirements. We did not receive any comments on this proposal. Therefore, we are finalizing 

our proposal to revise §414.610(h) to conform to the statutory requirements described above. 

These statutory requirements are 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. 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 through December 31, 2012. 

3. Amendment to section 1834(l) (12) of the Act 

Section 414 of the Medicare Prescription Drug, Improvement and Modernization Act of 

2003 (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 
732 

areas (a type of rural census tract). 

 Sections 3105(c) and 10311(c) of the Affordable Care Act amended section 

1834(l)(12)(A) of the Act to extend this rural bonus for an additional year through 

December 31, 2010. In the CY 2011 PFS final rule (75 FR 73385 through 73386 and 73625), we 

revised §414.610(c)(5)(ii) to conform the regulations to this statutory requirement. 

 Section 106(c) of the MMEA again amended section 1834(l)(12)(A) of the Act to extend 

the rural bonus described above for an additional year, through December 31, 2011. Therefore, 

in the CY 2012 ESRD PPS final rule (76 FR 70284 through 70285, 70315), we revised 

§414.610(c)(5)(ii) to conform the regulations to this statutory requirement. 

 Subsequently, section 306 (c) of the TPTCCA amended section 1834(l)(12)(A) of the Act 

to extend this rural bonus through February 29, 2012; and section 3007(c) of the MCTRJCA 

further amended section 1834(l)(12)(A) of the Act to extend this rural bonus through December 

31, 2012. Therefore, we are continuing to apply the 22.6 percent 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, 2012 and before January 1, 2013 where transportation originates in a qualified 

rural area.

 This rural bonus is sometimes referred to as the “Super Rural Bonus” and the qualified 

rural areas (also known as “super rural” areas) are identified during the claims adjudicative 

process via the use of a data field included on the CMS-supplied ZIP Code File. 

 In the proposed rule, we proposed to revise §414.610(c)(5)(ii) to conform the regulations 

to the statutory requirements set forth at section 306(c) of the TPTCCA and section 3007(c) of 

the MCTRJCA. We did not receive any comments on this proposal. Accordingly, we are 

finalizing our proposal to revise §414.610(c)(5)(ii) to conform the regulations to these statutory 

requirements. These statutory requirements are self-implementing. Together, these provisions 
733 

require a one-year extension of the rural bonus (which was previously established by the 

Secretary) through December 31, 2012, and do not require any substantive exercise of discretion 

on the part of the Secretary. 

B. Part B Drug Payment: Average Sales Price (ASP) Issues 

Section 1847A of the Act requires use of the average sales price (ASP) payment 

methodology for payment for drugs and biologicals described in section 1842(o)(1)(C) of the Act 

furnished on or after January 1, 2005. The ASP methodology applies to most drugs furnished 

incident to a physician's service, many drugs furnished under the DME benefit, certain oral anticancer drugs, and oral immunosuppressive drugs. 

1. Widely Available Market Price (WAMP)/Average Manufacturer Price (AMP) price 

substitution 

If the ASP payment limit for a drug or biological exceeds the WAMP or AMP by a 

threshold percentage, section 1847A(d)(3)(C) of the Act authorizes the Secretary to substitute the 

lesser of the widely available market price for the drug or biological, or 103 percent of the 

average manufacturer price as determined under section 1927(k)(1) of the Act. 

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 authorizes the Secretary to specify the threshold percentage for the WAMP or the AMP, or 

both. In the CY 2006 (70 FR 70222), CY 2007 (71 FR69680), 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 5 percent 

threshold. Beginning in CY 2011, we treated the WAMP and AMP based adjustments to the 

applicable threshold percentages separately. 
734 

a. WAMP Threshold and Price Substitution 

After soliciting and reviewing comments, we finalized proposals to continue the 

5 percent WAMP threshold for CY 2011 (75 FR 73469), and CY 2012 (76 FR 73287). For CY 

2013, we again had no additional information from OIG studies or other sources that led us to 

consider an alternative threshold. When making comparisons to the WAMP, we proposed that 

the applicable threshold percentage remain at 5 percent until such time that a change in the 

threshold amount is warranted, and we proposed to update §414.904(d)(3)(iv) accordingly. As 

mentioned above, the threshold has remained at 5 percent since 2005. Our proposal will 

eliminate the need for annual rulemaking until a change is warranted. 

For CY 2013, we did not propose any WAMP based price substitutions. As we noted in 

the CY 2011 PFS final rule with comment period (75 FR 73470) and reiterated in CY 2012 PFS 

final rule with comment period (76 FR 73287), we understand that there are complicated 

operational issues associated with the WAMP based substitution policy, and 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, including the opportunity to provide input with regard to the processes 

for substituting the WAMP for the ASP. 

Comment: Several commenters agreed with continuing a cautious approach regarding 

WAMP-based price substitutions and agreed with maintaining a 5 percent threshold. One 

commenter agreed with the elimination of annual rulemaking provided that access to drugs is not 

impacted and that the value can be modified with advance notice to stakeholders. One 

commenter suggested a higher threshold for the WAMP substitution due to concern about drug 

shortages and suggested that CMS study the threshold value issue further. 

Response: The majority of commenters agreed with maintaining a 5 percent WAMP 
735 

threshold. Because, as noted in the proposed rule and above, available data are limited, and we 

continue to have no information that would lead us to believe a different threshold is necessary, 

we disagree with implementing a higher threshold at this time. We also decline to actively study 

the matter further until such time as future study is warranted, for example, if better information 

were available for such study. The threshold can be reviewed as warranted and as WAMP-based 

price substitution policies develop and it can be modified as needed at a later time through 

rulemaking. Therefore, we are finalizing §414.904(d)(3)(iv) as proposed. 

b. AMP Threshold 

The AMP threshold has remained at 5 percent since 2005. As with the WAMP threshold, 

we had no information that led us to believe that the 5 percent threshold percentage for AMPbased price substitution is inappropriate or should be changed for CY 2013. We proposed that 

the applicable threshold percentage remain at 5 percent until such time that a change in the 

threshold amount is warranted, and we proposed to update §414.904(d)(3)(iii) accordingly. Our 

proposal eliminates the need for annual rulemaking until a change is warranted. 

Comment: Two commenters agreed with maintaining the 5 percent AMP price 

substitution threshold. One commenter suggested a higher threshold for the AMP substitution 

due to concern that a low threshold would trigger price substitution which would then affect the 

manufacture of drugs. The commenter suggested that CMS study the threshold value issue 

further. 

Response: We disagree with increasing the threshold or studying the threshold value 

further. Although we acknowledge that the definition of AMP is continuing to evolve, this 

threshold has been in place since 2005 and we have no specific information that persuades us to 

believe that a change in the AMP threshold is necessary at this time. Also, as with the WAMP 

threshold discussed in the section above, the AMP threshold can be reviewed as warranted, as 
736 

price substitution policies evolve, and the threshold can be modified as needed at a later time 

through rulemaking. Therefore, we are finalizing §414.904(d)(3)(iii) as proposed. 

c. AMP Price Substitution-Additional Conditions ` 

In the CY 2012 PFS rule, we specified that the substitution of AMP for ASP will be made 

only when the ASP exceeds the AMP by 5 percent in 2 consecutive quarters immediately prior to 

the current pricing quarter, or three of the previous four quarters immediately prior to the current 

quarter, and that matching sets of NDCs had to be used in the comparison (76FR 73289 through 

73295). The value of the AMP based price substitution must also be less than the ASP payment 

limit that is calculated for the quarter in which the substitution is applied. Also, the price 

substitution remains in effect for one quarter. 

We did not apply the price substitution policy in April 2012 because access concerns led 

us to reconsider whether it was prudent to proceed with price substitution during a developing 

situation that was related to a drug shortage that had not met the definition of a public health 

emergency under section 1847A(e) of the Act. In light of recent concerns about drug shortages, 

the resulting impact on patient care, beneficiary and provider access, as well as the potential for 

shortages to suddenly affect drug prices for the provider, under the authority in section 

1847A(d)(3)(C) of the Act, we proposed adding §414.904(d)(3)(ii)(C), which would prevent the 

AMP price substitution policy from taking effect if the drug and dosage form represented by the 

HCPCS code are reported by the FDA on their Current Drug Shortage list (or other FDA 

reporting tool that identifies shortages of critical or medically necessary drugs) to be in short 

supply at the time that ASP payment limits are being finalized for the next quarter. Further, we 

also clarified that this proposal to add to the safeguards finalized in CY 2012 only applied to 

calculations under the AMP-based price substitution policy. Our proposal intended to continue 

the cautious approach described in previous rules and to strike a balance between operational 
737 

requirements associated with receiving manufacturers' ASP reports, calculating the payment 

limits, and posting stable payment limits that will be used to pay claims. We believe that this 

approach also addresses concerns about access to care, known program issues identified by the 

OIG, and provides an opportunity for some modest program savings. However, we did not 

propose any other changes to the safeguards, timing, or notification that identifies the codes that 

will be substituted each quarter. We asked for comments on our approach as well as comments 

regarding additional specific safeguards for the AMP price substitution policy. 

Comment: In general, commenters supported implementation of a safeguard that would 

prevent AMP-based substitution of drugs that are known to be in short supply. Several 

commenters supported our proposal that prevents an AMP-based price substitution from taking 

effect for drugs that are reported to be in short supply. Two comments supported the use of the 

FDA’s drug shortage list while another commenter suggested that the American Society of 

Health-System Pharmacists (ASHP) shortage list be used because it might better identify 

impending shortages. One commenter suggested that the provision be expanded to include drugs 

that are potentially in short supply, but did not provide additional detail. One commenter 

supported the proposed shortage safeguard if CMS does not further delay the implementation of 

the AMP substitution policy. 

Response: We understand the commenters’ reasoning for suggesting that we use the 

ASHP list, which includes information about shortages that may not affect overall supply-for 

example the unavailability of a certain vial size from one manufacturer. We believe that such 

detailed information is very useful to clinicians and those who must procure drugs. 

Nevertheless, we believe that using the FDA list, which is compiled from information that is 

required to be reported by statute and represents shortages where overall demand is not being 

met, will provide us with a consistent standard that reflects national drug supply. Thus, we 
738 

decline to include the ASHP list in our standard. Also, after consultation with the FDA, we are 

also deleting the phrase “critical or medically necessary” from the proposed regulation text in 

order to make clear that CMS will not further interpret FDA’s drug shortage list. In other words, 

we are clarifying that a drug’s presence on the list will be sufficient to meet the standard in our 

final rule, and we will not be taking a position as to whether the drug is “critical or medically 

necessary” for this purpose. We believe that this modification will also help maintain a 

consistent standard on which we base our decisions. After reviewing the public comments, we 

are finalizing our proposal and corresponding regulation text at §414.904(d)(3)(ii)(C) with the 

modification described in this paragraph. 

Comment: Although we did not receive any detailed suggestions for new safeguards, two 

commenters also suggested creating safeguards that address AMP data errors and calculations be 

implemented. 

Response: We are acknowledging these comments, but since no specific 

recommendations were made, we will not be addressing them at this time. 

Comment: Several commenters stated that implementation of the AMP-based price 

substitution should be delayed until the AMP regulation is finalized and/or additional experience 

with calculating AMPs has been gained. Commenters expressed concerns about the differences 

in the calculation methodology for ASP and AMP and the uncertainty about how “5i” drugs will 

be affected. 

Response: We appreciate these comments; however, delaying the AMP-based 

substitution process is outside the scope of our proposals and we will not further delay 

implementation of the AMP-based price substitution policy at this time. In the proposed rule (77 

FR 44793), we stated that we are not proposing any other changes to the safeguards, timing or 

notification procedures for the AMP-based price substitution. We have explained our reasons for 
739 

proceeding with the AMP-based substitution in the CY 2012 PFS final rule (76 FR 73294-95), 

where we also discussed the evolving definition of AMP and “5i” drugs. In the CY 2012 PFS 

final rule we stated that we “understand that the updated definition of AMP encompasses sales of 

injected, infused, instilled, inhaled, and implanted drugs that are not generally dispensed through 

a retail community pharmacy, including a wider range of customers and discounted sales to nonpharmacy entities, and commenters' concerns that implementation of the most recent definition 

could decrease AMP for certain drugs. However, we do not have any specific information from 

commenters that persuades us to believe that the AMP-based price substitution policy will be 

applied frequently or to high cost/high volume items, despite the changes to the definition of 

AMP.” We also continue to believe that the safeguards finalized in the CY 2012 PFS rule and the 

additional safeguard finalized in this rule provide assurance that the price substitution policy will 

be applied only when appropriate. In summary, we appreciate the commenters’ concerns, but 

our assessment of the overall situation has not changed. 

Additional Part B drug-related comments that are outside the scope of this rule are listed 

in section 3 below. 

2. Billing for Part B Drugs Administered Incident to a Physician’s Services. 

This section discusses payment policies regarding billing for certain drugs under 

Medicare Part B. In 2010 and 2011, we issued two change requests (CRs 7109 and 7397) that 

summarized a number of longstanding drug payment policy and billing requirements. We 

considered these CRs to be merely clarifying, rather than changing, our policy. However, one 

item in the CRs, which stated that pharmacies may not bill for drugs that are used incident to 

physician’s service, has caused some concern. Specifically, we understood that some 

nonphysician suppliers—operating in part on the basis of erroneous guidance from a Medicare 

contractor--have been submitting claims for drugs that they have shipped to physicians’ offices 
740 

for use in refilling implanted intrathecal pumps. In light of concern over its potential effect on 

suppliers, we delayed implementation of the most recently updated CR (CR 7397 Transmittal 

2437, April 4, 2012) until January 1, 2013 so that we could undertake rulemaking, evaluate 

public comments on this issue, and determine whether CR 7397 should be implemented as 

planned, revised, or rescinded. 

Implanted pumps may qualify as Durable Medical Equipment (DME); however, unlike 

external pumps used to administer drugs, implanted pumps are typically refilled in a physician’s 

office. The implanted intrathecal pump is refilled by injecting the drug into a pump’s reservoir, 

which lies below the patient’s skin. The reservoir is connected to the pump, which delivers the 

drug to the intrathecal space through a tunneled catheter. The procedure of refilling an 

intrathecal pain pump is a service that is typically performed by the physician because of risk and 

complexity. 

To be covered by Medicare Part A or Part B, an item or service must fall within one or 

more benefit categories within such Parts, and must not be otherwise excluded from coverage. 

Drugs and biologicals paid under Medicare Part B drugs fall into three basic categories as 

follows: 

● Drugs furnished “incident to” a physician’s services. These are typically injectable 

drugs that are bought by the physician, administered in the physician’s office, and then billed by 

the physician to the Medicare Administrative Contractor (MAC). By definition, “incident to a 

physician’s professional service” requires the item or service to be billed by the physician. 

● Drugs administered through a covered item of DME. These drugs are supplies 

necessary for the effective use of DME and are typically furnished to the beneficiary by suppliers 

that are pharmacies (or general DME suppliers that utilize licensed pharmacists) for 

administration in a setting other than the physician’s office. Most DME drugs are billed to the 
741 

DME MAC. 

● Drugs specified by the statute. These include a variety of drugs, such as oral 

immunosuppressives and certain vaccines. 

Depending on the circumstances, drugs used to refill an implanted intrathecal pump can 

be paid under either the ``incident to'' or the DME benefit category or Medicare Part D. The 

CMS Benefit Policy Manual (100-02 Chapter 15 Section 50.3) states that drugs paid under the 

“incident to” provision are of a form that is not usually self-administered; are furnished by a 

physician; and are administered by the physician, or by auxiliary personnel employed by the 

physician and under the physician’s personal supervision. Section 60.1 A requires that “to be 

covered, supplies, including drugs and biologicals, must represent an expense to the physician or 

legal entity billing.” In what we believe is a typical situation, when physicians’ services are used 

to refill an intrathecal pump, the “incident to” requirements can be met because, consistent with 

our guidance and longstanding policy, the physician or other professional employed by his or her 

office performs a procedure to inject the drug into the implanted pump’s reservoir (that is, the 

drug is not self-administered), and the drug represents a cost to the physician because he or she 

has purchased it. 

Conversely, we believe that in the typical situation, payment to a pharmacy or other 

nonphysician supplier under the DME benefit for a drug dispensed for use in the physician’s 

office is both inappropriate and inconsistent with existing guidance. For example, DME 

prosthetics, orthotics, and supplies (POS) policy does not permit payment for prosthetics 

dispensed prior to the procedure that makes necessary the use of the device. Moreover, in the 

case of prescription drugs used in conjunction with DME, our guidance is clear that the entity 

that dispenses the drug needs to furnish it directly to the patient for whom a prescription is 

written. An arrangement whereby a pharmacy (or supplier) ships a drug to a physician’s office 
742 

for administration to a patient does not constitute furnishing the drug directly to the patient. 

We note that payment to pharmacies (or suppliers) for drugs used to refill an implanted 

pump can be made under the DME benefit category where the drug is directly dispensed to a 

patient and the implanted pump is refilled without a physician’s service. However, it is our 

understanding that implanted pumps are rarely refilled without utilizing the service of a 

physician. 

In the proposed rule, we stated our concern about stakeholders’ reports that, due to 

incorrect guidance from a contractor, Medicare payment policy on this issue has been applied in 

an inconsistent manner. We stated that we consider the contractor’s guidance to be erroneous. 

This inconsistency has permitted supplier claims for drugs dispensed by pharmacies to 

physicians’ offices to be paid in some jurisdictions and denied in others. We understand that the 

inconsistent application of our payment policy has influenced the business and professional 

practices of pharmacies/DME suppliers that prepare drugs for implanted pumps. We stated that 

we do not believe that payment for drugs used to refill implanted DME should continue to be 

made because such action is not supported under long standing policy and, as discussed above, is 

not appropriate. 

We proposed to clarify that we consider drugs used by a physician to refill an implanted 

item of DME to be within the “incident to” benefit category and not the DME benefit category. 

Therefore, for the drug to be paid under Part B, the physician must buy and bill for the drug, and 

a non-physician supplier that has shipped the drug to the physician’s office may not do so. We 

asked for comments on this proposal and its potential impact on beneficiaries and providers. 

Comment: One commenter questioned CMS’s assumptions in proposing the policy 

clarification and contends that contrary to these assumptions, pharmacy billing for drugs used by 

a physician to refill an implanted pump under the DME benefit is appropriate. Specifically, the 
743 

commenter questioned CMS’s assertion that the physician refilling the implanted pump is 

“administering” the drug, contending instead that the pump administers the drug and that the 

physician does not exclusively administer the drug. Second, the commenter disagrees with 

CMS’s statement that pharmacies’ shipping drugs to physician offices are not furnishing drugs 

directly to the patient and contends that these medications are dispensed specifically to the 

patient at the physician’s office. 

Response: We disagree with these comments. With respect to whether the physician is 

administering these drugs, we understand that the implanted pump serves to release the drug into 

a specific region of the patient’s body over a prolonged time period. However, the process of 

refilling the implanted pump, determining the correct pump settings, and making adjustments to 

those settings as needed is usually carried out by a licensed healthcare provider, typically a 

physician. In our view, the pump’s role is analogous to a drug with a sustained release rate (for 

example, leuprolide depot injection) that is injected or implanted into the body, which is 

similarly furnished incident to a physician’s professional service. Further, the relevant inquiry is 

not whether a drug is “exclusively” administered by a physician, but rather whether the drug is 

“not usually self-administered by the patient” and furnished incident to a physician’s 

professional service. Thus, even if the physician did not “exclusively” administer the drug 

because of the action of the pump, it does not follow that a more appropriate benefit category for 

such a drug would be the DME benefit category. 

 Under the incident to provision, we associate payment for the drug with the physician’s 

professional service, and the drug is a key component of the billable procedure that is paid 

incident to a physician’s professional service. As we have described earlier, when an implanted 

article of DME is refilled in the physician’s office, the drug required for the service must meet 

the three conditions of the incident to benefit described in the Claims Processing manual, 
744 

Chapter 15, Section 50.1, where the drug or biological must be of a form that is not usually selfadministered; must be furnished by the physician; and must be administered by the physician, or 

by auxiliary personnel employed by the physician and under the physician’s personal 

supervision. Based on discussion with stakeholders, it is our understanding that most refills of 

implanted DME that are done in the physician’s office meet these conditions. In contrast, under 

the DME benefit category, a pharmacist dispenses the drug as a supply necessary for the 

effective use an item of DME (including, an implanted pump) and a physician’s service is not 

utilized for the drug administration process. 

In addition, we disagree with the commenter’s assertion that by sending a drug to the 

physician’s office for a specific patient, it is furnishing the drug directly to the patient, because 

such delivery would not be made without the physician’s being at the delivery location to 

administer the drug in his or her office. It is notable that the commenter neglected to describe 

what happens to the drug that it asserts is delivered “directly” to the patient at the physician’s 

office if the patient cannot receive a pump refill at the time of such delivery. Presumably the 

physician’s office or the pharmacy, rather than the patient, would be responsible for the storage 

of the drug until it could be safely used or for disposal or return of an unused and unopened dose, 

which would indicate that at no time did the patient take “delivery” of the drug. In any event, in 

light of the physician’s integral role in receipt and administration of the drug, the DME benefit 

category does not appropriately apply to this situation. Moreover, the incident to benefit 

category does not permit pharmacy billing for the incident to drug. Pharmacy/DME supplier 

dispensed drugs that are to be used incident to a physician’s service do not meet the “incident to” 

conditions because the pharmacist does not refill the implanted pump. 

However, we believe that it is important to preserve the potential for paying a pharmacy 

for a drug that is used to refill implanted pumps in certain limited instances where a physician’s 
745 

service is not used. Although patients and caregivers do not typically refill implanted pumps, it 

is our understanding that in rare situations persons other than a physician (as defined by section 

1861(r) of the Act) could refill the pump, for example, when a patient cannot be transported to a 

physician’s office, but a suitably trained individual is available at the home. We believe that this 

situation is very uncommon, but we also believe that in certain situations, for example in remote 

locations, it may facilitate the administration of refills of implanted durable medical equipment 

in situations where a beneficiary cannot be transported to the office, but a qualified individual is 

available to fill the pump and the drug is dispensed directly to the patient at home. In these 

situations, the drug is not being administered by the physician, and therefore the drug cannot be 

billed incident to a physician’s service. As there is no service incident to a physician’s service 

and the drug is being dispensed directly to the beneficiary in the home for use in an implanted 

item of DME, the pharmacy may bill and be paid for the drug. 

Comment: Several commenters note that the proposed rule describes the error as being 

associated with only one contractor, but that several others since have allowed for and paid direct 

pharmacy claims for drugs used by physicians to refill implanted pumps. A comment from a 

group of pharmacies that compounds drugs for use in implanted pumps states that four 

contractors across 13 States have paid pharmacies directly in these instances. Commenters 

located in other states supported adoption of the erroneous approach in their states. One 

commenter stated that the majority of pharmacies in the country are in compliance with the buy 

and bill approach. 

Response: Although the proposed rule (77 FR 44793) stated that erroneous guidance 

came from “one contractor,” in the same paragraph we acknowledged that payments were made 

in some jurisdictions and denied in others. Thus, the proposed rule indicated that we understood 

that several contractors had paid pharmacies under the erroneous approach. Although we 
746 

understand that the use of the erroneous approach has expanded, this does not persuade us to 

make a national policy decision that incorporates a payment policy that is based on contractor 

error simply because it has become utilized in some areas. Moreover, the commenters 

recommending adoption of the erroneous approach notably did not assert that the physician “buy 

and bill” method has been problematic in their states, and these comments, in our view, support 

our belief that the erroneous approach is not a widespread problem. 

Comment: Several comments mentioned that regulation text at §424.57 permits 

pharmacy suppliers to be paid for drugs used with DME. One comment stated that 

administrative law judge (ALJ) decisions favorable to pharmacies that furnished drugs under the 

erroneous guidance were based on this regulation text. 

Response: We agree that pharmacy suppliers can be paid for drugs used as supplies for 

DME. This provision applies most frequently to situations like drugs used with nebulizers or 

external pumps where multiple doses of drugs are dispensed and delivered to a patient for use 

over a given time period. However, instances in which direct billing by a pharmacy or DME 

supplier for these drugs, which are self-administered via an item of DME, are distinguishable 

from the situation here, where a licensed healthcare provider’s professional service is required to 

ensure that the drug may be used with the item of DME. Physicians who refill these pumps in 

the office are generally not acting as DME suppliers. 

With respect to the assertion about ALJ decisions, we are persuaded only that they are evidence 

that our payment policy has been applied inconsistently, and do not consider them to be 

indicators of what the correct payment policy is or should be. 

 Comment: Several commenters believe that our proposed clarification is in conflict with 

state and federal laws regarding the dispensing and/or distribution of controlled substances and 

Food and Drug Administration (FDA) guidance. Specifically, commenters asserted that our 
747 

proposed clarification is inconsistent with Drug Enforcement Administration (DEA) rules that 

apply to dispensing of controlled substances and that operating under a distribution model would 

require them to register with the DEA as manufacturers, which would raise concerns under 

applicable state law. Further, two commenters suggested that our Part B drug billing policy 

instructs pharmacies to sell compounded products to physicians for resale to the patient in 

contravention of FDA guidance regarding pharmacy compounding compliance. Commenters 

noted that FDA’s policy guidance delineates “acts of drug manufacturing” that would apply to 

pharmacies complying with our proposed clarification because it would require them to sell 

compounded products to third parties who resell to individual patients, and it would cause them 

to fail to operate in conformance with applicable state law regulating the practice of pharmacy. 

Commenters, including one state board of pharmacy, also contended that with respect to 

compounded controlled substances used to refill implanted pumps, the procedures that would be 

required under our proposed clarification would not be allowable under state law. 

Response: We understand that the laws and regulations pertaining to how compounded 

doses of drugs used to refill implanted DME are obtained by the office are complex and may 

include requirements from a variety of sources, including the DEA, the FDA, and the states. 

This rule does not seek to interpret applicable laws, regulations, or guidance from these and other 

relevant sources, nor does it seek to distinguish among the varying uses of terms by these 

agencies, including terms such as compound, manufacture, distribute, or resell, which may have 

context-dependent, specific definitions that are important, but also can confuse issues related to 

Medicare part B payment policy. This rule pertains solely to Part B payment policy, and we take 

no position on any issue other than which party must bill for a drug used by a physician to refill 

an implanted item of DME. Thus, this rule does not address whether a pharmacy, for example, 

should be dispensing or distributing a drug used to refill implanted DME. Indeed, we do not 
748 

have authority to interpret or apply FDA, DEA or state laws or regulations. 

That being said, we wish to respond to these comments as fully as we can, in the interest 

of transparency. We do not agree with the suggestions that the buy and bill approach for 

obtaining drugs used by physician for refilling implanted pumps in the office is strictly 

prohibited, because if it were, our payment policy for drugs used to refill implanted DME, with 

which the majority of physician offices and pharmacies already comply, would have raised 

concerns from stakeholders across the country long before we issued the two CRs last year. 

 Further, we disagree that our policy is in conflict with laws pertaining to controlled 

substances. First, we note that our policy is not specific to controlled substances, and the 

comments do not persuade us to adopt a different policy for controlled substances used by a 

physician to refill an implanted item of DME from the Part B payment policy for all other 

controlled substances administered incident to a physician’s professional service. It has long 

been our policy that drugs furnished incident to a physician’s professional service must be 

purchased and billed by the physician, and in general physicians buy and bill for controlled 

substances furnished under the incident to benefit without being in violation of DEA 

requirements. We have consulted with DEA about the issue of controlled substances used in 

implanted DME, and they have confirmed our understanding of DEA rules as discussed below. 

It is our understanding from discussions with the DEA that it is a criminal violation of the 

law when a DEA-registered pharmacy dispenses a controlled substance and knowingly or 

intentionally delivers that substance to any person other than the patient or a member of the 

patient’s household. We understand that the DEA provides for registration of entities, including 

pharmacies, as DEA registered manufacturer/distributors that may distribute controlled 

substances to providers under conditions outlined by the DEA. We understand that the DEA’s 

“5 percent rule” may apply to pharmacies that are not manufacturers and that wish to provide 
749 

these drugs to the office; however, we also understand that the 5 percent rule may not apply to 

situations where a drug must be compounded from bulk chemicals. In any event, we have 

confirmed with the DEA that pharmacies can register with the DEA as a distributor/manufacturer 

and under such a registration, can sell these drugs to a physician’s office. The office would order 

the drugs using DEA Form 222 (http://www.deadiversion.usdoj.gov/faq/dea222.htm) which 

facilitates purchasing and tracking of controlled substances between registrants and 

accountability at the pharmacy and the office. We also note that the DEA provides its own 

specific definition of a manufacturer. Additional information is at 

http://www.deadiversion.usdoj.gov/drugreg/reg_apps/225/225_instruct.htm. 

Thus, we believe pharmacies can be in compliance with the DEA regulations in providing 

controlled substances to physicians who can then bill Medicare under the “incident to” benefit 

category. Indeed, we are concerned that current practices described by some commenters are 

inconsistent with DEA regulations. Some commenters described dispensing activities that 

appear to deliver the drugs to the office on behalf of the patient (that is, “dispensing for a 

patient”) in a manner that may not be consistent with DEA regulations, which require that 

controlled substances be dispensed directly to the patient, and not to an agent, person, or other 

entity that is acting on the patient’s behalf. We also have concerns about the ad hoc record 

keeping methods (like delivery logs) for controlled substance prescription delivery that were 

described in some comments. Such an approach does not appear to comply with practices that 

are required by the DEA for transfers or sales of drug between registrants. This process involves 

the use of DEA Form 222 and related record keeping that is described in DEA regulation. 

 We also note that not all of the drugs used in implanted pumps are drugs are controlled 

substances. Some of the analgesics (for example, ziconitide and clonidine) often used in 

implanted pumps are not opiates, and are not always used in conjunction with opiates. Agents 
750 

used to treat spasiticy (baclofen) are also not opiates. These medications are not controlled 

substances, and the DEA provisions discussed above do not apply. 

 With respect to comments about conflicts with FDA guidance, we cannot make 

statements about when the FDA may require that compounding pharmacies be considered 

manufacturers; as noted above, this is outside of CMS’s scope of authority and expertise. 

Nevertheless, we disagree that our proposed clarification would, in itself, require that 

compounding pharmacies be considered manufacturers. The FDA Compliance Policy Guidance 

on pharmacy compounding 

(http://www.fda.gov/ICECI/ComplianceManuals/CompliancePolicyGuidanceManual/ucm07439

8.htm) states that the guidance “does not create or confer any rights for or on any person and 

does not operate to bind FDA or the public.” The policy states that in determining whether to 

take enforcement action the FDA “will consider whether the pharmacy engages in ... [certain] 

acts.” Points 7 and 9 in the list of acts referred to by one commenter include the act of reselling a 

drug and State law. The use of an individualized dose of a drug that has been prepared by a 

pharmacy for use upon a physician’s order for a specific patient and is administered by a 

physician in an office incident to a procedure in the office is not reselling a drug. 

 Finally, many of the comments pertaining to State law involved dispensing activities. 

However, our proposal did not address, and we do not take a position now, with respect to 

whether a pharmacy should dispense or distribute a drug used by a physician to refill an 

implanted item of DME in the physician office. We understand that State laws pertaining to 

dispensing of prescriptions may be problematic because they are not uniform across States and 

the interpretation of all requirements may vary. However, the comments did not foreclose the 

possibility that an appropriately registered and licensed pharmacy could sell the drug to the 

physician’s office, for example when the pharmacy does not act as a dispenser of a prescription, 
751 

but acts as a distributor of a drug. In response to the state board of pharmacy’s comment, we 

note that the comment appears to indicate that prescriptions in the state must be dispensed in 

accordance with DEA requirements. As stated above, we believe it is possible to comply with 

DEA requirements under the buy-and-bill method. 

Our approach also minimizes program integrity concerns and avoids a situation where 

billing for a procedure and an item necessary for the procedure is done by two different entities 

that may submit claims with two dates of service. Such corresponding services are difficult to 

match during claims processing and the presumption that a drug that has been dispensed in 

advance of the pump refill will always be administered to the beneficiary may not always be 

correct. In other words, our approach minimizes the opportunity for fraud and abuse caused by 

splitting up payment for related components of a service between providers that bill separately. 

Further, as noted above and as borne out by our experience administering and overseeing 

the Medicare program, the buy and bill approach does not appear to be problematic in a majority 

of the country. Therefore, in considering these comments, we continue to believe that it is 

appropriate for Medicare payment policy to be uniform, in spite of the fact that suppliers in 

certain states may need to adjust their regulatory standing with the state in order to comply with 

our payment rules. As stated above, inconsistent application of the policy has influenced the 

business and professional practices of pharmacies/DME suppliers that prepare drugs for 

implanted pumps. Specifically, pharmacies that have been allowed to bill directly to Medicare 

have marketed this approach to physicians at the expense of pharmacies that have not been 

allowed to direct bill. Inconsistent application of the policy has given a distinct economic 

advantage to some pharmacies relative to others that we do not believe is equitable. A uniform 

policy is more fair and predictable for beneficiaries and health care providers, and is easier to 

administer and oversee and, as stated above, is consistent with longstanding Medicare law and 
752 

regulations and minimizes the potential for fraud and abuse. 

Nevertheless, if a physician does not have a cost for these drugs, the physician does not 

meet the requirements to bill for these drugs under Medicare Part B as an “incident to” drug. As 

explained above, these drugs are also not billable under Part B as DME supplies because the 

drugs are not being furnished directly to the beneficiary. However, these drugs may be payable 

to the pharmacy under Part D if the ingredients that are being compounded independently meet 

the definition of a Part D drugs—generally a commercial FDA approved drug product. 

We have considered the implications of the proposed clarification on patient care and 

Medicare providers (including physicians and pharmacies). Review of the comments also 

indicated that the issue is not national, but does affect the south central region of the contiguous 

United States more than other regions and therefore we believe that providers in most states 

follow the proposed approach and most states’ laws do not create insurmountable barriers for 

physician offices that administer refills of implanted DME equipment to obtain drugs. We do 

not believe that major revisions to policy should be based on erroneous guidance that originated 

from a single contractor, nor do we believe that we should permit an inconsistent practice to 

continue indefinitely, because the delay is affecting both those who are in compliance with 

national payment policy, as well as those who are not. 

 Comment: We received several comments on the potential impact of our proposal. Most 

commenters expressed concern about the financial impact of our proposal on physician practices, 

especially small practices. Three major concerns stated were the financial impact of having to 

buy potentially expensive drugs, the labor involved in submitting claims, and the time that 

elapses between the administration of the drug and when the drug claim is paid. Physicians and 

office staff that currently are obtaining the drugs through pharmacies that also bill for the drug 

were concerned that obtaining these drugs using a buy and bill approach is not financially 
753 

sustainable and would lead practices to discontinue providing pump refills. Several commenters 

stated that practices relied on the pharmacy-dispensed and pharmacy-billed approach. Two 

groups of pharmacies asserted that this clarification will affect their ability to be paid under 

Medicare Part B for providing intrathecal pain medications, especially medications that contain 

Schedule II controlled substances. 

 Comments about the potential impact to beneficiaries included suggestions that some 

practices would charge beneficiaries up front, that some physicians might convert medication 

regimens to the oral route -- which may not be as well tolerated or as efficacious, or that access 

could be impaired. 

 Response: We acknowledge that our policy clarification will affect physicians, suppliers 

and beneficiaries in cases where the pharmacies have been billing for drugs used by the 

physician to refill implanted DME. Based on the comments on our proposal, we do not believe 

that these pharmacies represent all or the majority of pharmacies or the providers who obtain 

pharmacy prepared drugs in their offices. As we have discussed elsewhere, we believe that the 

drug distribution pathway is available for physician offices to purchase these drugs from 

appropriately licensed and registered pharmacies in cases where the drugs cannot be dispensed. 

We do not believe we should incorporate a change or permit continued inconsistent 

application of our policies based on erroneous guidance. As we have stated above and in the 

proposed rule, the erroneous guidance significantly conflicts with longstanding national policies 

for drugs provided incident to physicians’ services and items furnished under the DME benefit. 

 Based on the comments, we understand that many pharmacies that prepare drugs used to 

refill implanted pumps and the providers with whom they have a relationship are unaffected by 

the policy clarification in the CRs and this rule. Based on publicly available information, we 
754 

understand that some pharmacies that prepare doses of intrathecally administered medications 

for Medicare beneficiaries (including some of the commenters who opposed our clarification) are 

already registered with the DEA as drug distributors. We understand that these entities can 

receive orders for controlled substances via the DEA 222 form and can sell (that is, distribute) 

the individually prepared doses to the physician provider, who in turn administers the drug and 

bills Medicare part B. 

As discussed above, our approach also minimizes program risk that arises from billing for 

a procedure and an item necessary for the procedure by two different entities that may submit 

claims with two dates of service. We believe fraud and abuse risk is minimized by requiring the 

same entity to bill for the drug and its administration. 

We are concerned by comments that suggested that some practices may charge Medicare 

patients up front. We would like to remind physicians that Medicare providers who accept 

assignment may not charge up front, and note that section 1842(o)(3)(A) of the Act requires 

these drugs to be paid on an assignment-related basis. Also, the routine use of advance 

beneficiary notices (ABNs) is not allowed ( See the Medicare Claims Processing Manual, 

chapter 30, Section 40.3.6 at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c30.pdf). 

Comment: Several comments stated that CMS’ proposed approach will cause physicians 

to discontinue the use of intrathecal pain managements and to switch to oral analgesics, thereby 

increasing the risk of diversion. 

Response: We do not believe this policy clarification will increase the risk of drug 

diversion. We acknowledge that diversion can occur, perhaps particularly in instances where an 

individual receives high doses of analgesics, but we do not believe that either the oral or 

injectable approach is entirely risk free. The risk of drug diversion and pump tampering also 
755 

exists with implanted pumps and has been reported in literature. 

 Comment: One commenter stated that CMS policy, as reflected in the Benefit Policy 

Manual, allows a physician to be paid for administering a drug that has not been bought by the 

office. The commenter suggests that CMS policy would permit the physician to bill for 

administration of a drug used to refill an implanted pump even if the physician did not incur the 

cost for it, and for this reason, the drug should be payable under the DME benefit. 

 Response: We disagree with the commenter’s conclusion. The Benefit Policy Manual the 

commenter cites (Chapter 15, section 60.1A) uses the example of drug administration in the case 

where the patient has purchased the drug, stating that the drug administration service would be 

covered, even though drug would not be. We do not believe it follows from this example that 

drugs used by a physician to refill an implanted item of DME should be included in the DME 

benefit category. In fact, we believe the manual provision cited by the commenter actually 

supports our position – namely, that the drug in question is not covered under Part B if the 

physician administering it incident to a professional service has not incurred the cost for it. 

 Comment: Two commenters expressed support for our clarification. One commenter 

described the policy as longstanding and believed that most pharmacies are in compliance with 

this standard. Another commenter stressed the importance of consistent payment policy and 

expressed concern that pharmacies that billed under the incident to provision not be subject to 

audits or recoupment if they were acting on good faith based on contractor guidance. 

Response: We agree with the comments that supported our policy clarification. We 

thank those who commented on additional issues for their thoughts. As we have stated 

previously, we believe Medicare’s policy on this issue has been longstanding. However, we 

acknowledge that there are pharmacies that were relying on incorrect contractor guidance to bill 

Medicare directly for these drugs. For these reasons, we do not plan to take enforcement action 
756 

for incorrect billing of drugs used to refill an implanted item of DME furnished in a physician’s 

office by pharmacies prior to January 1, 2013 if that incorrect billing stemmed directly from 

guidance from a Medicare contractor. 

Comment: Some commenters expressed concerns that the clarification is a change in 

policy. Another commenter believes that the fact that we delayed the CR amounts to a tacit 

approval of pharmacy billing for drugs used by physicians to refill implanted pumps. 

 Response: We disagree that this is a change in our policy. As we stated in the proposed 

rule, we consider the contractor guidance on pharmacy billing of drugs used to refill implanted 

items of DME to be erroneous. We believe it was erroneous for other contractors to adopt 

similar processes. Nevertheless, in light of stakeholder concerns, we delayed the implementation 

of two CRs and undertook this rulemaking process to ensure that even if our clarification were 

considered a change in policy, potentially affected parties would have notice and a meaningful 

opportunity to comment. Thus, our decision to delay the CRs’ implementation was not because 

we approved of, or even condoned, pharmacy billing for these drugs. Rather, we delayed the 

CRs’ implementation to permit further consideration of this issue and ultimately, this rulemaking 

process. As we undertake rulemaking with respect to payment for Part B drugs generally on an 

annual basis, we proposed this clarification at the earliest available opportunity. 

 Moreover, in addition to the other indications discussed elsewhere, our claims processing 

structure indicates that these drugs generally are billed by physicians incident to their 

professional service. CMS Change Request 2227 dated July 22, 2002 required that “bills for 

implanted DME ... accessories and supplies for the implanted DME must be billed to local 

carriers.” This instruction removed claims processing for drugs used to refill implanted DME 

from the DME MAC environment (where pharmacy-based part B claims are typically submitted) 

and assigned the responsibility to the local carrier, now referred to as a Medicare Administrative 
757 

Contractor (MAC) (where physicians’ claims are typically submitted). This instruction, now 10 

years old, indicates that we have long intended that payment for drugs used to refill implanted 

pumps in the physician’s office be received primarily by the physician’s office rather than nonphysician providers/DME suppliers. 

 Finally, we wish to clarify one other point. In the proposed rule, we stated that in the 

case of drugs used to refill an implantable item of DME, “the physician must buy and bill for the 

drug, and a nonphysician supplier that has shipped the drug to the physician’s office may not do 

so (except as may be permitted pursuant to a valid reassignment).” Our reference to a “valid 

reassignment” was intended to refer only to the fact that in certain limited cases, as specified in 

section 1842(b)(6) of the Act and its implementing regulations, a physician may reassign a claim 

for Medicare payment. To the extent that our reference to a “valid reassignment” in the 

proposed rule implied that a physician could permissibly reassign a claim for a drug used to refill 

an implanted item of DME to a pharmacy supplier, it was in error. 

Conclusion: After considering the comments and the potential impact on beneficiaries, 

health care providers and Medicare payment policy for DME and drugs used incident to a 

physician’s service, we are finalizing the provision as proposed. We are finalizing the 

clarification that we consider drugs used by a physician to refill any implanted item of DME to 

be within the “incident to” benefit category and not the DME benefit category, and we are 

adding regulation text at §410.26 to codify our policy. Therefore, to bill under the “incident to” 

benefit, the physician must buy and bill for the drug, and a non-physician supplier that has 

shipped the drug to the physician’s office may not do so. In certain circumstances, for example 

if the physician does not incur an expense for the drug, Medicare Part D may be able provide 

payment to the pharmacy for these drugs. We believe that our position is straightforward, is 

consistent with how national part B drug payment policy is applied in the physician office 
758 

setting, and is already adhered to across most of the country. Consistent with this final rule, CR 

7397 will go into effect on January 1, 2013. 

 We maintain that CR 7397 (and its predecessor CR 7109) does not change longstanding 

Part B drug payment policy for drugs paid under section 1847A of the Act, in particular, that a 

drug provided incident to a physician’s service must represent an expense to the physician. 

Neither laws nor regulations that authorize such payment have been changed since the erroneous 

guidance was brought to CMS’ attention. Corresponding instructions in the Benefit Policy 

Manual (Publication 100-02, Chapter 15, sections 50.3 and 60.1) also have not changed. The 

instructions in the CRs that clarified that payment for drugs furnished incident to the filling or 

refilling of an implanted pump or reservoir are determined under section 1847A of the Act and 

pharmacies (including DME suppliers that utilize pharmacists to dispense medications) may not 

bill Medicare Part B for drugs provided to a physician for administration to a Medicare 

beneficiary also have not changed. We believe that these facts confirm that our policy 

clarification is consistent with longstanding statute, regulation, and manual instructions that 

pertain to Medicare national policy and that our policy remains the appropriate one. 

3. Out of Scope Comments. 

In addition to comments requesting us to delay AMP-based price substitution that were 

discussed at the end of Section 1.c., we received comments pertaining to the creation of unique 

HCPCS codes for new branded drugs and biologicals, the payment amount for part B drugs, 

supply and dispensing fees, concerns about the timeliness of claims processing and claims 

denials, payment incentives that would decrease the impact of drug shortages, the duration of the 

quarterly AMP-based price substitution, notice of price substitution for manufacturers, and 

safeguards for WAMP-based price substitution. 

In the proposed rule, we stated that we are not proposing any other changes to the 
759 

safeguards, timing or notification procedures for the AMP-based price substitution. Comments 

on these and other issues listed in the paragraph above are outside the scope of this rule, and 

therefore, are not addressed in this final rule with comment period. 

C. Durable Medical Equipment (DME) Face-to-Face Encounters and Written Orders Prior to 

Delivery

1. Background 

Sections 1832, 1834, and 1861 of the Act establish that the provision of durable medical 

equipment, prosthetic, orthotics, and supplies (DMEPOS) is a covered benefit under Part B of 

the Medicare program. 

Section 1834(a)(11)(B)(i) of the Act, as redesignated by the Affordable Care Act, 

authorizes us to require, for Specified Covered Items, that payment may only be made under 

section 1834(a) of the Act if a physician has communicated to the supplier a written order for the 

item, before delivery of the item. Section 1834(h)(3) of the Act states that section 1834(a)(11) 

applies to prosthetic devices, orthotics, and prosthetics in the same manner as it applies to items 

of durable medical equipment (DME). In a December 7, 1992 final rule (57 FR 57675), we 

implemented this provision in §410.38(g), for DME items and §410.36(b) for prosthetic devices, 

orthotics, and prosthetics. Together these sections state that as a requirement for payment, CMS, 

a carrier, or, more recently, a Medicare Administrative Contractor (MAC) may determine that an 

item of durable medical equipment, and prosthetic and orthotic supplies (DMEPOS) requires a 

written physician order before delivery. In addition to the regulations listed at §410.38(g) and 

§410.36(b), we have stated in Chapter 5, Section 5.2.3.1 of the Program Integrity Manual, that 

the following items require a written order prior to delivery: (1) pressure reducing pads, mattress 

overlays, mattresses, and beds; (2) seatlift mechanisms; (3) transcutaneous electrical nerve 

stimulation (TENS) units; (4) power operated vehicles (POVs) and power wheelchairs. 
760 

Section 6407(b) of the Affordable Care Act amended section 1834(a)(11)(B) of the Act. 

The Affordable Care Act added language to the Act that requires for certain items of DME, a 

physician documenting that a physician, a physician assistant (PA), a nurse practitioner (NP), or 

a clinical nurse specialist (CNS) has had a face-to-face encounter with the beneficiary pursuant 

to the written order. Under section 1834(h)(3) of the Act, the items that require a written order 

verifying a face to face encounter may also include prosthetic devices, orthotics, and prosthetics. 

The encounter must occur during the 6 months prior to the written order for each item or during 

such other reasonable timeframe as specified by the Secretary. 

2. Provisions of the Proposed Regulations and Summary of the Public Comments 

We have made a series of modifications to the rule based on response to comments. As a 

result of comments, we are implementing several changes and clarifications to limit burden and 

still protect the Medicare Trust Funds. We have clarified that this requirement will begin only 

for new orders written after the effective date. We believe it is important to apply this 

requirement prospectively and not retroactively. To allow sufficient time for implementation, 

the effective date of this provision is July 1, 2013. Therefore, covered items ordered on or after 

July 1, 2013 will require a face-to-face encounter. Additionally, we have modified the timeline 

to require that a face-to-face encounter occur within 6 months before the written order. We have 

also added an additional criterion to remove items from the list of covered items. This is 

discussed in further detail below. 

Comment: Several commenters questioned if these requirements adequately address the 

central drivers of fraud in the home health care and DME supply industries. If the goal is to 

eliminate the situation where a physician signs a DME order for a patient they know little about, 

having a physician sign off on a PA note does little to meet the goal. 

Response: We believe that increasing physician involvement will help limit waste, fraud, 
761 

and abuse while encouraging beneficiaries to maintain access to the necessary services. We 

believe physician involvement will not only assist in reducing waste, fraud and abuse but it will 

also help to ensure that beneficiaries receive high quality DME to meet their specific needs. 

Further, because a face-to-face encounter documented by a physician is a statutory requirement, 

CMS is required to implement this provision. 

Comment: One commenter noted that the proposed rule does not address the role of the 

Certificate of Medical Necessity (CMN) under the DME face-to-face policy. 

Response: The commenter is correct that the face-to-face requirement addressed in this 

regulation does not change existing policy related to CMNs. The face-to-face requirement does 

not change the CMN process for those items that require a face-to-face. The face-to-face 

encounter can be completed at the same time as the CMN. 

Comment: A commenter noted that, the rule requiring face-to-face encounters and 

written orders prior to DME delivery uses the terms “physician” and “practitioner” 

inconsistently. Specifically, physician is the only term used to describe those authorized to order 

DME, which seems to imply that physicians are the only practitioners who may order DME. The 

proposal then goes on to state that PAs, NPs and physicians may perform the face-to-face visit 

for DME. 

Response: We would like to clarify that under section 1834(a)(11)(B)(ii) of the Act, 

physicians, physician assistants, clinical nurse specialists and nurse practitioners are authorized 

to conduct the face-to-face encounter. We collectively refer to physicians, NPs, PAs and CNSs 

as “practitioners.” However, according to the statute, the physician must document that the faceto-face encounter occurred when performed by the PA, NP, or CNS. Items of DME can be 

ordered as outlined in the scope of practice for the respective practitioners subject to applicable 

Medicare rules. However, the face-to-face must be performed by the physician, PA, NP or CNS 
762 

and documented by a physician. 

Comment: Several commenters requested that CMS clarify whether the hospitalist 

ordering the DME for the inpatient and who has the face-to-face encounter with the patient prior 

to discharge must meet the face-to-face encounter requirement. 

Response: Medicare beneficiaries discharged from a hospital do not need to receive a 

separate face-to-face encounter, as long as the physician or treating practitioner who performed 

the face-to-face encounter in the hospital issues the DME order within 6 months after the date of 

discharge. 

Comment: Several commenters requested clarification that this requirement is for new

DME orders and not for existing orders. Commenters were concerned that if the proposed faceto-face encounter requirements were to apply retroactively to orders already written (that is, each 

new shipment after the effective date of the final rule would need to comply with the 

requirements), suppliers may be required to obtain new physician orders for all of the Medicare 

beneficiaries whom they serve. 

Response: We clarify that this requirement is for new DME orders only. That is, items 

that have been ordered on or after the effective date of this final rule. 

Comment: Several commenters requested that the effective date of the rule be delayed 

until July 1, 2013, or such later date as found reasonable to provide adequate education to 

patients and suppliers about the new requirements. Commenters recommended that CMS 

provide extensive education on the documentation requirements, and alert beneficiaries to the 

new co-payment possibility associated with the face-to-face encounter while emphasizing the 

improved quality of care aspect of this rule. 

Response: We agree, and are, therefore, delaying the implementation date until July 1, 

2013. We believe that provides sufficient time to prepare for implementation. 
763 

Comment: A few commenters stated that to ensure the integrity of the competitive 

bidding program’s single payment amounts, CMS must either (1) ensure that the final rule adopts 

provisions that are wholly consistent with the current documentation requirements dictated by 

the LCDs; (2) exempt items subject to competitive bidding from the proposed documentation 

requirements during the bid program; or (3) permit suppliers to resubmit bids for these items that 

take these additional costs into account. 

Response: This requirement is a condition of payment that applies uniformly to these 

items regardless of whether they are paid for under the fee schedule or the competitive bidding 

program. There are no exceptions for items that are furnished in a competitive bidding area. 

Moreover, as noted in the impact analysis, we believe that this requirement will not result in 

significant costs for suppliers. 

a. DME Face-to-Face Encounters 

(1) General Requirements 

We had proposed to revise §410.38(g) to require, as a condition of payment for certain 

covered items of DME, that a physician must have documented and communicated to the DME 

supplier that the physician or a PA, an NP, or a CNS has had a face-to-face encounter with the 

beneficiary no more than 90 days before the order is written or within 30 days after the order is 

written. As described in the CY 2013 PFS proposed rule (77 FR 44794), we outlined the 

rationale for the 90 days before or 30 days after the order was written. 

During the face-to-face encounter, the physician, a PA, NP, or CNS must have evaluated 

the beneficiary, conducted a needs assessment for the beneficiary or treated the beneficiary for 

the medical condition that supports the need for each covered item of DME. As a matter of 

practice, this information would be part of the beneficiary’s medical record and include the 

identity of the practitioner who provided the face-to-face assessment. We believe that requiring 
764 

a face-to-face encounter to document the medical condition that supports the need for the 

covered item of DME reduces the risk of fraud, waste, and abuse since these visits help ensure 

that a beneficiary’s condition warrants the covered item of DME. 

Section 1834(a)(11)(B)(ii) of the Act, as amended by section 6407(b) of the Affordable 

Care Act, states that a physician must document that the physician, a PA, NP, or CNS has had a 

face-to-face encounter (other than with respect to encounters in which “incident to” services are 

involved) with the beneficiary. “Incident to” services are defined in section 1861(s)(2)(A) of the 

Act. Likewise, for the purpose of this regulation, a face-to-face encounter must be documented 

by a physician and any encounter that is covered as an “incident to” service does not satisfy the 

requirements of this regulation. 

The following is a summary of the comments we received regarding the documentation 

of a face-to-face encounter and the timeframe in which it must occur. 

Comment: Many commenters suggested that CMS revise the rule to require that face-toface encounters occur only before the date of the written order, and not after the written order is 

issued. 

Response: After consideration of these comments we have removed the option for the 

face-to-face encounter to occur 30 days after the written order. We believe it is critical that the 

face-to-face be conducted before the item is delivered to the beneficiary’s home. Allowing faceto-face encounters to occur 30 days after the order could result in medically unnecessary items 

being delivered to beneficiaries. Further, suppliers could deliver the item but then be unable to 

bill Medicare if the face-to-face encounter does not occur. 

Comment: Many commenters believed the timeframe should be revised to allow the 

face-to-face encounter to occur in the 6-month period preceding the order, as authorized by the 

statute. 
765 

Response: In response to comments, CMS is modifying the encounter timeframe so that 

the face-to-face encounter must now occur 6 months prior to the written order, as opposed to the 

3 months we previously had proposed. We believe this modified timeframe best balances the 

need to protect the Medicare Trust Funds by limiting waste, fraud and abuse while limiting 

burden. 

Comment: Many commenters stated that the 30 days after the written order specifically 

puts the suppliers at financial risk. Many commenters expressed concern that it is not reasonable 

to expect suppliers to furnish the item without documentation that the in-person encounter took 

place. Once a beneficiary has received the Specified Covered Item of DME, he or she has little 

incentive to see a doctor. The supplier, meanwhile, will not be paid for the item unless it has 

obtained a signed Advance Beneficiary Notice of Noncoverage (ABN) from the beneficiary. 

Therefore, many commenters suggested that the face-to-face encounter should not be allowed to 

occur after the written order and delivery of the Specified Covered Item. They believed neither 

the beneficiary, nor the physician will have much impetus to follow through with the encounter 

once the equipment is delivered, and the supplier will then be unable to bill Medicare. A few 

commenters suggested that if the timeframe is not revised, CMS should compensate suppliers for 

the first 30 days if the physician does not present documentation. 

Response: We concur that it is critical that the face-to-face encounter be conducted 

before the item is furnished to the beneficiary’s home. We are revising the timeframe for the 

face-to-face encounter to occur and removing the 30 days after the written order. The face-toface encounter must occur in the 6 months before the order is written. We will not offer any 

compensation or liability waivers because the supplier should be able to obtain the 

documentation before supplying the item. 

Comment: A few commenters suggested that if the timeframe is not revised, CMS must 
766 

make clear that suppliers would be entitled to payment under the waiver of liability provisions in 

section 1879(a)(1) of the Act in the event that the beneficiary does not follow through with the 

face-to-face visit, as the DME supplier would have no way to know that the visit would not take 

place. According to the commenters, section 1879(a)(1) clearly states that if a contractor denies 

payment because of a determination that the services was medically unnecessary, which would 

include a denial for a lack of a face-to-face encounter, the supplier should nonetheless be paid if 

the supplier did not know and had no reason to know that the payment would be denied. 

Response: As noted previously, we are revising the encounter timeframe to be in the 6 

months before the DME order is written. We believe it is critical that the face-to-face encounter 

be conducted before the item is delivered to the beneficiary’s home. Since we have removed the 

30 days after the order requirement, the waiver of liability provisions do not need to be 

addressed. 

Comment: Several practitioner organizations supported the proposed 90 days before or 

30 days after the order is written timeframe for the face-to-face encounter. These commenters 

believed it was a reasonable timeframe for the face-to-face to occur. 

Response: The vast majority of commenters expressed concerns about the proposed 

timeframe. The supplier industry specifically expressed serious concerns regarding the provision 

in the proposed rule that allowed the face-to-face order to occur 30 days after the written order. 

Therefore, with this final rule with comment period, we are eliminating the option for the faceto-face encounter to occur 30 days after the written order and revising the timeframe for a faceto-face encounter to occur 6 months preceding the written order. 

We will monitor the implementation of this rule to ensure there are no unintended 

consequences that negatively impact the practitioner, supplier, and beneficiary communities. In 

addition, we do not believe the new timeframe will have a significant impact on beneficiaries’ 
767 

access to medically necessary, quality DME, since we believe that many beneficiaries already 

see their practitioner during a 6-month period of time. We believe the new timeframe will make 

it easier for beneficiaries to access DME then the previously proposed timeframe. 

Comment: A few commenters cautioned that this proposal will cause a certain amount of 

confusion since certain DME items, such as power mobility devices (PMDs) as outlined in 

§410.38(c), have a 45 day face-to-face encounter requirement as opposed to the proposed 90 day 

requirement for other DME items. Commenters believe greater consistency among face-to-face 

requirements for DME will reduce confusion and improve compliance by healthcare 

professionals. Several commenters expressed a desire to have this regulation supersede the PMD 

face-to-face regulation. 

Response: This regulation implements section 1834(a)(11)(B) of the Act. It does not 

supersede the PMD regulation as specified in §410.38(c), which we issued under different 

authority. We believe that a longer timeframe is necessary for these DME items than the 45-day 

timeframe for PMDs because of the wide variety of DME items covered by this rule. This 

regulation does not apply to PMDs and does not supersede other regulations specific to PMDs. 

We look forward to engaging in extensive education to help to clarify the requirements. 

Comment: Several commenters suggested that CMS should consider a risk-based 

approach where specified conditions would be excluded from the face-to-face encounter 

requirement within the proposed timeframe. Prior to finalizing the proposed rule, most 

commenters suggested that CMS should work more closely with physicians and supplier 

stakeholders to determine the best approach in establishing a timeframe for the face-to-face 

encounter. 

Response: In response to comments, we have removed the requirement allowing the 

face-to-face encounter to occur 30 days after the written order and instead are requiring the face-
768 

to-face to be conducted in the 6 months preceding the written order. However, we are not using 

a risk based approach to determine the methodology and timeframe for the DME face-to-face 

requirement. We believe that a risk based approach would be difficult to implement and would 

create undue confusion. We further believe that it is unnecessary particularly in light of the 

longer timeframe. 

Comment: Several commenters expressed concerns that the longstanding Medicare 

policy allows beneficiaries to receive items they urgently need by allowing verbal 

communication between practitioners and suppliers; then a written order is required before 

billing. Commenters caution that the coverage policy should not prevent Medicare beneficiaries 

from receiving statutorily-covered, medically necessary items. 

Response: We do not believe this provision will prevent Medicare beneficiaries from 

receiving medically necessary DME. Regarding the longstanding policy, outlined in the 

Program Integrity Manual, Chapter 5, for items that do not require a written order before 

delivery, suppliers are allowed to dispense DME to the beneficiary based upon a verbal order, 

however a supplier must have a written order before submitting a claim for payment. For items 

that do require a written order before delivery, a supplier must have a written order (with the 

face-to-face documentation) prior to delivery when submitting a claim for payment. This 

provision will ensure that beneficiaries are only receiving medically necessary DME. We 

encourage open communication between the practitioners and suppliers to ensure that 

beneficiaries receive medically necessary items in a timely fashion. In addition, we will monitor 

the implementation of this rule to ensure there are no unintended consequences that negatively 

impact the beneficiary, practitioner and supplier communities. 

Comment: Several commenters believe that the agency is implementing a flawed statute, 

and urge the Secretary to carefully consider the impact on patients, particularly in rural and urban 
769 

underserved areas. These commenters were especially concerned that NPs and Clinical Nurse 

Midwives (CNMs) are not able to fulfill the face-to-face requirement for DME. Commenters 

cautioned that ordering DME is clearly an activity that is within the scope of practice of nurse 

practitioners. They believed that a statutory barrier preventing nurse practitioners from 

independently documenting face-to-face encounters limits the agency and, most importantly, the 

patient’s ability to receive timely and important care. 

Response: We recognize the concerns commenters have expressed regarding the impact 

that this statute might have on beneficiaries, particularly in rural and urban underserved areas if 

NPs are not allowed to fulfill the face-to-face requirement. NPs, PAs, and CNSs can still 

conduct the face-to-face encounter and order DME within their scope of practice. However, in 

this final rule, we are implementing the statutory requirement in section 1834(a)(11)(B)(ii) of the 

Act, that a physician must document that the face-to-face encounter occurred when performed by 

a PA, NP, or CNS. CNMs are not listed in the statute as a practitioner that may conduct the 

face-to-face encounter. Moreover, we believe that CNMs are distinct from CNSs. 

Comment: A few commenters expressed concerns that NPs have no control over how 

quickly physicians will actually document the face-to-face encounters that they conduct. The 

commenters were concerned that there may be instances in which it will be difficult to ensure 

documentation is submitted by the physician to the supplier within 30 days after an order is 

written, potentially delaying patient access to the equipment they need while documentation is 

being completed. 

Response: We have removed the ability for the face-to-face encounter to occur up to 30 

days after the order. We are implementing a statutory requirement that the physician must 

document the face-to-face encounter even when performed by a PA, NP or CNS within the 6 

months preceding the written order. We urge physicians, PAs, NPs and CNSs to work together 
770 

to ensure that all beneficiaries receive needed DME. Additionally, we believe that 6 months 

prior to the written order provides sufficient time for coordination between the NP, PA, or CNS 

and the physician to document the face-to-face encounter. In addition, we will monitor the 

implementation of this rule to ensure there are no unintended consequences that negatively 

impact the practitioner, supplier, and beneficiary communities. 

Comment: Several commenters stated that CMS should assume that practitioners’ 

medical judgment determined that the face-to-face encounter is valid. 

Response: We appreciate the commenters’ recommendation that physicians/treating 

practitioners should be given the presumption that their medical judgment determined that the 

face-to-face encounter is valid or medically necessary. However, we must ensure that all CMS 

requirements are met, and cannot accept this recommendation. Therefore, just because a face-toface encounter is performed does not mean that all CMS requirements are met, including medical 

necessity. 

Comment: Several commenters expressed concern that there is no evidence that 

requirements for physician oversight or supervision increases quality or reduces fraud. The 

commenter further stated that during the past 15 years, there is little evidence that NPs and CNSs 

engaged in fraudulent or abusive ordering of DME and there is little efficiency or true 

accountability in relying on documentation by a physician who has not evaluated the patient 

rather than the NP or CNS who has performed that examination. 

Response: This rule does not address the ordering practices of NPs and CNSs. Rather, 

the statute requires that physicians document the face-to-face encounters of NPs, CNSs and PAs 

with beneficiaries for certain covered items of DME. Section 1834(a)(11)(B)(ii) of the Act 

requires that a physician must document that the face-to-face encounter occurred when 

performed by a PA, NP, or CNS. The degree to which NPs and CNSs are engaged in fraudulent 
771 

or abusive ordering of DME is not specifically addressed by this Affordable Care Act provision; 

however, as we stated earlier and also in the proposed rule, we believe that requiring a face-toface encounter that supports the need for the covered item of DME will reduce the risk of fraud, 

waste, and abuse since these visits help ensure that a beneficiary’s condition warrants the 

covered item of DME. 

Comment: Several commenters stated that for some beneficiaries needing items such as 

transcutaneous electrical nerve stimulation (TENS), it is common for physical therapists, 

occupational therapists, chiropractors, and other participating Medicare health care professionals 

to conduct the face-to-face encounter while physicians continue to be responsible for producing 

the written order and documenting that the face-to-face encounter has occurred. A few 

commenters stated that it should be sufficient for a speech pathologist to conduct the face-to-face 

encounter for items such as a speech generating device. A few commenters stated that sleep 

physicians should also be allowed to provide DME. 

Response: We appreciate these commenters’ suggestions regarding including additional 

types of practitioners that could potentially provide DME face-to-face encounters. It is important 

to keep in mind that chiropractors are not allowed to bill Medicare for DME items. Other 

practitioners must be working within their scope of practice. The statute specifies that while the 

physician must document his or her own face-to-face encounter, only a physician, NP, PA, or 

CNS may conduct the face to face encounter, however it must be documented by a physician. 

Moreover, a sleep physician who meets the Medicare definition of physician can be considered a 

physician for purposes of this face-to-face encounter. 

Comment: Several commenters stated that if this rule is to prevent fraud on the 

physician/non-physician side, then having a strong rationale for the DME equipment in their 

encounter note should provide sufficient documentation to determine the medical need for the 
772 

DME. The commenters believe this documentation establishes the trail of the request and 

justification for each piece of DME. No additional paperwork should be transmitted and no 

interpretation of the encounter note (by non-clinician DME suppliers) would need to be done. 

The process could create a clear auditing trail for investigators. 

Response: We appreciate these comments; however, we must implement the regulation 

based on the provisions of section 1834(a)(11)(B)(ii) of the Act, which requires a physician to 

document the occurrence of a face-to-face encounter for covered items of DME. Throughout the 

development of the proposed rule and based on comments, we attempted to balance the 

implementation of the statute while limiting burden on providers, suppliers and beneficiaries, and 

while ensuring that beneficiaries continued to have access to medically necessary DME. 

In response to comments, we removed language that allowed the face-to-face encounter 

to occur 30 days after the written order and modified the timeframe to now be within the 6 

months preceding the written order. We believe that this will allow suppliers to deliver 

medically necessary DME while trying to eliminate the possibility that the face-to-face encounter 

will never be conducted. 

In the proposed rule, we noted that a face-to-face encounter may be accomplished via a 

telehealth encounter if all Medicare telehealth requirements as defined under section 1834(m) of 

the Act and the implementing regulations in §410.78 and §414.65 are met as described in more 

detail in the CY 2013 PFS proposed rule (77 FR 44794). Further, a single face-to-face 

encounter, including those facilitated through the appropriate use of telehealth, can support the 

need for multiple covered items of DME as long as it is clearly documented in the pertinent 

medical record that the beneficiary was evaluated or treated for a condition that supports the 

need for each covered item, during the specified timeframe. 
773 

As described in more detail in the CY 2013 PFS proposed rule (77 FR 44795), we 

proposed requirements for a written order as a condition of payment. For purposes of this final 

rule with comment period, which is focused on implementing section 1834(a)(11)(B) of the Act 

and reducing fraud, waste, and abuse, an order without minimum elements would be considered 

incomplete and would not support a claim for payment. 

The following is a summary of the comments we received regarding the written order 

proposal. 

Comment: Many commenters expressed a belief that instructions and requirements 

related to the order need to be clear and less burdensome. Commenters expressed the need for 

clarity and/or requested removal of the need for physicians to describe “necessary and proper 

usage instructions”, diagnosis codes, and the National Provider Identifier (NPI) in the written 

order. 

Response: We appreciate the commenters’ recommendation. We agree that instructions 

that limit burden are important. We have removed the proposed requirement for orders to 

include: “necessary and proper usage instructions” and the diagnosis. Due to the large number 

of covered DME items and the fact that there could be many diagnoses and usage instructions for 

each, we agree that these proposed requirements may be overly burdensome. While this 

information will not be required on the DME order under this regulation, we will still expect to 

see related diagnoses included in the beneficiary’s medical record. We would also expect 

“necessary and proper usage instructions” to be provided to the beneficiary or care giver for 

proper usage of the item. The remaining five elements listed: (1) the beneficiary name; (2) the 

item of DME ordered; (3) prescribing practitioner NPI; (4) the signature of the prescribing 

practitioner; and (5) the date of the order are the minimum needed for CMS to consider the order 

valid. This does not supersede other requirements. 
774 

Comment: Several commenters stated that for some DME items, the proposed face-toface encounter requirements represent a significant change for Medicare beneficiaries, providers 

and DME suppliers. Commenters noted that even though some of the proposals are relatively 

minor, such as requiring the prescribing practitioner’s NPI to be included on the written orders, 

they require providers and suppliers to change their standard practices. Such “minor” changes 

are significant since non-compliance may adversely affect the payment for DME. 

Response: We appreciate these comments. Our goal is to limit provider and supplier 

burden while still preventing waste, fraud and abuse. To that end, in response to comments, we 

have removed the requirement that instructions for necessary and proper usage, and the diagnosis 

be included on the order. However, we are retaining the other requirements as a way to limit 

waste, fraud and abuse. 

As a result of the comments, we are requiring at a minimum, the written order contains: 

(1) the beneficiary name; (2) the item of DME ordered; (3) the signature of the prescribing 

practitioner; (4) prescribing practitioner NPI; (5)the date of the order. Orders should still comply 

with standards of practice and therefore may be more detailed. 

As noted previously, section 1834(h)(3) of the Act incorporates by cross reference 

prosthetic devices, orthotics, and prosthetics to the items encompassed by section 1834(a)(11)(B) 

of the Act. At this time, we are not implementing the proposed changes to §410.36(b) to require 

documentation of a face-to-face encounter for prosthetic devices, orthotics, and prosthetics that, 

according to §410.36(b), require a written order before delivery in this final rule. We intend to 

use future rulemaking to determine which prosthetic devices, orthotics, and prosthetics, require, 

as a condition of payment, a written order before delivery supported by documentation of a faceto-face encounter with the beneficiary consistent with section 1834(a)(11)(B)(ii) of the Act. 

The following is a summary of comments we received regarding prosthetic devices, 
775 

orthotics, and prosthetics. 

Comment: In many cases, the acute condition (for example, amputation, stroke, polio, 

etc.) that caused the initial medical need for the prosthesis or orthotics no longer requires specific 

medical treatment by a physician. In this scenario, Medicare beneficiaries often look to their 

orthotist or prosthetist to continue to provide the prosthetics or orthotics (P & O) necessary to 

restore and maintain functional abilities. Commenters were concerned that if applied to P & O 

patients, the face-to-face requirement for P & O care would result in extensive administrative 

burdens for P & O clinicians and the physicians who prescribe these services, as well as pose a 

significant impediment for their patients. 

Response: We appreciate this comment and will consider it as we contemplate future 

rule making for P & O. 

Comment: For prosthetic devices, orthotics, and prosthetics, commenters urged CMS to 

conduct an evaluation of the impact of the requirements for selected DME items before deciding 

whether there should be any expansion to other product categories. Second, commenters 

believed that CMS should limit any such requirement to items for which there is sufficient 

evidence of fraud and abuse, and not based solely on the reimbursement amount of the item. 

Commenters continued to have concerns about what data CMS used to establish and verify the 

level of fraud among Medicare physicians, specifically as related to that data comparing 

physician suppliers vs. commercial suppliers, and by specialty area within physician suppliers. 

Several commenters noted that when CMS considers whether to apply the new face-toface encounter requirements to enteral nutrition, CMS should be mindful of the existing 

requirements and not impose redundant requirements or request duplicative information. 

Response: We appreciate these comments, and will consider them, including physician 

vs. commercial suppliers, as we consider future rule making for P & O. 
776 

We also stated in the proposed rule that none of our proposals superseded any regulatory 

requirements that more specifically address a face-to-face encounter requirement for a particular 

item of DME. 

(2) Physician Documentation 

The statute requires that a physician document that the physician or a PA, NP or CNS has 

had a face-to-face encounter with the beneficiary. As described in the CY 2013 PFS proposed 

rule (77 FR 44795), we proposed two options for how this could be done. 

The following is a summary of the comments we received regarding the physician 

documentation proposal. 

Comment: Several commenters believed a standardized form that documents the 

elements CMS and its contractors require for coverage of a DME item should be recognized by 

CMS as part of the beneficiary’s medical record and should establish the beneficiary’s medical 

need for the item. 

Response: The amount of necessary clinical information needed to demonstrate that all coverage 

and coding requirements are met will vary depending on the item/service. For example, we have National 

and Local Coverage Determinations which address many of these items/services. The commenters appear 

to be describing a template. However, we do not prohibit the use of templates to facilitate recordkeeping. We also do not endorse or approve any particular templates. A physician or practitioner may 

choose any template to assist in documenting medical information. 

We do caution, however, that some templates provide limited options and/or space for the 

collection of information such as by using “check boxes,” predefined answers, and limited space to enter 

information. We discourage the use of such templates. Our experience with claim review shows that 

‘limited space’ templates often fail to capture sufficient detailed clinical information to demonstrate that 

all coverage and coding requirements are met. Furthermore, physicians or practitioners should be aware 

that templates designed to gather selected information primarily for reimbursement purposes are often 
777 

insufficient to demonstrate that all coverage and coding requirements are met. These ‘limited space’ 

documents often do not provide sufficient comprehensive information to adequately show that the 

medical necessity criteria for the item/service have been met. 

Comment: A few commenters expressed a belief that the documentation requirements 

should be the same for physicians as they are for nurse practitioners and other non-physician 

providers. 

Response: We agree that the documentation requirements for the face-to-face encounter 

should be the same. However, it is duplicative to have the physician document that the face-toface occurred when they themselves conducted the face-to-face encounter. Therefore, we are not 

requiring additional documentation requirements for the physician in addition to what they are 

required to document during the actual face-to-face encounter. 

As a result of the comments, the submission of the pertinent portion of the medical record 

documented by the physician is sufficient to document that the face-to-face encounter has 

occurred, when the physician conducts the face-to-face encounter. Documentation of the faceto-face encounter must include an evaluation of the beneficiary, needs assessment for the 

beneficiary, or treatment of the beneficiary for the medical condition that supports the need for 

each covered item of DME. A written order is still required for these covered items of DME. 

(3) Physician Documentation of Face-to-Face Encounters Performed by a Physician Assistant, 

Nurse Practitioner, or Clinical Nurse Specialist 

As described in the CY 2013 PFS proposed rule (77 FR 44795), we had considered four 

options for the physician documentation of a face-to-face encounter performed by a PA, NP, or 

CNS. 

The following is a summary of the comments we received regarding how physician 

documentation requirements should be handled when the face-to-face encounter with the 

beneficiary is conducted by a PA, NP, or CNS. 
778 

Comment: Many commenters believed that CMS should allow each of the outlined 

options so that practices may choose which option will best meet their needs and those of the 

patient. 

Response: We believe there needs to be a standard accepted practice for documenting the 

face-to-face encounter when performed by a PA, NP or CNS. We believe that this will promote 

consistency and ensure that there is clear guidance on the requirements. 

Comment: Some commenters believe that if an ordering physician certifies the date of a 

face-to-face encounter on the signed written order that should be sufficient documentation for the 

supplier to establish medical necessity for the DME items. This method of documentation is 

most efficient for physicians, and it is easily verified by DME suppliers when establishing that 

medical necessity requirements are met. 

Response: While we appreciate this comment, a verification of a date added to a written 

order does not prove that an adequate face-to-face occurred. Detailed face-to-face 

documentation is required to ensure the item of DME is medically necessary and appropriate for 

the individual beneficiary. 

Comment: Commenters believe there is no justification for requiring less information on 

the beneficiary’s medical need for DME if a physician personally conducts the evaluation than if 

a nurse practitioner assesses the patient. Typically, the physician communicates the order 

directly to the supplier who, in turn, initiates intake and assessment based on a written 

confirmation of the physician’s verbal order, which is later ratified by the physician’s signature 

and date. 

Response: We are not requiring less information on the need for DME if a physician 

conducts the evaluation than would be deemed appropriate if a nurse practitioner assesses the 

patient. We are not requiring additional documentation requirements for the physician above 
779 

what they are required to perform in documenting the actual face-to-face encounter. 

Comment: Many commenters expressed a desire to limit their burden. Commenters 

expressed that overly unnecessary copying, drafting, and distribution of records from the 

MD/DO to the physician supplier is burdensome at the very least, interferes with the physicianpatient relationship, and is generally not in the best interests of the Medicare beneficiary. 

Response: We have worked to develop a rule that weighs our responsibility to implement 

the statutory provision, while minimizing provider and supplier burden. As a result of 

comments, we are allowing flexibility on how the supplier is notified of the face-to-face 

encounter. We have tried to limit the burden by requiring that the physician sign/cosign the 

pertinent portion of the medical record to document when a face-to-face encounter was 

performed by a NP, PA or CNS. This step is not needed when the physician personally conducts 

the face-to-face encounter. 

As a result of the comments, we are requiring the physician documenting the face-to-face 

encounter performed by a NP, PA or CNS, must sign or cosign the pertinent portion of the 

medical record indicating the occurrence of a face-to-face encounter for the beneficiary for the 

date of the face-to-face encounter, thereby documenting that the beneficiary was evaluated or 

treated for a condition relevant to an item of DME on that date of service. Other signature 

requirements described in the manual, such as those for determining a legible signature remain in 

force. This option provides evidence that the physician reviewed the relevant documentation to 

support that a face-to-face encounter occurred for that date of service. A signed order (in 

contrast to a signed medical record) would not satisfy the requirement described in this option 

that the physician “sign/cosign the pertinent portion of the medical record.” 

(4) Supplier Notification 

Since the supplier submits the claims for the covered items of DME, the supplier must 
780 

have access to the documentation of the face-to-face encounter. All documentation to support 

the appropriateness of the item of DME ordered, including documentation of the face-to-face 

encounter, must be available to the supplier. As with certain other items and services submitted 

for Medicare payment, we require the entity submitting the claim to maintain access to the 

written order and supporting documentation relating to written orders for covered items of DME 

and provide them to us upon our request or at the request of our contractors. 

As described in CY 2013 PFS proposed rule (77 FR 44795), we had considered four 

options for the supplier notification of the face-to-face encounter. 

The following is a summary of the comments we received regarding the supplier 

notification proposal. 

Comment: Several commenters expressed concerns that physicians have reported 

deceptive practices by DME suppliers who have sent letters to physicians on letterhead 

appearing to be co-branded with CMS but without CMS authorization. The letters have indicated 

that because the DME supplier is undergoing a CMS audit, the physician must produce extensive 

and costly medical record documentation and submit it to the DME supplier. 

Response: Suppliers are required to have the documentation available upon request by 

CMS. CMS has worked to limit the burden associated with this regulation. However, the CMS 

seal and logo are for the official use of CMS and its authorized contractors only and must not be 

used by suppliers or others within the private sector. Under section 1140 of the Act, individuals 

or organizations may be subject to a civil money penalty for the misuse of words, symbols, or 

emblems or names in reference to Social Security or Medicare. If physicians have information 

about suppliers or others who are misusing CMS words, symbols, or emblems, they should 

contact the HHS Office of Inspector General. Organizations or individuals concerned about 

suppliers who may be misrepresenting themselves or CMS should contact the contractor that 
781 

processes their claims. CMS requires that suppliers have access to the documentation to support 

their claims. Suppliers may request supporting documentation, including documentation of a 

face-to-face encounter, from the physician, but suppliers must not misuse CMS words, symbols, 

or emblems when making those requests. Suppliers may, of course, share unaltered CMS 

educational material. 

Comment: Commenters suggested that CMS clarify in its regulation that after a 

physician or beneficiary has submitted a medical record and documentation of the face-to-face 

visit to the DME supplier, the DME supplier must retain a copy of that already-submitted record, 

and the physician is not required to supply subsequent medical records or documentation to the 

DME supplier. 

Response: The face-to-face encounter is a condition of payment for the supplier. 

Suppliers must make this information available to CMS upon request. 

Comment: Commenters urged CMS to give physicians and other practitioners maximum 

flexibility by allowing them to choose among the options CMS has proposed. To avoid creating 

new burdens for physicians, commenters recommend that the new process for communicating 

documentation to suppliers resemble, as closely as possible, current processes used by 

physicians. Commenters believe that this may be similar to the second option discussed in the 

proposed rule, and, if this is the case, they recommended using that option. 

Response: In response to comments, we are not requiring a particular method of 

transmission for supplier notification that the face-to-face encounter has occurred in order to 

limit burden and not create a hindrance to access to care. Practitioners and suppliers can 

communicate the information and requirements through existing business processes for 

transmitting this information. CMS will monitor the effects of this provision on beneficiaries’ 

access to medically necessary DME. We also note that this documentation must be made 
782 

available to suppliers to allow them to ensure all requirements are met. Suppliers must make this 

documentation available to CMS upon request. 

Comment: Many commenters believe that the adopted rules should give adequate 

protection to downstream DME suppliers who act in good faith in response to information 

communicated by physician practices. Commenters believe that whatever documentation and 

communication policies CMS adopts for face-to-face encounters should give suppliers absolute 

peace of mind that their subsequent dispersing of DME items will not later be second-guessed by 

CMS or its contractors. 

Response: We believe that by removing the ability for the face-to-face encounter to 

occur 30 days after the written order suppliers will be afforded more protection as all 

documentation will be available at the time of order. Completion of the face-to-face requirement 

is a condition of payment and could be subject to audit. Therefore, this documentation must be 

available to CMS on request. CMS will monitor the effects of this provision on beneficiaries’ 

access to medically necessary DME. 

Comment: A few commenters strongly opposed the fourth option of requiring the 

physician to provide a copy of the face-to-face documentation to the beneficiary and disagreed 

with the reasoning that this option would, “ensure that the supplier receives the documentation of 

face-to-face encounter directly and limits the supplier’s need to rely on the PA, NP, or CNS to 

receive this documentation completed by the physician.” 

Response: We appreciate this concern, and therefore, will not require this particular 

method for transmission of this communication. 

Comment: Several commenters expressed a concern that the ordering practitioner has 

little interest or incentive to ensure the necessary paperwork is provided to the supplier since the 

practitioner/physician still gets reimbursed for their services regardless of whether they have 
783 

inadequate documentation and fail to provide such documentation to the suppliers. A few 

commenters stated that the DME supplier should not be responsible for scheduling the face-toface visits to ensure the requirement is met. Commenters also believed physicians who are 

continually noncompliant with the rule should be subject to corrective action. 

Response: We encourage suppliers and practitioners to work together to ensure that 

beneficiaries receive necessary and appropriate care. Completion of the face-to-face requirement 

is a condition of payment. Therefore, this documentation must be available to CMS upon 

request. We believe that by removing the 30 days after the order is written timeframe for the 

face-to-face encounter, the supplier will be able to know before delivery if all requirements have 

been meet. CMS does provide education on documentation requirements to physicians and other 

practitioners including through MLN articles. 

As a result of the comments received, we are not requiring a particular method of supplier 

notification. Instead, since this is a condition of payment, we only require that the supplier must 

have all documentation to support the claim upon request. We believe this will limit the burden 

on practitioners and suppliers while helping to ensure beneficiary access to DME. 

b. Covered Items 

Section 1834(a)(11)(B)(i) of the Act (as redesignated by the Affordable Care Act 

authorizes us to specify covered items that require a written order prior to delivery of the item. 

Under section 1834(a)(11)(B)(ii) of the Act, these orders must be written pursuant to a physician 

documenting that a face-to-face encounter has occurred. Accordingly, to reduce the risk of 

fraud, waste, and abuse, we proposed a list of Specified Covered Items that would require a 

written order prior to delivery. Our final list of Specified Covered Items is in Table 89. In future 

years, updates to this list will appear annually in the Federal Register and the full updated list 

will be available on the CMS website. 
784 

As highlighted in the January 2007 Government Accountability Office (GAO) report 

entitled, “Improvements Needed to Address Improper Payments for Medical Equipment and 

Supplies,” it is estimated that there were $700 million in improper payments across the spectrum 

of DMEPOS from April 1, 2005, through March 31, 2006. GAO did not specifically recommend 

the use of DME face-to-face encounters as a remedial action in its report. However, the GAO 

did recommend making improvements to address improper payments in the DMEPOS arena. 

This final rule with comment period is one way in which we are working to prevent DME 

improper payments. 

Though we initially considered making all items encompassed by section 1834(a)(11)(B) 

of the Act (including prosthetic and orthotic items described in section 1834(h)(3) of the Act) 

subject to a face-to-face encounter requirement, we have first proposed a more limited criteriadriven list to balance a comprehensive face-to-face requirement to prevent fraud, waste, and 

abuse while mitigating any undue negative effect on practitioners and suppliers by including all 

items. We welcomed comments on limiting the associated burden of this proposed rule by 

refining the number of items subject to a face-to-face encounter, while still protecting the 

Medicare Trust Funds. 

The following is a summary of the comments we received regarding the covered items 

proposal. 

Comment: Commenters appreciated CMS’s efforts to reduce fraud, waste, and abuse.

Commenters expressed that “as CMS implicitly acknowledges” in the preamble to the proposed 

rule that the statute does not compel the Secretary to require a written order prior to delivery for 

all DME. Rather, the Secretary “is authorized” to require a written order prior to delivery for 

DME items that are “specified covered items”. However, for any DME items that are Specified 

Covered Items, the Secretary is obligated to require documentation by a physician that the order 
785 

is based on a face-to-face encounter between the beneficiary and an authorized practitioner. 

Commenters stated that CMS should apply the new encounter and documentation requirements 

initially to a smaller number of HCPCS codes and first evaluate the impact of the requirements 

on beneficiary access to DME and costs to providers before expanding the list in the future. 

Commenters suggested the new face-to-face encounter requirements should not apply to 

instances where a physician is ordering an item of DME that is substantially similar to the item 

already being used by the beneficiary. 

Response: We believe that this is an important provision aimed at reducing fraud, waste, 

and abuse. We used a criterion driven approach to select these items, and did not receive 

sufficiently detailed alternative criteria to those proposed. We believe limiting new face-to-face 

encounter requirements only to instances where a physician is ordering an item of DME that is 

substantially similar to the item already being used by the beneficiary is insufficiently broad to 

make significant inroads into reducing fraud, waste and abuse. It would also be difficult to 

determine and what qualifies as “substantially similar.” 

Comment: Commenters stated that requiring that a physician sign-off on commonly 

prescribed items, such as blood glucose monitors and standard wheelchairs that are currently 

ordered by NP, PA, and Advance Practice Nurses including CNSs may create a barrier for 

consumers, many of whom routinely receive this needed equipment from nonphysician 

practitioners , and runs contrary to current Medicare reimbursement practice. Several 

commenters raised concerns that the agency’s broad list of proposed covered items includes 

several items that NPs and CNSs order routinely for frequent conditions and diagnoses, such as 

glucose monitors. Commenters stated that requiring physician documentation before these items 

may be supplied is likely to delay patient care and potentially lead to serious complications and 

more severe conditions. 
786 

Response: We are implementing the statutory requirements of this provision to require a 

physician has to document the occurrence of a face-to-face encounter for certain covered items 

of DME. Face-to-face encounters conducted by NPs, PAs, and CNS are allowed, but as the 

statute states these encounters must be documented by a physician. CMS does not believe that 

this regulation will create a barrier to beneficiaries including those who are prescribed orders 

from PAs, NPs and Advance Practice Registered Nurses including CNSs . 

We use a criterion driven approach to select these items and are implementing this 

provision in accordance with the statute. We do not believe that this requirement will delay a 

beneficiary from getting necessary care particularly with the longer timeframe. In addition, we 

will monitor the implementation of this rule to ensure there are no unintended consequences that 

negatively impact the practitioner, supplier, and beneficiary communities. 

Comment: Commenters recommended that CMS exercise its discretion and create a 

smaller list. Commenters suggested excluding from the list of Specified Covered Items any 

DME covered under an NCD or LCD that requires a physician to see the beneficiary before 

ordering the item. These include oxygen and oxygen equipment (E0441, E0442, E0443, and 

E0444) and all ventilators including CPAPs and RADs. 

Additionally, commenters recommended any items necessary to ensure a safe discharge 

from an inpatient stay and preserve continuity of care, including wheelchairs, infusion pumps, 

hospital beds and accessories, negative pressure wound therapy (NPWT), and ambulatory items, 

be excluded from the list of Specified Covered Items. 

Commenters stated that the need for glucometers and nebulizers (E0570, E0575, E0580) 

for this population is obvious; if translated to office or clinic visits needed to monitor then in the 

absence of the availability of this equipment, or even the extra time it will take physicians and 

nurse practitioners to obtain the extra documentation to order these items. This represents a 
787 

significant amount of unnecessary time and cost with poorer patient outcomes. 

Many commenters expressed the view that a face-to-face encounter for speech generating 

device (SGD) should be excluded since it will adversely affect an aphasia patient’s ability to 

obtain the equipment required for function communication. They believe the face-to-face 

encounter requirement is an undue hardship for people needing a speech generating device. A 

SGD already requires a Certificate of Medical Necessity before ordering. 

Commenters noted the current proposed list of Specified Covered Items includes 

equipment that have a fee schedule amount well below $1000, including accessories to the 

primary equipment. To require a separate face-to-face encounter to document need for an 

accessory for primary equipment already vetted in a previous face-to-face encounter and 

currently in the possession of the beneficiary seems unduly burdensome. To that point, 

commenters stated, that wheelchair accessories should not be included on the Specified Covered 

Item list. Section 410.38 (c)(3)(ii) states that accessories for PMDs may be ordered by the 

physician/treating practitioner without conducting a face-to-face encounter with the beneficiary. 

Response: In areas where a face-to-face is required by the NCD or LCD the 

documentation requirements of this regulation are in addition to those documents for the NCD or 

LCD. The face-to-face should comply with the requirements of the applicable NCD/ LCD and 

its occurrence must be documented by a physician. CMS reminds providers and suppliers that 

multiple items can be supported by a single face-to-face encounter. 

For a beneficiary who is discharged from the hospital, the face-to-face encounter may 

occur in that setting. This mitigates the concern of items needed to safely discharge the 

beneficiary. 

We are removing items from the covered list of items where regulations explicitly state 

that a face-to-face encounter is not necessary such as power wheelchair accessories. We used a 
788 

criteria-driven approach in order to create this list, and speech generating devices specifically are 

items meet one of our criteria. There are items below $1,000 on the list because these items still 

have an aggregate effect on the Medicare Trust Funds. While commenters recommended we 

remove individual items, we are not convinced that any of our criteria are inappropriate. 

Comment: Some commenters supported the inclusion of ventilators, respiratory assist 

device CPAP/ BiPAP, and chest wall oscillators on the list of items that require a face-to-face 

encounter. 

Response: We agree and have included these items on the Specified Covered Item list. 

Comment: Commenters questioned if aggregate rental cost was included in the $1000 

threshold. 

Response: The threshold criterion does not include aggregate rental costs of DME. 

Comment: Many commenters believe the overwhelming majority of orders for DME are 

already made in an appropriate medical context. That is, DME is typically ordered as part of a 

beneficiary’s routine medical care consistent with coverage determinations issued by CMS and 

its contractors. Consequently, they believe it is unnecessary for CMS to require additional inperson evaluations or documentation for many categories of DME. Moreover, when DME is 

ordered on discharge from an inpatient stay, they believe it is likewise unnecessary for CMS to 

impose an additional face-to-face physician visit or documentation requirement because the 

beneficiary’s need for equipment would have been evaluated during the stay. Other similar 

comments are that the face-to-face encounter requirements will generate considerable additional 

administrative burden for physicians, patients and suppliers, and overall healthcare costs due to 

increases patient morbidities as a result of expired prescriptions or inability to obtain 

documentation that will delay getting DME. Finally, commenters believed there is no hard 

evidence that this provision will have a positive impact. 
789 

Response: We are implementing the statutory requirement using a criteria-driven 

approach in order to create this list. We have taken into account many of the comments received 

in revising the rule to address the potential burden concerns, extending the proposed timeline to 6 

months, removing the 30 days post written order option, and allowing face to face encounters to 

occur at the hospital prior to discharge. While commenters recommended removal of individual 

items, there was no mention of removing any of the specific criteria, nor was a detailed 

alternative methodology provided. While commenters recommended individual items to 

remove, we must maintain a criteria-driven approach our criteria were outlined in 77 FR 44797. 

Comment: Commenters were very concerned that the proposed rule does not make clear 

that the burden to obtain documentation of face-to-face encounters will not be placed on 

pharmacies. 

Response: We worked to implement this statute in a way that limits burden to providers 

and suppliers while ensuring beneficiary access to care. All entities billing Medicare for a 

covered item of DME are subject to this provision. CMS does not believe that it is appropriate to 

carve out an exception for pharmacies. If a pharmacy bills Medicare for one of these covered 

items then this documentation must be available upon request. 

Comment: Commenters encouraged the Agency to (1) assess regularly how additional 

documentation requirements could limit patient access to DME items and increase the 

documentation burden on providers, (2) describe what types of educational programs it will 

develop to help providers understand the DME documentation requirements necessary for 

Medicare coverage, and (3) evaluate what incentives could be offered to encourage providers to 

focus on reducing documentation error rates. 

Response: We do not believe that this requirement will limit patient access to necessary 

DME particularly in light of the longer timeframe. We balanced the need to protect the 
790 

Medicare Trust Funds while limiting burden. We are not being prescriptive on how the face-toface encounter must be communicated to the supplier and believe this will help limit provider 

burden. CMS will issue an MLN article regarding this requirement. Incentives for document 

error rate are outside the scope of this regulation. 

As a result of the comments, we are maintaining our criteria- driven list, however, we are 

removing items from the covered list of items where regulations explicitly state that a face-toface encounter is not necessary. 

As described in the CY 2013 PFS proposed rule (77 FR 44796), we described our 

proposed criteria, as well as the reasons we selected these criteria. We first noted that our 

proposed list of Specified Covered Items contains DME items only. We intended to use future 

rulemaking to apply section 1834(a)(11)(B)(ii) of the Act to add prosthetics and orthotics. We 

believe that our proposed current focus on DME items is an appropriate way of balancing our 

goals of reducing fraud, waste, and abuse and limiting burden on beneficiaries and the supplier 

community. We also proposed to focus initially on DME items for several reasons. 

We welcomed comments on limiting the associated burden of this proposed regulation by 

refining the number of items subject to a face-to-face encounter, while still meeting the 

requirements of the statute. 

The proposed list of Specified Covered Items contains items that meet at least one of the 

following four criteria: (1) items that currently require a written order prior to delivery per 

instructions in our Program Integrity Manual; (2) items that cost more than $1,000; (3) items that 

we, based on our experience and recommendations from the Durable Medical Equipment 

Medicare Administrative Contractors, believe are particularly susceptible to fraud, waste, and 

abuse; (4) items determined by CMS as vulnerable to fraud, waste and abuse based on reports of 

the HHS Office of Inspector General, Government Accountability Office or other oversight 
791 

entities. We are adding a criterion to remove any items where regulations explicitly state that a 

face-to-face encounter is not necessary. As described in the CY 2013 PFS proposed rule (77 FR 

44796), we outlined each of these criteria. 

Our final list of Specified Covered Items is in Table 89 of this final rule with comment 

period. We further proposed to update this list of Specified Covered Items annually to add any 

new items that are described by a HCPCS code for the following types of DME: 

● TENS unit 

● Rollabout chair 

● Manual Wheelchair accessories 

● Oxygen and respiratory equipment 

● Hospital beds and accessories 

● Traction-cervical 

Note that the list does not include power mobility devices (PMDs), which are subject to 

already existing face-to-face requirements, as previously discussed. In addition, we proposed to 

add to the list any item of DME that in the future appears on the DMEPOS Fee Schedule with a 

price ceiling at or greater than $1,000. Items not included in one of the proposed automatic 

pathways would be added to the list of Specified Covered Items through notice and comment 

rulemaking. 

Through updates in the Federal Register, we propose removing HCPCS codes from the 

list that are no longer covered by Medicare or that are discontinued HCPCS codes. 

The DME list of Specified Covered Items are as follows, the original list was at 77 FR 44798: 

TABLE 89: DME List of Specified Covered Items 

HCPCS 

Code Description 

E0185 Gel or gel-like pressure mattress pad 
792 

HCPCS 

Code Description 

E0188 Synthetic sheepskin pad 

E0189 Lamb's wool sheepskin pad 

E0194 Air fluidized bed 

E0197 Air pressure pad for mattress standard length and width 

E0198 Water pressure pad for mattress standard length and width 

E0199 Dry pressure pad for mattress standard length and width 

E0250 Hospital bed fixed height with any type of side rails, mattress 

E0251 Hospital bed fixed height with any type side rails without mattress 

E0255 Hospital bed variable height with any type side rails with mattress 

E0256 Hospital bed variable height with any type side rails without mattress 

E0260 

Hospital bed semi-electric (Head and foot adjustment) with any type 

side rails with mattress 

E0261 

Hospital bed semi-electric (head and foot adjustment) with any type 

side rails without mattress 

E0265 

Hospital bed total electric (head, foot and height adjustments) with 

any type side rails with mattress 

E0266 

Hospital bed total electric (head, foot and height adjustments) with 

any type side rails without mattress 

E0290 Hospital bed fixed height without rails with mattress 

E0291 Hospital bed fixed height without rail without mattress 

E0292 Hospital bed variable height without rail without mattress 

E0293 Hospital bed variable height without rail with mattress 

E0294 

Hospital bed semi-electric (head and foot adjustment) without rail 

with mattress 

E0295 

Hospital bed semi-electric (head and foot adjustment) without rail 

without mattress 

E0296 

Hospital bed total electric (head, foot and height adjustments) 

without rail with mattress 

E0297 

Hospital bed total electric (head, foot and height adjustments) 

without rail without mattress 

E0300 Pediatric crib, hospital grade, fully enclosed 

E0301 

Hospital bed Heavy Duty extra wide, with weight capacity 350-600 

lbs with any type of rail, without mattress 

E0302 

Hospital bed Heavy Duty extra wide, with weight capacity greater 

than 600 lbs with any type of rail, without mattress 

E0303 

Hospital bed Heavy Duty extra wide, with weight capacity 350-600 

lbs with any type of rail, with mattress 

E0304 

Hospital bed Heavy Duty extra wide, with weight capacity greater 

than 600 lbs with any type of rail, with mattress 

E0424 

Stationary compressed gas Oxygen System rental; includes contents, 

regulator, nebulizer, cannula or mask and tubing 

E0431 

Portable gaseous oxygen system rental includes portable container, 

regulator, flowmeter, humidifier, cannula or mask, and tubing 

E0433 Portable liquid oxygen system 
793 

HCPCS 

Code Description 

E0434 

Portable liquid oxygen system, rental; includes portable container, 

supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, 

cannula or mask, and tubing 

E0439 

Stationary liquid oxygen system rental, includes container, contents, 

regulator, flowmeter, humidifier, nebulizer, cannula or mask, and 

tubing 

E0441 Oxygen contents, gaseous (1 month supply) 

E0442 Oxygen contents, liquid (1 month supply) 

E0443 Portable Oxygen contents, gas (1 month supply) 

E0444 Portable oxygen contents, liquid (1 month supply) 

E0450 

Volume control ventilator without pressure support used with 

invasive interface 

E0457 Chest shell 

E0459 Chest wrap 

E0460 Negative pressure ventilator portable or stationary 

E0461 

Volume control ventilator without pressure support node for a 

noninvasive interface 

E0462 Rocking bed with or without side rail 

E0463 

Pressure support ventilator with volume control mode used for 

invasive surfaces 

E0464 

Pressure support vent with volume control mode used for 

noninvasive surfaces 

E0470 

Respiratory Assist Device, bi-level pressure capability, without 

backup rate used non-invasive interface 

E0471 

Respiratory Assist Device, bi-level pressure capability, with backup 

rate for a non-invasive interface 

E0472 

Respiratory Assist Device, bi-level pressure capability, with backup 

rate for invasive interface 

E0480 Percussor electric/pneumatic home model 

E0482 

Cough stimulating device, alternating positive and negative airway 

pressure 

E0483 High Frequency chest wall oscillation air pulse generator system 

E0484 Oscillatory positive expiratory device, non-electric 

E0570 Nebulizer with compressor 

E0575 Nebulizer, ultrasonic, large volume 

E0580 

Nebulizer, durable, glass or autoclavable plastic, bottle type for use 

with regulator or flowmeter 

E0585 Nebulizer with compressor & heater 

E0601 Continuous airway pressure device 

E0607 Home blood glucose monitor 

E0627 Seat lift mechanism incorporated lift-chair 

E0628 Separate Seat lift mechanism for patient owned furniture electric 

E0629 Separate seat lift mechanism for patient owned furniture non-electric 
794 

HCPCS 

Code Description 

E0636 

Multi positional patient support system, with integrated lift, patient 

accessible controls 

E0650 Pneumatic compressor non-segmental home model 

E0651 

Pneumatic compressor segmental home model without calibrated 

gradient pressure 

E0652 

Pneumatic compressor segmental home model with calibrated 

gradient pressure 

E0655 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on half arm 

E0656 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on trunk 

E0657 

Non- segmental pneumatic appliance for use with pneumatic 

compressor chest 

E0660 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on full leg 

E0665 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on full arm 

E0666 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on half leg 

E0667 

Segmental pneumatic appliance for use with pneumatic compressor 

on full-leg 

E0668 

Segmental pneumatic appliance for use with pneumatic compressor 

on full arm 

E0669 

Segmental pneumatic appliance for use with pneumatic compressor 

on half leg 

E0671 Segmental gradient pressure pneumatic appliance full leg 

E0672 Segmental gradient pressure pneumatic appliance full arm 

E0673 Segmental gradient pressure pneumatic appliance half leg 

E0675 

Pneumatic compression device, high pressure, rapid 

inflation/deflation cycle, for arterial insufficiency 

E0692 Ultraviolet light therapy system panel treatment 4 foot panel 

E0693 Ultraviolet light therapy system panel treatment 6 foot panel 

E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet 

E0720 

Transcutaneous electrical nerve stimulation, two lead, local 

stimulation 

E0730 

Transcutaneous electrical nerve stimulation, four or more leads, for 

multiple nerve stimulation 

E0731 Form fitting conductive garment for delivery of TENS or NMES 

E0740 

Incontinence treatment system, Pelvic floor stimulator, monitor, 

sensor, and/or trainer 

E0744 Neuromuscular stimulator for scoliosis 

E0745 Neuromuscular stimulator electric shock unit 

E0747 

Osteogenesis stimulator, electrical, non-invasive, other than spine 

application. 
795 

HCPCS 

Code Description 

E0748 Osteogenesis stimulator, electrical, non-invasive, spinal application 

E0749 Osteogenesis stimulator, electrical, surgically implanted 

E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive 

E0762 

Transcutaneous electrical joint stimulation system including all 

accessories 

E0764 

Functional neuromuscular stimulator, transcutaneous stimulations of 

muscles of ambulation with computer controls 

E0765 FDA approved nerve stimulator for treatment of nausea & vomiting 

E0782 Infusion pumps, implantable, Non-programmable 

E0783 Infusion pump, implantable, Programmable 

E0784 External ambulatory infusion pump 

E0786 Implantable programmable infusion pump, replacement 

E0840 Tract frame attach to headboard, cervical traction 

E0849 

Traction equipment cervical, free-standing stand/frame, pneumatic, 

applying traction force to other than mandible 

E0850 Traction stand, free standing, cervical traction 

E0855 Cervical traction equipment not requiring additional stand or frame 

E0856 Cervical traction device, cervical collar with inflatable air bladder 

E0958 Manual wheelchair accessory, one-arm drive attachment 

E0959 Manual wheelchair accessory-adapter for Amputee 

E0960 Manual wheelchair accessory, shoulder harness/strap 

E0961 Manual wheelchair accessory wheel lock brake extension handle 

E0966 Manual wheelchair accessory, headrest extension 

E0967 Manual wheelchair accessory, hand rim with projections 

E0968 Commode seat, wheelchair 

E0969 Narrowing device wheelchair 

E0971 Manual wheelchair accessory anti-tipping device 

E0973 Manual wheelchair accessory, adjustable height, detachable armrest 

E0974 Manual wheelchair accessory anti-rollback device 

E0978 Manual wheelchair accessory positioning belt/safety belt/ pelvic strap 

E0980 Manual wheelchair accessory safety vest 

E0981 Manual wheelchair accessory Seat upholstery, replacement only 

E0982 Manual wheelchair accessory, back upholstery, replacement only 

E0983 

Manual wheelchair accessory power add on to convert manual 

wheelchair to motorized wheelchair, joystick control 

E0984 

Manual wheelchair accessory power add on to convert manual 

wheelchair to motorized wheelchair, Tiller control 

E0985 Wheelchair accessory, seat lift mechanism 

E0986 Manual wheelchair accessory, push activated power assist 

E0990 Manual wheelchair accessory, elevating leg rest 

E0992 Manual wheelchair accessory, elevating leg rest solid seat insert 

E0994 Arm rest 
796 

HCPCS 

Code Description 

E1014 Reclining back, addition to pediatric size wheelchair 

E1015 Shock absorber for manual wheelchair 

E1020 Residual limb support system for wheelchair 

E1028 

Wheelchair accessory, manual swing away, retractable or removable 

mounting hardware for joystick, other control interface or positioning 

accessory 

E1029 Wheelchair accessory, ventilator tray 

E1030 Wheelchair accessory, ventilator tray, gimbaled 

E1031 Rollabout chair, any and all types with castors 5" or greater 

E1035 

Multi-positional patient transfer system with integrated seat operated 

by care giver 

E1036 Patient transfer system 

E1037 Transport chair, pediatric size 

E1038 Transport chair, adult size up to 300lb 

E1039 Transport chair, adult size heavy duty >300lb 

E1161 Manual Adult size wheelchair includes tilt in space 

E1227 Special height arm for wheelchair 

E1228 Special back height for wheelchair 

E1232 

Wheelchair, pediatric size, tilt-in-space, folding, adjustable with 

seating system 

E1233 

Wheelchair, pediatric size, tilt-in-space, folding, adjustable without 

seating system 

E1234 

Wheelchair, pediatric size, tilt-in-space, folding, adjustable without 

seating system 

E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system 

E1236 Wheelchair, pediatric size, folding, adjustable, with seating system 

E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system 

E1238 

Wheelchair, pediatric size, folding, adjustable, without seating 

system 

E1296 Special sized wheelchair seat height 

E1297 Special sized wheelchair seat depth by upholstery 

E1298 Special sized wheelchair seat depth and/or width by construction 

E1310 Whirlpool non-portable 

E2502 

Speech Generating Devices prerecord messages between 8 and 20 

Minutes 

E2506 Speech Generating Devices prerecord messages over 40 minutes 

E2508 Speech Generating Devices message through spelling, manual type 

E2510 

Speech Generating Devices synthesized with multiple message 

methods 

E2227 Rigid pediatric wheelchair adjustable 

K0001 Standard wheelchair 

K0002 Standard hemi (low seat) wheelchair 

K0003 Lightweight wheelchair 
797 

HCPCS 

Code Description 

K0004 High strength ltwt wheelchair 

K0005 Ultra Lightweight wheelchair 

K0006 Heavy duty wheelchair 

K0007 Extra heavy duty wheelchair 

K0009 Other manual wheelchair/base 

K0606 AED garment with electronic analysis 

K0730 Controlled dose inhalation drug delivery system 

c. Physician Payment 

We understand that there is a burden associated with the requirement placed on the physician to 

document that a face-to-face encounter has occurred between a PA, a NP or a CNS, and the 

beneficiary. As discussed in section III.M.3 of this final rule with comment period, we are 

establishing work and malpractice RVUs for HCPCS codes for G0454 by crosswalking to the 

work and malpractice RVUs for CPT code 99211 ((Level 1 office or other outpatient visit, 

established patient). With regard to practice expense RVUs, we are not including any direct 

practice expense inputs for clinical labor, disposable medical supplies, or equipment in the direct 

PE input database for this code; practice expense RVUs will reflect resources for overhead costs 

only. The work, malpractice, and practice expense RVUs for HCPCS code G0454 are reflected 

in Addendum B of this CY 2013 PFS final rule with comment period

www.cms.gov/physicianfeesched/. A complete list of the interim final times assigned to HCPCS 

code G0454 is available on the CMS website at www.cms.gov/physicianfeesched/. 

This code is to compensate a physician who documented that a PA, a NP, or a CNS 

practitioner has performed a face-to-face encounter for the list of Specified Covered Items. This 

G-code becomes effective when this provision of the regulation becomes effective. We believe 

that the existing Evaluation and Management (E&M) codes are sufficient for practitioners 

furnishing face-to-face encounters. This new G-code will be specifically designed and mapped 
798 

only for a physician who completes the documentation of the face-to-face encounter furnished by 

a PA, NP, or CNS. Only a physician who does not bill an associated E&M code for the 

beneficiary in question would be eligible for this G-code. If multiple written orders for covered 

items of DME originate from one visit, the physician can receive the G-code payment only once 

for documenting that the face-to-face encounter has occurred. The G-code would be mapped so 

that only eligible DME items would be covered. Upon request, we will need to see 

documentation of the face-to-face encounter in order to verify the appropriateness of the G-code 

payment. 

The following is a summary of the comments we received regarding the physician 

payment proposal. 

Comments: One commenter recommended against adoption of the new G-code, seeing 

little or no difference in the proposed documentation requirement for face-to-face encounters 

conducted by a physician practice’s nonphysicians than other documentation requirements 

already imposed upon physicians. A few commenters stated that if CMS believes that physicians 

should be reimbursed for documenting face-to-face patient encounters conducted by 

nonphysicians in their employ, then the agency should more systematically determine all 

instances in which CMS-imposed administrative burdens on physicians warrant Medicare 

reimbursement and seek Congressional (statutory) authority for such reimbursement policies. 

Response: In this final rule, we were only addressing additional work involved with 

documenting face-to-face encounters furnished by a PA, NP, or CNS for certain DME items. 

Other areas of CMS-imposed administrative burden on physicians are beyond the scope of our 

regulation. The work, malpractice, and practice expense RVUs for this code (HCPCS code 

G0454) are reflected in Addendum B of this CY 2013 PFS final rule with comment period at 

www.cms.gov/physicianfeesched/. 
799 

Comment: Several commenters supported the creation of a G-code, with a proposed 

payment of $15 to reimburse physicians for the work involved in documenting face-to-face 

encounters with Physician Assistants or Nurse Practitioners. Commenters believed that it is 

important to properly reimburse physicians for time and effort. Some commenters request more 

information on how the dollar figure was arrived at and whether it is truly budget neutral. 

Response: The work, malpractice, and practice expense RVUs for this code (HCPCS 

code G0454) are reflected in Addendum B of this CY 2013 PFS final rule with comment period 

at www.cms.gov/physicianfeesched/. This code is subject to budget neutrality under the 

physician fee schedule and has been accommodated for in the final rule. This code is cross 

walked to 99211. 

Comment: Many commenters raised concerns about the statement that according to 

CMS, “only a physician who does not bill an E & M code for the beneficiary in question would 

be eligible for this G-code.” Commenters believed appropriate policy should allow for the billing 

of an E & M service that is clearly unrelated to the patient’s need for, and documentation of, 

DME authorization. 

Response: We will clarify in the final rule that this code is only for use when a physician 

documents the face-to-face encounter performed by a PA, NP, or CNS for certain DME items. 

Comment: Several commenters believed that there should be an additional payment for 

the suppliers in addition to the additional payment for the practitioners conducting the face-toface encounter. 

Response: The only area available for additional payment is the physician documenting 

that a face-to-face encounter occurred by a PA, NP, or CNS. We believe that the other 

documentation of the face-to-face encounter is within the normal scope of practice. The supplier 

receives the payment for the item and this face-to-face encounter is a condition of payment. 
800 

Comment: This proposal fails to acknowledge the additional burden imposed on nurse 

practitioners and other providers who are required to coordinate with physicians to ensure the 

additional documentation of patient encounters in which the physician was not involved. If this 

unnecessary and burdensome documentation requirement cannot be eliminated, then nurse 

practitioners and other nonphysician providers who are required to attempt to ensure that it is 

complied with should also be able to bill for the proposed additional payment. 

Response: We must follow the statute which states that a physician must document that 

the face-to-face encounter occurred. In this instance, we are recognizing the additional physician 

work that may be involved through the addition of a new G-code to compensate providers for 

this documentation requirement. We believe any necessary coordination with a physician 

following a face-to-face encounter with a beneficiary is covered appropriately under the 

corresponding E/M code that would be billed by the PA, NP, or CNS for documenting the 

occurrence. 

D. Elimination of the Requirement for Termination of Non-random Prepayment Complex 

Medical Review (§421.500 through §421.505)

 Medical review is the process performed by Medicare contractors to ensure that billed 

items or services are covered and are reasonable and necessary as specified under section 

1862(a)(1)(A) of the Act. We enter into contractual agreements with contractors to perform 

medical review functions. On December 8, 2003, the Congress enacted the MMA. Section 934 

of the MMA amended section 1874A of the Act by adding a new subsection (h) – regarding 

random prepayment reviews and non-random prepayment complex medical reviews and 

requiring us to establish termination dates for non-random prepayment complex medical reviews. 

Although section 934 of the MMA set forth requirements for random prepayment review, our 

contractors do not perform random prepayment review. However, our contractors do perform 
801 

non-random prepayment complex medical review. 

 On September 26, 2008, we published a final rule in the Federal Register (73 FR 55753) 

entitled, “Medicare Program; Termination of Non-Random Prepayment Complex Medical 

Review” that specified the criteria contractors would use for the termination of providers and 

suppliers from non-random prepayment complex medical review as required under the MMA. 

The final rule required contractors to terminate the non-random prepayment complex medical 

review of a provider or supplier no later than 1 year following the initiation of the complex 

medical review or when calculation of the error rate indicates the provider or supplier has 

reduced its initial error rate by 70 percent or more. (For more detailed information, see the 

September 26, 2008 final rule (73 FR 55753)). 

On March 23, 2010, the Congress enacted the Patient Protection and Affordable Care Act 

(Pub. L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (HCERA) 

(Pub. L. 111-152) (together known as the Affordable Care Act). Section 1302 of the HCERA, 

repealed section 1874A(h) of the Act. 

 Section 1302 of the HCERA repealed section 1874A (h) of the Act, and therefore, 

removed the statutory basis for our regulation. Thus, we proposed to remove the regulatory 

provisions in 42 CFR part 421, subpart F, that require contractors to terminate a provider or 

supplier from non-random prepayment complex medical review no later than 1 year following 

the initiation of the medical review or when the provider or supplier has reduced its initial error 

rate by 70 percent or more. As a result of this proposal, contractors would not be required to 

terminate non-random prepayment medical review by a prescribed time but would instead 

terminate each medical review when the provider or supplier has met all Medicare billing 

requirements as evidenced by an acceptable error rate as determined by the contractor. 

The following is a summary of the public comments received and our responses: 
802 

Comment: Commenters stated that the lack of statutory authority is not a valid reason for 

withdrawing the regulation establishing requirements for termination of non-random prepayment 

complex review. CMS continues to possess the general regulatory authority to maintain the 

regulation. 

Response: We believe that the repeal of section 1874A(h) of the Act reflects 

Congressional intent to require CMS to repeal the regulation CMS issued under that authority. 

Regardless of whether or not CMS could promulgate a different regulation establishing 

termination dates for non-random prepayment review based on it general rulemaking authority, 

we nonetheless believe that the existing regulation must be removed. We also believe that 

sections 1815(a), 1833(e), 1862(a)(1)(A), and 1893 of the Act provide the statutory authority to 

conduct non-random prepayment complex medical review and we do not need to have another 

regulation in place for oversight of this work. We strive to balance our need to protect the 

integrity of the Medicare Trust Fund and our need to reduce improper payments against our 

interest in limiting provider and supplier burden. 

Comment: Some commenters expressed concerns about the Agency’s proposal to 

remove all protections for practitioners undergoing non-random prepayment review and the 

discretion of each contractor to determine an acceptable error rate for eliminating non-random 

prepayment review. Other commenters expressed concern that Medicare contractors will have 

too much power and authority. They suggested that contractors do not or cannot articulate the 

thresholds that must be met to be taken off prepayment review. They recommended that CMS 

have a uniform, rational, and predictable process that permits providers/suppliers to be removed 

from non-random prepayment complex medical review. 

Response: We provide guidance to our contractors on the medical review process. The 

guidance is provided in Chapter 3 of the Program Integrity Manual (Pub. 100-08). This guidance 
803 

requires contractors to minimize potential future losses to the Medicare Trust Fund through 

targeted claims review and through progressive corrective actions that are tailored to the types of 

errors contractors identify related to provider and supplier specific behavior. This requirement 

reflects CMS’ goal to limit the burden on providers and suppliers while aiming to achieve 

efficiencies in the Medicare Program. 

Comment: Commenters stated that the prepayment review process is burdensome and 

that reviews are often inconsistent and result in costly, unorganized compliance efforts for 

suppliers. 

Response: We believe that sections 1815(a), 1833(e) and 1862(A)(1)(a) of the Act 

provide authority for the collection of documentation as may be necessary to determine the 

amounts due to a provider or supplier and to determine medical necessity of the services 

rendered. We strive to balance our need to protect the integrity of the Medicare Trust Fund and 

our need to reduce improper payments against our interest in limiting provider burden. 

Comment: Commenters suggested that CMS consider broader contractor reforms to 

assess contractors’ activities and evaluate the appropriateness of their use of prepayment review. 

Commenters also suggested that CMS publish guidelines on contractor requirements, public 

reports of contractor initiatives, have a public complaint and resolution process (or an 

independent entity to review and appeal by the provider or supplier for lifting the non-random 

prepayment complex medical review), and increase methods of communications with suppliers 

and beneficiaries. 

Response: CMS has many activities underway that can be found at www.cms.hhs.gov

website to monitor contractor oversight and compliance with national guidelines. We welcome 

all suggestions on how to improve the Medicare prepayment complex medical review process. 

Comment: Commenters are concerned that the entire prepayment medical review 
804 

process will now be subject to agency guidelines set forth in manuals rather than formal 

regulation. 

Response: Section 1893 of the Act provides that contractors will perform medical review 

of claims to promote the integrity of the Medicare program. We do not believe another 

regulation is necessary and that the guidance to contractors on the medical review process is set 

forth in statute and manuals is adequate. The guidance is provided primarily in Chapter 1 and 

Chapter 3 of the Program Integrity manual (Pub. 100-08). 

Comment: Commenters encouraged CMS to employ greater physician education and 

outreach to solve the issue of improper billing before placing physicians under prepayment 

review. 

Response: We provide physician education and outreach through various avenues 

including educational articles and Open Door Forums. Contractors are also instructed to provide 

education to physicians that are placed on prepayment review and more details can be found on 

the contractor’s individual websites. 

After reviewing the public comments, we are finalizing these provisions as proposed. 

We believe we need to do so in order to balance protection of the integrity of the Medicare Trust 

Fund and reduction of improper payments against limiting provider burden. 

E. Ambulance Coverage - Physician Certification Statement

We proposed to revise §410.40(d)(2) by incorporating nearly the same provision found at 

§410.40(d)(3)(v) to clarify that a physician certification statement (PCS) does not, in and of 

itself, demonstrate that a non-emergency, scheduled, repetitive ambulance service is medically 

necessary for Medicare coverage. The Medicare ambulance benefit at section 1861(s)(7) of the 

Act allows for coverage of an “ambulance service where the use of other methods of 

transportation is contraindicated by the individual’s condition, but. . . only to the extent provided 
805 

in regulations.” In other words, the definition of the benefit itself embodies the clinical medical 

necessity requirement that other forms of transportation must be contraindicated by a 

beneficiary’s condition. Section 410.40(d) interprets the medical necessity requirement. 

Notably, even aside from the requirements of section 1861(s)(7), section 1862(a)(1)(A) of the 

Act dictates that any service that is not medically necessary under the Act and regulations is not 

a covered benefit. 

Despite these statutory provisions and the language of the present regulation at 

§410.40(d)(2) that we believe already requires both medical necessity and a PCS, some courts 

have recently concluded that §410.40(d)(2) establishes that a sufficiently detailed and timely 

order from a beneficiary’s physician, to the exclusion of any other medical necessity 

requirements, conclusively demonstrates medical necessity with respect to nonemergency, 

scheduled, repetitive ambulance services. 

Absent explicit statutorily-based exceptions, we have consistently maintained that the 

Secretary is the final arbiter of whether a service is reasonable and necessary and qualifies for 

Medicare coverage. For example, in HCFA Ruling 93-1, we said “[i]t is HCFA’s ruling that no 

presumptive weight should be assigned to the treating physician’s medical opinion in 

determining the medical necessity of inpatient hospital or SNF services under section 1862(a)(1) 

of the Act. A physician’s opinion will be evaluated in the context of the evidence in the 

complete administrative record. Even though a physician’s certification is required for payment, 

coverage decisions are not made based solely on this certification; they are made based on 

objective medical information about the patient’s condition and the services received. This 

information is available from the claims form and, when necessary, the medical record which 

includes the physician’s certification.” 

Medical necessity is not just an integral requirement of Medicare’s ambulance benefit in 
806 

particular, but, as noted above, section 1862(a)(1)(A) of the Act dictates that services must be 

reasonable and necessary to qualify for any Medicare coverage. Numerous U.S. Circuit Courts 

of Appeal have held that PCSs or certificates of medical necessity do not, in and of themselves, 

conclusively demonstrate medical necessity. The same applies in the context of non-emergency, 

scheduled, repetitive ambulance services—the PCS is not, in and of itself, the sole determinant 

of medical necessity, and, as we discuss below, we believe the existing regulation at 

§410.40(d)(2) already demonstrates that. To erase any doubt, however, we proposed a revision 

to §410.40(d)(2) to explicitly clarify this principle. 

Since being finalized in the February 27, 2002 Federal Register (67 FR 9100, 9132), 

§410.40(d)(2) has stated that “Medicare covers medically necessary non-emergency, scheduled, 

repetitive ambulance services if the ambulance provider or supplier, before furnishing the service 

to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying 

that the medical necessity requirements of paragraph (d)(1) of this section are met.” Although a 

physician certifies with respect to medical necessity, the Secretary is the final arbiter of whether 

a service is medically necessary for Medicare coverage. As demonstrated by the inclusion of the 

phrase “medically necessary,” and by various other clarifying points, we made clear that a PCS, 

while necessary, does not on its own conclusively demonstrate the medical necessity of nonemergency, scheduled, repetitive ambulance services. 

The preamble to the February 27, 2002 final rule (Medicare Program; Fee Schedule for 

Payment of Ambulance Services and Revisions to the Physician Certification Requirements for 

Coverage of Nonemergency Ambulance Services (67 FR 9100)) and the 1999 final rule with 

comment (FRC) (Medicare Program; Coverage of Ambulance Services and Vehicle and Staff 

Requirements (64 FR 3637)) support this interpretation. 

For example, in describing comments regarding medical necessity and physician 
807 

certification in the 1999 FRC, we said: “[t]wo ambulance suppliers commented that physicians 

are unaware of the coverage requirements for ambulance services and that their decisions to 

request ambulance services may be based on ‘family preference or the inability to safely 

transport the beneficiary by other means rather than on the medical necessity requirement 

imposed by Medicare.’” We responded that section 1861(s)(7) of the Act allows coverage only 

under certain limited circumstances, and suggested that “[t]o facilitate awareness of the Medicare 

rules as they relate to the ambulance service benefit, ambulance suppliers may need to educate 

the physician (or the physician’s staff members) when making arrangements for the ambulance 

transportation of a beneficiary.” We continued that “[s]uppliers may wish to furnish an 

explanation of applicable medical necessity requirements, as well as requirements for physician 

certification, and to explain that the certification statement should indicate that the ambulance 

services being requested by the attending physician are medically necessary.” (76 FR 3637, 

3641) Since we recognize the significant program vulnerability – that the physicians writing 

PCSs might not be fully cognizant of the Medicare ambulance benefit’s medical necessity 

requirements (and encourage suppliers to help remedy that by educating physicians), it would not 

be reasonable to vest exclusively in the PCS the authority to demonstrate an ambulance 

transport’s medical necessity. We made a similar point in response to a separate comment: “It is 

always the responsibility of the ambulance supplier to furnish complete and accurate 

documentation to demonstrate that the ambulance service being furnished meets the medical 

necessity criteria.” (76 FR 3637, 3639). 

In the section of the February 27, 2002 final rule preamble describing the PCS 

requirements, we said: “[i]n all cases, the appropriate documentation must be kept on file and, 

upon request, presented to the carrier or intermediary. It is important to note that the presence of 

the signed physician certification statement does not necessarily demonstrate that the transport 
808 

was medically necessary. The ambulance supplier must meet all coverage criteria for payment to 

be made.” (67 FR 9100, 9111) Although we incorporated that passage into the final rule only at 

§410.40(d)(3)(v), we intended, and we believe our intent was clear from the preamble narrative, 

that the principle apply equally to all nonemergency ambulance transports. 

The OIG report entitled “Medicare Payments for Ambulance Transports” (OEI-05-02-

00590) (January 2006) also supports our position. Based on its analysis of a sample of calendar 

year 2002 claims, the OIG reported that “27 percent of ambulance transports to or from dialysis 

facilities did not meet Medicare’s coverage criteria.” The OIG added “the ongoing and repetitive 

nature of dialysis treatment makes transports to and from such treatment vulnerable to abuse. 

Although the condition of some patients warrants repetitive, scheduled ambulance transports for 

dialysis treatment, many dialysis transports do not meet coverage criteria.” The OIG 

recommended that we instruct our contractors to implement prepayment edits with respect to 

dialysis transports and have them request wide-ranging documents when conducting 

postpayment medical review. The fact that we agreed with the OIG’s recommendations 

demonstrated our belief that the PCS was not the sole determinant of medical necessity. 

Likewise, the fact that the OIG mentioned our ambulance coverage regulations, including the 

PCS requirement, but did not recommend altering or clarifying the regulations with respect to 

medical necessity demonstrated that we were of like mind; that, while a physician certifies with 

respect to medical necessity, the Secretary is the final arbiter of whether a service is medically 

necessary. 

Accordingly, we proposed to revise §410.40(d)(2) to add nearly the same provision 

presently found at §410.40(d)(3)(v), except for the reference to a “signed return receipt” that 

does not pertain to non-emergency, scheduled, repetitive ambulance services. We proposed to 

accomplish this by redesignating the current language as §410.40(d)(2)(i), and adding the 
809 

clarifying language to a new §410.40(d)(2)(ii). The proposed §410.40(d)(2)(ii) clarifies that a 

signed physician certification statement does not, in and of itself, demonstrate that an ambulance 

transport was reasonable and necessary. Rather, for all ambulance services, providers, and 

suppliers must retain on file all appropriate documentation and present such documentation upon 

request to a Medicare contractor. A CMS contractor may use such documentation to assess, 

among other things, whether the service satisfied Medicare’s medical necessity, eligibility, 

coverage, benefit category, or any other criteria necessary for Medicare payment to be made. 

For example, the patient’s condition must be such that other means of transportation would be 

contraindicated, and the services provided must be reasonable and necessary for the diagnosis or 

treatment of illness or injury. 

We also proposed to fix the typographical error “fro,” which should be “from”, in the 

existing § 410.40(c)(3)(ii). 

The following is a summary of the comments received on the physician certification 

statement proposal and our responses: 

Comment: Several commenters stated that it appears that CMS believes that the 

provider, not the physician signing the PCS, is responsible for the content of the PCS and that 

CMS does not intend to hold the physician signing the PCS responsible for the content of the 

PCS. Commenters also questioned whether the proposed rule would mean that the ambulance 

provider/supplier cannot rely on a properly physician-signed PCS as a tool in the process of 

proving medical necessity. The commenters disagreed with CMS’ statement that ‘no 

presumptive weight’ should be assigned to the treating physician’s medical opinion in 

determining medical necessity, recommending instead that CMS adopt a presumption that a 

repetitive transport is medically necessary when the ambulance provider/supplier has a valid 

physician-signed PCS. The commenters stated that CMS is not only requiring ambulance 
810 

providers/suppliers to police themselves, but physicians as well. As a result, it is the ambulance 

provider/supplier who must bear the sole risk of not being reimbursed for a claim that CMS 

deems does not meet medical necessity. 

Response: Ambulance providers are not responsible for the content of a properly 

prepared PCS, but, to the extent ambulance providers wish to be reimbursed by Medicare, they 

are responsible for ensuring they provide ambulance transports to eligible beneficiaries that meet 

Medicare’s ambulance coverage and medical necessity criteria. We believe the PCS is one 

safeguard to help ensure that the medical necessity criteria of Medicare’s ambulance transport 

benefit is met, but it is not the only safeguard. Indeed, especially since a PCS may be written as 

much as 2 months before the service is provided, we must be mindful of other safeguards 

including the totality of the medical record and the physical presentation of the beneficiary when 

the service is rendered. Furthermore, the ambulance provider/supplier is not obligated to provide 

a service in the absence of a properly signed PCS. There is no expectation by CMS that 

ambulance providers/suppliers police physician practice. 

Comment: Several commenters stated that while the proposed rule focuses on revisions 

to the PCS regulations in the case of repetitive transports, they strongly urged CMS to modify 

the requirements for non-repetitive, non-emergency transports and to address the burden of the 

PCS in that context by eliminating it. Current PCS requirements, they asserted, impose 

unreasonable burdens on providers/suppliers that far outweigh any benefit of the PCS to the 

Medicare Program. 

Response: We disagree because, as we note repeatedly in these responses, we believe the 

PCS is a valuable safeguard and an important tool that helps ensure that we pay only for claims 

that meet all Medicare coverage and payment criteria, and will not be making any changes in this 

final rule to the requirements for non-repetitive, non-emergency transports. 
811 

 Comment: Several commenters stated that CMS gives ambulance providers/suppliers no 

assurance that Medicare will cover the service, even if they have an attending physician’s order 

for the ambulance service. They are concerned that ambulance providers/suppliers have to 

decide whether they are going to disregard an order from a beneficiary’s attending physician 

simply because the patient’s insurer might not give any weight to that order. 

Response: By statute and regulation, Medicare may only pay for medically necessary 

ambulance transports and as with any service, we have the discretion to review a claim to ensure 

it satisfies all Medicare coverage and payment criteria. To satisfy coverage criteria, medical 

necessity must be supported by adequate medical record documentation. 

Comment: Several commenters stated that the DOJ strategy for pursuing ambulance 

providers/suppliers should not have any bearing on CMS policy for coverage of claims, that the 

requirement for ambulance providers/suppliers to obtain a PCS should be based on the need for 

medical judgment on the level of care required by the patient, and that ambulance 

providers/suppliers should be able to rely on the PCS for such. These commenters noted that if 

the PCS requirement is for some other non-medical purpose such as DOJ policy, or is simply a 

CMS requirement for an exercise in futility, the PCS requirement should be struck in its entirety. 

Response: As noted in the responses above and by virtue of its statute and regulations, 

Medicare only pays for medically necessary ambulance transports. The PCS is an important tool 

that we use as a safeguard to help ensure medical necessity, but as we mention above, it is not 

the only tool, nor, in and of itself, is it a conclusive determinant of medical necessity. 

Comment: Several commenters stated that CMS should also exempt from PCS 

requirements the two following types of transports: ground intercepts with air ambulance; and 

hospital-to-hospital transports. These commenters noted that these modifications to the PCS 
812 

requirement would apply for non-emergency, non-repetitive transports, thus limiting its 

application. 

Response: Not only do we disagree since we believe the PCS is a valuable safeguard, but 

we note that we did not propose to relax or exempt PCS requirements in any situation. 

Comment: Several commenters stated that the proposed rule ignores the fact that when 

ambulance providers/suppliers are contacted to transport a patient for a non-emergency transport, 

they are often given little information about the patient’s condition. Ambulance 

providers/suppliers must rely on information from the attending physician who has intimate 

knowledge about the patient’s ambulatory state. 

Response: While we appreciate that obtaining information may sometimes be 

challenging, this does not alter our responsibility to only pay Medicare claims that satisfy all 

Medicare coverage and payment criteria. As we noted in the preamble to the proposed rule and 

in an earlier response, it may be incumbent upon ambulance providers/suppliers to help educate 

physicians or their staff members regarding the rules pertaining to Medicare’s ambulance service 

benefit and to request additional information at the time ambulance transport is requested to 

gauge whether the transport meets Medicare’s coverage and payment criteria. 

Comment: Several commenters believed that a PCS from an attending physician 

obtained before the ambulance service should carry the same weight as physician orders that 

prescribe other Medicare-covered services. When a physician signs the PCS, these commenters 

noted, he or she is providing the same support that auditors rely upon to determine medical 

necessity. 

Response: Although we do not disagree that a physician PCS carries the same weight as 

physician orders that prescribe other Medicare-covered services, we note that we similarly audit 
813 

physician orders for medical necessity based on supporting medical record documentation as 

those orders, like the PCS in the ambulance context, in and of themselves are not determinative. 

Comment: Several commenters stated that since CMS already requires ambulance 

providers/suppliers to maintain documentation that demonstrates medical necessity for all 

ambulance transports, they believe that CMS should likewise rely on documentation from 

ambulance providers/suppliers for the types of non-emergency transports for which a PCS is 

currently required, and therefore, requested that CMS eliminate the PCS requirement for all nonemergency ambulance transports and all scheduled, repetitive ambulance transports completely. 

Response: We do rely on the medical documentation for ambulance transports, but, as 

described both in the preamble and in other responses, believe the PCS is an additional important 

safeguard that helps ensure medical necessity. 

 Comment: Several commenters expressed that obtaining a PCS remains challenging for 

ambulance providers/suppliers because, among other reasons, physicians may refuse to sign a 

PCS or because facilities and physicians sometimes confuse the PCS requirements for repetitive 

and non-repetitive transport patients, requiring the ambulance provider/supplier to spend 

substantial time justifying why they are seeking the PCS and what is required. 

Response: While we understand the challenges providers/suppliers may face in obtaining 

a PCS, as noted above our primary responsibility is ensuring we pay only properly payable 

Medicare claims and we believe that the PCS is a necessary tool in helping to determine medical 

necessity. 

Comment: Several commenters believed that CMS does not intend to hold physicians 

accountable for their signed certifications about medical necessity. Despite the fact that a signed 

PCS must be obtained from a physician, these commenters noted that ambulance 
814 

providers/suppliers bear the sole burden of determining whether Medicare’s medical necessity 

criteria have been met. 

Response: The fact that ambulance providers/suppliers, just like other 

providers/suppliers, may face some risk of non-payment when submitting claims for Medicare 

payment cannot alter our primary responsibility to only play claims that meet all Medicare 

coverage and payment criteria. Although, as we have explained, we cannot rely exclusively 

upon the PCS as a determinant of medical necessity, the PCS is an important tool to help 

establish medical necessity for the ambulance transport of a Medicare beneficiary. 

Comment: Several commenters recommended that CMS allow additional facility 

personnel, such as LPNs, social workers, or case managers to be authorized signatories for the 

PCS requirement. 

Response: We are limiting the changes in this final rule to those outlined in the proposed 

rule. We did not propose to revise our policy regarding who may sign a PCS. As a result, we 

take no position at this time on whether LPNs or other additional facility personnel should be 

authorized signatories. 

After reviewing the public comments, we are finalizing the revisions to §410.40(c)(3)(ii) 

and §410.40(d)(2) as proposed.

F. Physician Compare Website

1. Background and Statutory Authority 

 Section 10331(a)(1) of the Affordable Care Act requires that, by no later than 

January 1, 2011, we develop a Physician Compare Internet website with information on 

physicians enrolled in the Medicare program under section 1866(j) of the Act, as well as 

information on other eligible professionals who participate in the Physician Quality Reporting 

System (PQRS) under section 1848 of the Act. 
815 

 CMS launched the first phase of Physician Compare (http://www.medicare.gov/find-adoctor/provider-search.aspx) on December 30, 2010. The initial phase included the posting of 

the names of eligible professionals that satisfactorily submitted quality data for the 2009 PQRS, 

consistent with section 1848(m)(5)(G) of the Act. Since the initial launch of the website, we 

have continued to build and improve Physician Compare. Currently users can search by 

selecting a location and specialty for physicians or other healthcare professionals. Search results 

provide basic information about approved Medicare providers, such as primary and secondary 

specialties, practice locations, group practice affiliations, hospital affiliations, Medicare 

Assignment, education, languages spoken, and gender. As required by section 1848(m)(5)(G) of 

the Act, we have added the names of those eligible professionals who are successful electronic 

prescribers under the Medicare Electronic Prescribing (eRx) Incentive Program. As such, 

physician and other healthcare professional profile pages indicate if professionals satisfactorily 

participated in the PQRS and/or are successful electronic prescribers under the eRx Incentive 

Program based on the most recent data available for these two quality initiatives. 

2. Public Reporting of Physician Performance 

 Section 10331(a)(2) of the Affordable Care Act also requires that, no later than 

January 1, 2013, and for 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 that provides comparable quality and patient experience measures. This 

plan is outlined below. 

 Comment: We received several comments requesting that CMS clarify its plans with 

respect to making PQRS data publicly available through Physician Compare no later than 

January 1, 2013. 

 Response: We appreciate the commenters’ interest in public reporting on Physician 
816 

Compare. Please note that CMS has met the Affordable Care Act requirements to implement a 

plan prior to January 1, 2013 for making physician performance information available on 

Physician Compare, and intends to continue to outline elements of that plan through rulemaking. 

To the extent that scientifically sound measures are developed and are available, we are 

required to include, to the extent practicable, the following types of measures for public 

reporting: 

● Measures collected under the PQRS. 

● An assessment of patient health outcomes and functional status of patients. 

● An assessment of the continuity and coordination of care and care transitions, 

including episodes of care and risk-adjusted resource use. 

● An assessment of efficiency. 

● An assessment of patient experience and patient, caregiver, and family engagement. 

● An assessment of the safety, effectiveness, and timeliness of care. 

● Other information as determined appropriate by the Secretary. 

As required under section 10331(b) of the Affordable Care Act, in developing and implementing 

the plan, we must include, to the extent practicable, the following: 

● Processes to ensure that data made public are statistically valid, reliable, and accurate, 

including risk adjustment mechanisms used by the Secretary. 

● Processes for physicians and eligible professionals whose information is being 

publicly reported to have a reasonable opportunity, as determined by the Secretary, to review 

their results before posting to Physician Compare. 

● Processes to ensure the data published on Physician Compare provides a robust and 

accurate portrayal of a physician’s performance. 

● Data that reflects the care provided to all patients seen by physicians, under both the 
817 

Medicare program and, to the extent applicable, other payers, to the extent such information 

would provide a more accurate portrayal of physician performance. 

● Processes to ensure appropriate attribution of care when multiple physicians and other 

providers are involved in the care of the patient. 

● Processes to ensure timely statistical performance feedback is provided to physicians 

concerning the data published on Physician Compare. 

● Implementation of computer and data infrastructure and systems used to support valid, 

reliable, and accurate reporting activities. 

 Section 10331(d) of the Affordable Care Act requires us to consider input from 

multi-stakeholder groups in selecting quality measures for Physician Compare, which we seek to 

accomplish through rulemaking and focus groups. In developing the plan for making 

information on physician performance publicly available through Physician Compare, section 

10331(e) of the Affordable Care Act requires the Secretary, as the Secretary deems appropriate, 

to consider the plan to transition to value-based purchasing for physicians and other practitioners 

that was developed under section 131(d) of the Medicare Improvements for Patients and 

Providers Act of 2008. 

 We are required, under section 10331(f) of the Affordable Care Act, to submit a report to 

the Congress by January 1, 2015, on Physician Compare development, and include information 

on the efforts and plans to collect and publish data on physician quality and efficiency and on 

patient experience of care in support of value-based purchasing and consumer choice. Section 

10331(g) of the Affordable Care Act provides that any time before that date, we may continue to 

expand the information made available on Physician Compare. 

 We believe section 10331 of the Affordable Care Act supports our overarching goals of 

providing consumers with quality of care information to make informed decisions about their 
818 

healthcare, while encouraging clinicians to improve on the quality of care they provide to their 

patients. In accordance with section 10331 of the Affordable Care Act, we intend to utilize 

Physician Compare to publicly report physician performance results. 

 In implementing our plan to publicly report physician performance, we will use data 

reported under the existing PQRS as an initial step for making physician “measure performance” 

information public on Physician Compare. By “measure performance” in relation to the PQRS, 

we mean the percent of times that a particular clinical quality action was reported as being 

performed, or a particular outcome was attained, for the applicable persons to whom a measure 

applies as described in the denominator for the measure. For measures requiring risk adjustment, 

“measure performance” refers to the risk adjusted percentage of times a particular outcome was 

attained. 

 We previously finalized a decision to make public on Physician Compare the 

performance rates on the quality measures that group practices submit under the 2012 PQRS 

group practice reporting option (GPRO) (76 FR 73417). Therefore, we are targeting to post 

performance information collected through the GPRO web interface for group practices 

participating in the 2012 PQRS GPRO on Physician Compare in 2013 or early 2014. 

Specifically, we will make public performance information for measures included in the 2012 

PQRS GPRO that meet the minimum sample size, and that prove to be statistically valid and 

reliable. As we previously established, if the minimum threshold is not met for a particular 

measure, or the measure is otherwise deemed not to be suitable for public reporting, the group’s 

performance rate for that measure will be suppressed and not publicly reported. We previously 

established a minimum threshold of 25 patients for reporting performance information on 

Physician Compare (76 FR 73418). Although we considered keeping the threshold for reporting 

performance data on Physician Compare at 25 patients, we proposed to change the minimum 
819 

patient sample size, from 25 patients to 20 patients, beginning with data collected for services 

furnished in 2013 (77 FR 44803). 

The following is summary of the comments we received regarding the new minimum 

patient sample size proposal: 

Comment: We received comments related to the reduction in patient threshold for public 

reporting. Most commenters opposed the reduction, stating that the lower threshold may be less 

accurate and statistically valid. One commenter pointed to literature supporting the previous 

threshold of 25, and suggested that CMS maintain this threshold, though the commenter did not 

expressly state which literature they were referencing, and one suggested a patient size of 30. 

We received comments stating that this reduced sample size was insufficient to apply across all 

measures, and that the sample size should be determined based on the measure to which it is 

applied. One commenter requested further detail on what it would mean for a measure to be 

suitable for public reporting. Several comments were supportive of the proposal stating that this 

may increase participation. 

Response: We appreciate the commenters’ feedback regarding reducing the patient 

sample size for public reporting from 25 patients to 20 patients. We are committed to reporting 

quality of care data that is statistically valid, reliable, and accurate, and will only post data that 

meet this standard of reliability regardless of threshold, and regardless of measure type. Should 

we find a measure meeting the minimum threshold to be invalid or unreliable for any reason, the 

measure will not be reported. 

We appreciate the comment that this reduction may increase participation; however we 

note that this proposal only relates to Physician Compare. While the decreased threshold may 

increase participation for other quality reporting programs, we do not believe it will have an 

impact on Physician Compare. 
820 

We believe this threshold of 20 patients to be sufficient to protect patient privacy for 

reporting on the site, and should thus be applied to every measure reported on Physician 

Compare. Currently, this is the reliability threshold being finalized for both the Value-Based 

Modifier (VBM) and the proposed PQRS criteria for reporting measure groups. As we work to 

align quality initiatives and minimize reporting burden on physicians and other healthcare 

professionals, we will finalize our proposal to reduce the reporting threshold from 25 to 20 

patients. 

In the Shared Savings Program final rule (76 FR 67948), we finalized Accountable Care 

Organization (ACO) public reporting provisions in the interest of promoting greater transparency 

regarding the ACOs participating in the program. We finalized requirements for ACOs to 

publicly report certain data, as well as data that we would publicly report. Because ACO 

providers/suppliers that are eligible professionals are considered to be group practices for 

purposes of qualifying for a PQRS incentive under the Shared Savings Program, we indicated 

that performance on quality measures reported by ACOs at the ACO TIN level, on behalf of their 

ACO providers/suppliers who are eligible professionals, using the GPRO web interface would be 

reported on Physician Compare in the same way as for the groups that report under the PQRS. 

In April 2012, we added functionality to Physician Compare allowing users to search for 

group practices in preparation for the addition of 2012 PQRS GPRO data. A full website 

redesign is slated for early 2013 to further prepare the site for the introduction of quality data and 

ACO information. With each enhancement, we work to improve the usability and functionality 

of the site, providing consumers with more tools to help them make informed healthcare 

decisions. 

In CY 2012, we intend to enhance the accuracy of “administrative” information displayed 

on the eligible professional’s profile page, and to add additional data. By administrative data, we 
821 

are referring to information about eligible professionals that is pulled from the Provider 

Enrollment, Chain, and Ownership System (PECOS) and other readily available external data 

sources. Specifically, we intend to add whether a physician or other health care professional is 

accepting new Medicare patients, board certification information, and to improve the foreign 

language and hospital affiliation data. We also intend to include the names of those eligible 

professionals who participated in the Medicare EHR Incentive Program, as authorized by section 

1848(o)(3)(D) of the Act, and the names of those eligible professionals who satisfactorily 

participated under the PQRS GPRO for 2011. We will continue to update the names of those 

eligible professionals and group practices who satisfactorily participated under the PQRS, and 

those who are successful electronic prescribers under the eRx Incentive Program based on the 

most recent program year data available. 

Comment: We received one comment in support of the inclusion of eRx and PQRS 

Incentive Program Data or Administrative data on the site, and one comment requesting that 

participation information for PQRS be limited to those who satisfactorily report this information. 

Response: We appreciate the commenter's feedback and support for including eRx and 

PQRS Incentive Program participation data on Physician Compare. We intend to continue to post 

the names of those eligible professionals and group practices who satisfactorily participated 

under the PQRS, and those who are successful electronic prescribers under the eRx Incentive 

Program on the website as we are required to report this information publicly, and Physician 

Compare offers an excellent venue for making this information available to consumers. 

Comment: We received comments regarding the posting of Medicare EHR Incentive 

Program participation and Meaningful Use participation information on Physician Compare. 

One commenter requested that CMS post the names of all those who participate in the Medicare 

EHR Incentive Program, not just those who did so successfully. One commenter requested that 
822 

we add a note to distinguish what stage of Meaningful Use the eligible professional is taking 

part. 

Response: We intend to post the names of those eligible professionals who successfully 

participated in the Medicare EHR Incentive Program on Physician Compare, when feasible. We 

will further evaluate the suggestion regarding stages of Meaningful Use, but at this time CMS 

does not intend to distinguish between stages of participation. 

In support of the HHS-wide Million Hearts Initiative, we proposed to post the names of 

the eligible professionals who report the PQRS Cardiovascular Prevention measures group (77 

FR 44803). This is consistent with the requirements under section 10331 of the Affordable Care 

Act to provide information about physicians and other eligible professionals who participate in 

the PQRS. 

The following is a summary of the comments received regarding the proposal to post the 

names of eligible professionals who report the PQRS Cardiovascular Prevention measures group 

in support of the Million Hearts Initiative: 

Comment: Commenters generally supported our proposal. Some commenters pointed out 

that the PQRS Cardiovascular Prevention measures group may not apply to all professionals or 

all specialties, and were therefore in support of the proposal only if those professionals who did 

not report on the measures group were not negatively represented for their lack of participation. 

One commenter requested that the mechanism of data submission also be reported on the site. 

Response: At this time, we are targeting posting the names of eligible professionals who 

satisfactorily report PQRS Cardiovascular Prevention measures group in support of the Million 

Hearts Initiative in 2014 for the 2013 reporting period. As with all participation data of this 

nature on Physician Compare, if a professional is participating in this program by satisfactorily 

reporting on the PQRS Cardiovascular Prevention measures group, an indicator will be noted on 
823 

their profile page; if a professional is not satisfactorily reporting on this measures group, no 

indicator will be included. We believe this approach serves to acknowledge those who 

participate without negative reflection on those who do not. While we appreciate the comment 

that data submission mechanism also be reported on the site, it is not technically feasible to 

report that information at this time. 

3. Future Development of Physician Compare 

Consistent with Affordable Care Act requirements, it is our intent to phase in an 

expansion of Physician Compare over the next several years by incorporating quality measures 

from a variety of sources, as technically feasible. For our next phase, we proposed to make 

public on Physician Compare, performance rates on the quality measures that group practices 

submit through the GPRO web interface under the 2013 PQRS GPRO and the Medicare Shared 

Savings Program (77 FR 44803). We indicated that we anticipated the 2013 PQRS GPRO web 

interface measures data would be posted no sooner than 2014. These data would include 

measure performance rates for measures included in the 2013 PQRS GPRO web interface that 

met the proposed minimum sample size of 20 patients, and that proved to be statistically valid 

and reliable. 

When technically feasible, and targeted for posting on the site in 2014, we proposed to 

publicly report composite measures that reflect group performance across several related 

measures (77 FR 44803). As an initial step we intend to develop disease module level composite 

scores for PQRS GPRO measures. Under the Medicare Shared Savings Program, ACOs are 

required to report on composite measures for Diabetes Mellitus (DM) and Coronary Artery 

Disease (CAD) (76 FR 67891). Accordingly, in an effort to align the PQRS GPRO measures 

with the GPRO measures under the Shared Savings Program, we proposed to add composite 

measures for DM and CAD into the PQRS starting in reporting year 2013. We also indicated we 
824 

would consider future development of composites for the remaining disease level modules within 

the GPRO web interface. As more data are added to Physician Compare over time, we stated we 

would consider adding additional disease level composites across measure types as technically 

feasible and statistically valid. 

The following is a summary of the comments received regarding our proposal to post 

performance rates on the quality measures that group practices submit through the GPRO web 

interface under the 2013 PQRS GPRO and the Medicare Shared Savings Program, and to report 

composite measures at the disease module level for 2013 GPRO data: 

Comment: One commenter supported our proposal to post PQRS GPRO and ACO 

performance rates as it was limited to measures reported through the GPRO web interface, and 

suggested CMS not expand reporting to data collected via other reporting mechanisms at this 

time. Another commenter expressed support of our proposal to post composite measures at the 

disease module level, but requested that CMS postpone the posting of these composites until 

physicians and groups have time to review their performance as it pertains to individual elements 

of the composite. 

Response: We are dedicated to providing quality of care data on Physician Compare as 

soon as feasible so that healthcare consumers have access to information to help them make 

informed healthcare decisions. We are finalizing our proposal to post performance rates on the 

quality measures that group practices submit through the GPRO web interface under the 2013 

PQRS GPRO and the Medicare Shared Savings Program. In an effort to align PQRS GPRO 

measures with the GPRO measures under the Shared Savings Program, we are finalizing our 

proposal to generate composite measures for DM and CAD based on measures reported through 

the GPRO web interface for groups participating in program year 2013 PQRS GPRO and ACOs 

participating in the Shared Savings Program. This requirement regarding posting of ACO data is 
825 

finalized at §425.308. We target posting these data in 2014 for the 2013 reporting period, as 

technically feasible, as we believe these data are valuable to consumers in evaluating group 

practices and ACOs. We will provide a 30-day preview period prior to publication of quality 

data on Physician Compare so that ACOs and group practices can view their data as it will 

appear on Physician Compare before it is publicly reported. 

Consistent with the requirement under section 10331(a)(2) of the Affordable Care Act to 

implement a plan to make comparable information on patient experience of care measures 

publicly available, we proposed to post patient experience survey-based measures from the 

Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) 

(77 FR 44804). As discussed in section G.6.c. of this final rule with comment period, we 

proposed to collect the following patient experience of care measures for group practices 

participating in the PQRS GPRO (77 FR 44964): 

• CAHPS: Getting Timely Care, Appointments, and Information 

• CAHPS: How Well Your Doctors Communicate 

• CAHPS: Patients’ Rating of Doctor 

• CAHPS: Access to Specialists 

• CAHPS: Health Promotion and Education 

These measures capture patients’ experiences with clinicians and their staff, and patients’ 

perception of care. We proposed, no earlier than 2014, to publicly report 2013 patient 

experience data for all group practices participating in the 2013 PQRS GPRO, not limited to 

those groups participating via the GPRO web interface, on Physician Compare. At least for 

2013, we noted that we intended to administer and collect patient experience survey data on a 

sample of the group practices’ beneficiaries. As we intend to administer and collect the data for 

these surveys, we indicated that we did not anticipate any notable burden on the groups. 
826 

For ACOs participating in the Shared Savings Program, consistent with the PQRS 

proposal to publicly report patient experience measures on Physician Compare starting in 2013, 

we proposed to publicly report patient experience data in addition to the measure data reported 

through the GPRO web interface (77 FR 44804). Specifically, the patient experience measures 

that would be reported for ACOs include the CAHPS measures in the Patient/Caregiver 

Experience domain finalized in the Shared Savings Program final rule (76 FR 67889): 

• CAHPS: Getting Timely Care, Appointments, and Information 

• CAHPS: How Well Your Doctors Communicate 

• CAHPS: Patients’ Rating of Doctor 

• CAHPS: Access to Specialists 

• CAHPS: Health Promotion and Education 

• CAHPS: Shared Decision Making 

For patient experience data reported under either the PQRS GPRO or the Medicare 

Shared Savings Program, we also considered an alternative option of providing confidential 

feedback to group practices and ACOs using 2013 patient experience data before publicly 

reporting patient experience data on Physician Compare (77 FR 44804). In lieu of publicly 

reporting the patient experience data relating to 2013 PQRS GPRO and ACOs participating in 

the Shared Savings Program, we considered using the 2013 results as a baseline to be shared 

confidentially with the group practices and ACOs, during which time the group practices and 

ACOs would have the opportunity to review their data, and implement changes to improve 

patient experience scores. Under this alternative option, program year 2014 patient experience 

data would be the first to be publicly reported on Physician Compare, and we would publicly 

report 2014 patient experience data for ACOs and group practices participating in the 2014 

PQRS GPRO on Physician Compare no earlier than 2015. We invited public comment on our 
827 

proposal to begin publicly reporting patient experience data for program year 2013, and also the 

alternative option of delaying public reporting of patient experience of care data on Physician 

Compare until program year 2014 in order to give group practices and ACOs the opportunity to 

make changes to the processes used in their practices based on the review of their data from 

program year 2013 (77 FR 44804). 

The following is a summary of the comments we received regarding our proposal to 

publicly report patient experience data: 

Comment: Many commenters supported the alternate proposal to post 2014 data in 2015, 

and to use 2013 data as confidential feedback for providers to review their results. Most 

commenters believed this would give groups a chance to improve their results before they are 

publically reported, and some commenters suggested that groups have the opportunity to 

resurvey patients prior to the posting of results. 

Response: We appreciate the commenters’ feedback regarding the posting of patient 

experience data for 2014 in 2015 and using the results of patient experience data collected for 

program year 2013 as a confidential reporting period so that physicians can review their data and 

improve on their performance before the start of public reporting. We are dedicated to providing 

patient experience data on Physician Compare as soon as feasible so that healthcare consumers 

can have access to this important information to help them make informed decisions. After 

considering the public comments, our final decision is to provide all ACOs and group practices 

an opportunity to see their patient experience data in reports provided by the data collection 

vendor before it is published. A 30-day preview period prior to publication will allow ACOs and 

group practices to see their data as it will appear on Physician Compare before it is reported. This 

30-day period is in line with the preview period provided for other public reporting programs 

such as Hospital Compare. 
828 

Understanding the strong desire from consumers for these data, and given our 

commitment to public reporting, we are finalizing our proposal to target the reporting of patient 

experience data, collected no earlier than 2013, on Physician Compare in 2014, if technically 

feasible, for groups of one hundred or more eligible professionals reporting via the GPRO web 

interface, including ACOs participating in the Shared Savings Program. The requirement 

regarding posting of ACO data is finalized at §425.308. We believe that by limiting this posting 

requirement to group practices and ACOs participating via the GPRO web interface, and by 

allowing group practices and ACOs to preview their data during a 30-day preview period, we are 

able to address the concerns of the provider community while making this data available to 

healthcare consumers and meeting the mandates set forth by the Affordable Care Act. Due to 

patient privacy and confidentiality, we will not implement the suggestion that groups have the 

opportunity to resurvey patients prior to the posting of results. 

Comment: Some commenters expressed concern over the cost of implementing a patient 

experience survey, and others questioned whether the surveys were adequately tailored to certain 

types of groups and settings, such as emergency departments, stating that the survey used should 

be validated for a variety of settings. Some of these commenters suggested that different 

surveys, such as S-CAHPS for surgical settings should be used based on setting. One 

commenter also suggested that the entire CAHPS survey should be used as opposed to only 

using certain domains. 

Response: We are dedicated to accurate, valid, and reliable public reporting on Physician 

Compare and are aware that each group practice is unique in size and scope. We have closely 

evaluated the available data collection mechanisms, and are confident that CG-CAHPS is a welltested collection mechanism with strong support from the healthcare community, and that it 

provides the best opportunity to collect useful and accurate data for the largest number of group 
829 

practices. We will use only those survey domains that are applicable to group practices or ACOs 

respectively, and believe that these domains have been well tested, and will therefore provide the 

best data for the largest number of groups. 

We are dedicated to supporting group practices in the reporting of these important data. 

Thus, we are finalizing a policy under which CMS will administer the patient experience of care 

survey for calendar year 2013 and 2014 for all group practices of 100 or more eligible 

professionals that sign up for the PQRS GPRO web interface. Similarly, as discussed in the 

Shared Savings Program Final Rule, CMS will fund and administer the CAHPS survey for 

ACOs participating in the Shared Savings Program in 2013 (76 FR 67875). 

As we continue to improve administrative and provider level data, we proposed posting 

the names of those physicians who earned a PQRS Maintenance of Certification Program 

Incentive as data becomes available, and targeted for 2014 (77 FR 44804). 

The following is a summary of the comments we received related to posting the names of 

physicians who earned a PQRS Maintenance of Certification Program Incentive: 

Comment: Many commenters were supportive so long as there were no negative 

reflections on those who did not receive the incentive; however, one commenter did not believe 

this information was relevant to Physician Compare. 

Response: We are finalizing our proposal to include the names of eligible professionals 

who earned an incentive in the PQRS Maintenance of Certification Program Incentive as data are 

available, and targeted for 2014. To address concerns regarding negative impact, as with all data 

of this nature currently on Physician Compare, if an eligible professional is participating in the 

program, an indicator will be noted on their profile page; if a professional is not participating, no 

indicator or negative indication will be included. We believe this approach serves to 

acknowledge those who earned a PQRS Maintenance of Certification Program Incentive without 
830 

reflecting negatively on those who did not. We also believe that this information will be helpful 

to healthcare consumers as they work to make informed healthcare decisions and is thus relevant 

to Physician Compare. 

Comment: We received one comment requesting that ABMS Maintenance of 

Certification status be posted on the site, and one suggesting that information about ABMS 

Maintenance of Certification also be posted. 

Response: We appreciate the commenter's feedback regarding including ABMS 

Maintenance of Certification data on Physician Compare. At this time, we are targeting to post 

the names of eligible professionals who earned a PQRS Maintenance of Certification Program 

incentive as data are available, and targeted for 2014. We do not currently have plans to also 

include the ABMS MOC information, but will consider this for future rulemaking. 

We considered allowing measures that have been developed and collected by approved 

and vetted specialty societies to be reported on Physician Compare, as deemed appropriate, and 

as they are found to be scientifically sound and statistically valid (77 FR 44804). We proposed 

including additional claims-based process, outcome and resource use measures on Physician 

Compare, and noted that we intend to align measure selection for Physician Compare with 

measures selected for the Value Based Modifier (VBM) (section III.K). 

We received several comments related to reporting measures developed and collected by 

specialty societies. The following is a summary of the comments we received: 

Comment: Many commenters believe this was a good way to identify measures that are 

most appropriate for certain specialties, and to reduce the reporting burden on those specialties as 

the measures are already being collected, and their data are already available. Several 

commenters offered to assist CMS in gathering these data. A few commenters requested 

clarification on what measures would be posted, how CMS would vet these measures. 
831 

Response: We appreciate the commenters’ feedback regarding reporting of measures 

developed by specialty societies on Physician Compare. We understand the importance of 

publicly reporting measures that are most appropriate for all specialties, and believe working 

with specialty societies to identify quality measure data that are already collected and available 

reduces the reporting burden on these specialties while providing accurate, reliable, and valid 

data on the site. This approach also provides an opportunity to expand public reporting to 

specialties and types of physicians not currently represented. We intend to work with specialty 

societies to identify the most appropriate data sources and mechanism for inclusion on Physician 

Compare. 

We will work to ensure that any specialty society data included on Physician Compare is 

approved, vetted, scientifically sound, and statistically reliable. As with PQRS measures and 

other measures posted on Physician Compare, any measures under consideration will be 

subjected to the Measures Application Partnership (MAP) pre-rulemaking process prior to being 

considered for posting on the site. Please note that such measures will be addressed in future 

rulemaking. 

We received comments related to our proposed alignment of Physician Compare with the 

VBM. The following is a summary of the comments we received: 

Comment: One commenter did not support our proposal to align with PQRS or the VBM 

as they believed this data may be overwhelming to healthcare consumers. The commenter went 

on to say that Physician Compare should distinguish itself as a site committed to communicating 

validated and meaningful information, and not try to align with these programs. 

Response: We appreciate the commenters’ feedback regarding the proposal to align 

public reporting on Physician Compare with elements of PQRS and the VBM. We are committed 

to working toward reporting measures that are accurate and complete. Please note that not all 
832 

measures collected will be posted on the site, and only those measures that are deemed 

appropriate for public reporting and useful to consumers will be posted. We believe alignment 

with PQRS and the VBM on Physician Compare provides significant opportunities as we move 

toward a payment model related to quality and cost efficiencies. Aligning quality initiatives also 

provides an opportunity for publically reporting more quality data while also minimizing the 

reporting burden on eligible professionals. We will continue to align our public reporting goals 

with these programs. 

Comment: One commenter questioned how CMS is able to report performance data on 

Physician Compare within one year, but points out the technical infeasibility of calculating 

performance-based payments within that same time frame. 

Response: We appreciate the commenter's feedback regarding a timeline for public 

reporting on Physician Compare in relation to the timeline for calculating performance-based 

payments. We are working on a phased approach to public reporting across a number of data 

sources and are looking to do so in a way that does not increase reporting burden, allows 

accurate reporting, and supports the agency’s mission and goals. For these reasons, we are 

working to align the measures reported on Physician Compare with other CMS quality 

initiatives, such as PQRS and VBM as technically feasible. Please note that not all measures 

included in these other initiatives will be publicly reported on the site, and that the programs 

have distinct timelines. Performance-based payments require additional calculation beyond that 

which we proposed to publicly report. While Physician Compare has a plan to report 

performance data as soon as technically feasible, we will not report that data before it has been 

accurately calculated, and has proved to be statistically valid and reliable. 

We proposed to include group level ambulatory care sensitive condition admission 

measures of potentially preventable hospitalizations developed by the HHS Agency for 
833 

Healthcare Research and Quality (AHRQ) that meet the proposed minimum sample size of 20 

patients, and that prove to be statistically valid and reliable (measure details are available at 

http://www.qualitymeasures.ahrq.gov/content.aspx?id=27275) (77 FR 44804). We proposed 

reporting these measures on Physician Compare no earlier than 2015 for those group practices 

composed of 2 - 99 eligible professionals participating in the proposed 2014 PQRS GPRO, and 

for ACOs. 

We received comments related to our proposal to post group level ambulatory care 

sensitive condition admission measures of potentially preventable hospitalizations developed by 

AHRQ. The following is a summary of the comments we received: 

Comment: Most commenters opposed the posting of these measures, and one commenter 

stated that they strongly opposed the addition of these measures. One commenter requested 

clarification as to what testing and validation had been done around these measures. 

Response: We are committed to only including quality of care measures on Physician 

Compare that are properly vetted and tested, as well as statistically valid and reliable. We have 

decided to allow other programs within CMS to work with these measures, gather the data, and 

provide feedback to the groups prior to posting on Physician Compare. We will not finalize our 

proposal to post group level ambulatory care sensitive condition admission measures of 

potentially preventable hospitalizations at this time. Instead, we will consider the input we 

received as we further evaluate the inclusion of such measures on Physician Compare, and 

address this issue in future rulemaking. 

We also proposed to publicly report performance rates on quality measures included in 

the 2015 PQRS and VBM for individual eligible professionals (77 FR 44804). We indicated, 

however, that further details on what measures would be included in the 2015 reporting period 

will be addressed in future rulemaking. We also proposed that public reporting of 2015 PQRS 
834 

and administrative claims-based quality measures for individuals would occur no earlier than 

2016. 

We received several comments related to the posting of individual-level measures on 

Physician Compare. The following is a summary of the comments we received: 

Comment: Some commenters supported our proposal, and one requested that this 

information be made available as soon as technically feasible stating the information was 

valuable to consumer decision making. One commenter requested that CMS consider including 

data that is reported through a variety of reporting mechanisms such as claims and registries to 

ensure all reporting individuals would be represented regardless of reporting mechanism. 

Response: We agree that individual-level measure data is important in helping 

consumers make informed healthcare decisions, and agree that this information should be posted 

on the site as soon as technically feasible. We will move up this plan and target posting 

individual-level measure data in 2015 using 2014 data if technically feasible. Please note that 

further discussion of this topic, and the measures to be included will be addressed in future 

rulemaking. 

Comment: One commenter opposed the posting of individual-level measure data stating 

this data may be overwhelming to consumers. The commenter went on to caution that measures 

posted on Physician Compare should be selected based on how well they resonate with 

consumers. Another commenter expressed concerns regarding the different reporting 

mechanisms available in PQRS, and how measures reported through the different mechanisms 

would be represented. 

Response: We appreciate the commenter’s concerns around the posting of these 

measures. We are committed to including only the most accurate, statistically reliable and valid 

quality of care measure data on Physician Compare when the data are publicly reported. Any 
835 

data found to be invalid or inaccurate for any reason will not be publicly reported. We will 

ensure that these data are collected and presented appropriately, regardless of the mechanism 

through which they are collected, and that they accurately reflect performance. Measures to be 

posted on the site will be selected based on a variety of criteria including consumer interest, and 

will be subject to consumer testing. Please note that further discussion of this topic, and the 

measures to be included will be addressed in future rulemaking. 

For all measures publicly reported on Physician Compare, we proposed to post a standard 

of care, such as those endorsed by the National Quality Forum (77 FR 44804). Such information 

would serve as a standard for consumers to measure individual provider, and group level data. 

We received comments related to our proposal to post a standard of care on Physician 

Compare. The following is a summary of the comments we received: 

Comment: One commenter supported our proposal to post a standard such as those 

endorsed by the NQF. Some commenters sought clarification around the standard to be used, 

and expressed concerns that an NQF standard may be limiting to certain specialties, stating that 

NQF standards are heavily focused on primary care. Commenters also suggested consumer 

testing if such as standard is to be posted to insure the information is understandable to 

consumers. 

Response: We appreciate the commenters’ feedback regarding posting a standard of care 

on Physician Compare. We are currently considering including an NQF standard for those 

measures reported on Physician Compare where a standard of care is endorsed, available, and 

applicable. We are declining to finalize our proposal at this time and are only seeking additional 

comment. We will address this issue in future rulemaking. 

We received several comments not directly related to our proposals which are 

summarized below. 
836 

Comment: The majority of commenters was concerned about the accuracy of data 

currently on Physician Compare, and urged CMS to consider this feedback in its plans for future 

development. Commenters stated that data on Physician Compare did not meet certain standards 

of accuracy, and one called for a cessation of the site until concerns could be addressed. Some 

commenters expressed frustration about the difficulty they experienced in getting their 

information updated or corrected, and some requested a way to update their information on the 

site. Some commenters requested that data be updated in a timely fashion to ensure it is up-todate and accurate. One commenter expressed concerns related to data collection mechanisms 

and comparability on Physician Compare. 

Response: We are committed to including accurate and up-to-date information on 

Physician Compare and continue to work to make improvements to the information presented. 

The current primary data source for Physician Compare is PECOS. In order for a physician, 

other healthcare professional, or group practice’s information to appear on Physician Compare, 

their enrollment record in PECOS must be current and in ‘‘approved’’ status, a valid physical 

location or address must be identified, and the professional must have an NPI. It is critical that 

data in PECOS be accurate and up-to-date to ensure the data on Physician Compare are also 

accurate and up-to-date. CMS is evaluating other options for physician, healthcare professionals 

and group practices to update their information, and is looking at other available data sources to 

validate PECOS data to further improve accuracy as we continue to improve the data presented 

on Physician Compare. 

We are equally committed to including only the most accurate, statistically reliable and 

valid quality of care measure data on Physician Compare when those data are publicly reported. 

We are committed to ensuring that these data are comparable and presented appropriately 

regardless of the mechanism through which they are collected, and that they accurately reflect 
837 

performance. We will ensure these data are updated in a timely fashion as technically feasible, 

and will provide a 30-day preview period for physicians and group practices to view their data 

prior to it being posted on the site. 

Comment: We received comments requesting a disclaimer be placed on the site for the 

purpose of explaining why measures may not apply to certain groups, and that the absence of 

data on a particular measure does not imply poor performance or poor quality. 

Response: We agree with the commenters that disclaimers and other forms of 

explanatory language are necessary to help inform healthcare consumers and other users of the 

site. Regarding the request for a disclaimer, or clarification explaining the absence of 

participation or measure data, we are evaluating disclaimer language for use on Physician 

Compare when data are published on the site, and will take this feedback into consideration. 

Comment: We received several comments cautioning that too much data on the site 

could cause confusion for consumers and other users of the site. 

Response: We appreciate the commenters’ feedback, and understand their concerns. As 

required under section 10331(b) of the Affordable Care Act, in developing and implementing the 

plan to include performance data on Physician Compare, we must include, to the extent 

practicable, processes to ensure that the posted data are statistically valid, reliable, and accurate, 

including risk adjustment mechanisms used by the Secretary, as well as processes to ensure 

appropriate attribution of care when multiple providers are involved in the care of the patient. 

We understand that this information is complex, and are committed to providing data on 

Physician Compare that are useful to beneficiaries in assisting them to make informed healthcare 

decisions, while being accurate, valid, reliable, and complete. We will closely evaluate all 

quality measures under consideration for public reporting on the website to ensure they are 

presented in a way that is helpful to beneficiaries and, through consumer testing and stakeholder 
838 

outreach, will work to ensure that the number of measures and data sources presented is done in 

such a way that the information is valuable to consumers. 

Comment: We received several comments requesting that a section of Physician 

Compare be dedicated to hospital-based physicians, or that Physician Compare link to Hospital 

Compare for certain hospital-based physicians so users may view data on hospital-based 

physician through a variety of perspectives. 

Response: We appreciate the commenters’ feedback regarding customizing a section of 

Physician Compare for hospital-based physicians. Physician Compare is tasked with providing 

consumers with useful information about Medicare physicians and other healthcare professionals 

who provide services in a variety of specialties and care settings. At this time, it is not feasible 

to customize the website for specific physician groups, but we will consider this feedback as we 

continue to evaluate if such customization is beneficial to consumers and potentially feasible in 

future development. We will continue to evaluate a link between Physician Compare and 

Hospital Compare as appropriate. 

Comment: We received comments requesting that CMS include other healthcare 

professionals on Physician Compare and not limit the site to physicians. 

Response: We appreciate the commenter's feedback. Currently the site does feature 

information on physicians and other healthcare professionals as required by the Affordable Care 

Act. 

Comment: We received one comment stating that CMS should consider a distillation of 

quality data into a reporting system such as star ratings for physicians and group practices. 

Response: We appreciate the commenter’s suggestion, and agree that a reporting system 

such as star ratings can be helpful to users in consuming these data. We will continue to evaluate 

star ratings and other methods of displaying measure data based on the measures selected for 
839 

posting on the site. 

Comment: We received one comment requesting that additional education, residency and 

administrative information for physicians and other healthcare professionals be posted on the 

site. 

Response: We appreciate the feedback regarding the inclusion of education, and other 

administrative information on Physician Compare. At this time, Physician Compare includes 

some educational and residency information. We are working to include Board Certification 

information on the site as feasible, and will continue to evaluate additional information and data 

sources that can provide beneficial information for consumers as they are available in the future. 

All posting of this additional information will be addressed in future rulemaking. 

We are committed to making Physician Compare a constructive tool for Medicare 

beneficiaries, successfully meeting the Affordable Care Act mandate, and in doing so, providing 

consumers with information needed to make informed healthcare decisions. We have developed 

a plan, and started to implement that plan with a phased approach to adding physician quality 

data to Physician Compare. We believe this staged approach to public reporting of physician 

quality information allows consumers access to information that is currently available while we 

continue to develop the infrastructure necessary to support additional types of data and 

information on physicians’ quality measure performance. Implementation of subsequent phases 

of the plan will need to be developed and addressed in future notice and comment rulemaking, as 

needed. 

G. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting 

System
840 

 There are several healthcare quality improvement programs that affect physician 

payments under the Medicare PFS. The National Quality Strategy establishes three aims for 

quality improvement across the nation: better health, better healthcare, and lower costs. This 

strategy, the first of its kind, outlines a national vision for quality improvement and creates an 

opportunity for programs to align quality measurement and incentives across the continuum of 

care. We believe that this alignment is especially critical for programs involving physicians. 

The proposals that follow facilitate the alignment of programs, reporting systems, and quality 

measures to make this vision a reality. We believe that alignment of CMS quality improvement 

programs will decrease the burden of participation on physicians and allow them to spend more 

time and resources caring for beneficiaries. Furthermore, as the leaders of care teams and the 

healthcare systems, physicians and other clinicians serve beneficiaries both as frontline and 

system-wide change agents to improve quality. However, we believe that to improve quality, 

quality measurement and reporting is an important component. It is our intent that the following 

requirements will improve alignment of physician-focused quality improvement programs, 

decrease the burden of successful participation on physicians, increase engagement of physicians 

in quality improvement, and ultimately lead to higher quality care for beneficiaries. 

This section contains the requirements for the Physician Quality Reporting System 

(PQRS). The PQRS, as set forth in section 1848(a), (k), and (m) of the Act, is a quality reporting 

program that provides incentive payments and payment adjustments to eligible professionals 

based on whether or not they satisfactorily report data on quality measures for covered 

professional services furnished during a specified reporting period. We note that, in developing 

these requirements, it was our goal to align program requirements between these quality 

reporting programs, such as the eRx Incentive Program, EHR Incentive Program, Medicare 

Shared Savings Program, and value-based payment modifier, wherever possible. We believe 
841 

that alignment of these quality reporting programs will lead to greater overall participation in 

these programs, as well as minimize the reporting burden on eligible professionals. 

Please note that, during the comment period following the proposed rule, we received 

comments that were not related to our specific proposals for PQRS in the CY 2013 Medicare 

PFS proposed rule. While we appreciate the commenters' feedback and intend to use these 

comments to better develop PQRS, these comments will not be specifically addressed in this CY 

2013 Medicare PFS final rule, as they are beyond the scope of this rule. However, we will take 

these comments into consideration when developing policies and program requirements for 

future years. 

The regulation governing the PQRS is located at §414.90. The program requirements for 

years 2007-2012 of the PQRS that were previously established, as well as information on the 

PQRS, including related laws and established requirements, are available at 

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. Please also note that in this final rule with comment period, we 

are making technical changes to §414.90 to aid in the readability of the regulation. 

1. Methods of Participation 

There are two ways an eligible professional can participate in the PQRS: (1) as an 

individual or (2) as part of a group practice participating in the PQRS group practice reporting 

option (GPRO). 

a. Participation as an Individual Eligible Professional – Traditional Reporting Mechanisms 

As defined at §414.90(b), the term ‘‘eligible professional’’ means any of the following: 

(1) a physician; (2) a practitioner described in section 1842(b)(18)(C) of the Act; (3) a physical 

or occupational therapist or a qualified speech-language pathologist; or (4) a qualified 

audiologist. For more information on which professionals are eligible to participate in the 
842 

PQRS, we refer readers to the ‘‘List of Eligible Professionals’’ download located in the ‘‘How to 

Get Started” section of the PQRS CMS website at http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html. There is no 

requirement to self-nominate to participate in the PQRS as an individual eligible professional for 

the incentive or to use claims, registry, or EHR reporting mechanisms. 

b. Participation as a Group Practice in the GPRO 

(1) Definition of Group Practice 

We proposed to modify §414.90(b) to define group practice as “a single Tax 

Identification Number (TIN) with 2 or more eligible professionals, as identified by their 

individual National Provider (NPI), who have reassigned their Medicare billing rights to the 

TIN” (77 FR 44806). We proposed to change the number of eligible professionals comprising a 

PQRS group practice from 25 or more to 2 or more to allow all groups of smaller sizes to 

participate in the GPRO. We believe that expanding the scope of group practices eligible to 

participate under the program will lead to greater program participation. To participate in the 

GPRO, a group practice would be required to meet this proposed definition at all times during 

the reporting period for the program year in which the group practice is selected to participate in 

the GPRO. 

We solicited public comments on the proposed definition of group practice. The 

following is a summary of the comments we received regarding this proposal. 

Comment: Several commenters supported our proposal to change the definition of group 

practice to include groups of 2-24 eligible professionals because the commenters believed that 

the proposal would allow more group practices to participate in the GPRO. 

Response: We appreciate the commenters' feedback and are finalizing our proposal to 

modify §414.90(b) to define a group practice as "a single Tax Identification Number (TIN) with 
843 

2 or more eligible professionals, as identified by their individual National Provider Identifier 

(NPI), who have reassigned their billing rights to the TIN." We hope that expanding the GPRO 

to allow small group practices of 2-24 eligible professionals to participate in the GPRO will 

encourage greater participation in PQRS. 

Comment: Although some commenters supported our proposal to change the definition 

of group practice to include groups of 2-24 eligible professionals, the commenters urged CMS 

not to make additional changes to this definition in the near future. The commenters note that 

CMS has changed the group practice definition every year since it was included as a PQRS 

reporting option in 2010, leading to confusion for many eligible professionals and group 

practices participating in PQRS. 

Response: Each year, we have sought to improve the GPRO based on stakeholder 

feedback and data we receive from past participation. The GPRO has also changed due to a 

desire to align this GPRO with other quality reporting programs, such as the Medicare Shared 

Savings Program. Nonetheless, we understand the complexity and confusion caused by 

changing this definition each year and will keep that in mind in the future when proposals are 

presented. 

Comment: One commenter opposed our proposal to change the definition of group 

practice to include groups of 2-24 eligible professionals until the implications of such a change 

are more clearly understood. Furthermore, the commenter believes the proposal confuses the 

alignment of the PQRS program with the VBM that proposes to incorporate groups of 25 or 

more eligible professionals. 

Response: We understand the commenters’ concern and acknowledge that our proposal 

to define a group practice as groups of 2 or more eligible professionals does not align perfectly 

with our proposal to apply the Value-based Payment Modifier to physician groups of 25 or more 
844 

eligible professionals (see section K). However, we note that, although our goal is overall 

alignment with the Value-based Payment Modifier, there may be instances, such as this one, 

where the two programs may not completely align. For example, although we are expanding the 

definition of group practice to define a group practice as a group of 2 or more eligible 

professionals, the Value-based Payment Modifier, as described in section K, will only apply to 

physician group practices of 100 or more in 2013. Therefore, smaller groups of 2-99 eligible 

professionals will remain unaffected by the final policies we are finalizing under the Value-based 

Payment Modifier in 2013. 

When determining program requirements, we considered factors other than alignment 

with the Value-based Payment Modifier. For example, aside from alignment, we adopted 

policies that we believe will increase overall participation in PQRS, as well as increase the 

likelihood that eligible professionals will meet the criteria for satisfactory reporting for the 2013 

and 2014 PQRS incentives and 2015 and 2016 PQRS payment adjustments. We believe that 

expanding the definition of group practices to groups of 2 or more eligible professionals will 

help to achieve these goals, because we are providing group practices with additional ways to 

participate in PQRS. 

Comment: Some commenters disagreed with our proposal to define a group practice as "a 

single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by 

their individual National Provider Identifier (NPI), who have reassigned their billing rights to the 

TIN" rather than limiting the definition of group practice to physicians. The commenters believe 

this classification is misleading, as a solo physician with a nurse practitioner or other eligible 

professional working in the practice would be classified as a group practice under this definition. 

Response: We thank the commenter for expressing their concern regarding the definition 

of a group practice. We note that section 1848(m)(3)(c) of the Act, which governs group 
845 

practice reporting under the PQRS, explicitly identifies “eligible professionals in a group 

practice” (and further affords us the authority to define group practice). So we do not believe the 

definition of group practice under the PQRS is limited to physicians. We also note that the 

PQRS applies to “eligible professionals,” which is defined under section 1848(k)(3)(B) of the 

Act to include physicians and other types of practitioners that are specifically identified. Also, 

from a policy perspective, we believe it is important to measure the care given by healthcare 

professionals other than physicians. Therefore, we are finalizing the PQRS definition of a group 

practice to include all eligible professionals, not just physician group practices. 

(2) Election Requirement for Group Practices Selected to Participate in the GPRO 

 Please note that, for group practices participating in PQRS through other Medicare 

programs (such as but limited to those group practices participating as Accountable Care 

Organizations (ACOs) under the Medicare Shared Savings Program), certain provisions in this 

section may not apply. For information on how to participate in PQRS through other Medicare 

programs, please refer to the requirements for those respective programs. 

 GPRO Self-Nomination Statement. We established the process for group practices to be 

selected to participate in the GPRO in the CY 2012 PFS final rule with comment period (76 FR 

73316). However, this section contains additional processes for a group practice’s selfnomination statement that we proposed for group practices selected to participate in the GPRO 

for 2013 and beyond. For the requirement that group practices wishing to participate in the 

GPRO submit a self-nomination statement (76 FR 73316), for 2012, we accepted these selfnomination statements via a letter accompanied by an electronic file submitted in a format 

specified by CMS because it was not operationally feasible to receive self-nomination statements 

via the web at that time. In the CY 2012 Medicare PFS final rule with comment period, we 

noted that we anticipated that CMS would have the ability to collect self-nomination statements 
846 

via the web for the 2013 PQRS Therefore, we proposed that, for 2013 and beyond, a group 

practice must submit its self-nomination statement via the web. 

 We noted that this web-based functionality is still being developed by CMS. Therefore, 

in the event this web-based functionality would not be available in time to accept selfnomination statements for the 2013 PQRS, we proposed that, in lieu of submitting selfnomination statements via the web, a group practice would be required to submit its selfnomination statement via a letter accompanied by an electronic file submitted in a format 

specified by CMS (such as a Microsoft excel file) (77 FR 44807). We proposed that this selfnomination statement would be mailed to the following address: Centers for Medicare & 

Medicaid Services, Center of Clinical Standards and Quality, Quality Measurement and Health 

Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850. 

If mailing the self-nomination statement, we would require that this self-nomination statement 

be received by no later than 5 PM Eastern Standard Time on January 31 of the year in which the 

group practice wishes to participate in the GPRO. 

 We invited public comment on the proposed method for submitting a GPRO selfnomination statement. The following is a summary of the comments we received on this 

proposal. 

 Comment: One commenter was concerned about the use and efficiency of a web portal 

for accepting GPRO self-nomination statements due to a potentially increased number of selfnomination statements that will be accepted through the web and potential delays in the web 

portal. 

 Response: We understand the commenter's concerns regarding the potential for delays in 

the web portal. However, we believe that accepting self-nomination statements via the web will 

be the most efficient way for group practices to complete and CMS to accept and process GPRO 
847 

self-nomination statements. Therefore, we are finalizing our proposal to accept GPRO selfnomination statements via the web for 2013 and beyond. We also anticipate an increase in the 

number of GPRO self-nomination statements received due to our expansion of the GPRO as well 

as use of the PQRS GPRO for the application of the Value-based Payment Modifier. Therefore 

we are working to further develop the web portal to account for increased traffic. Please note 

that group practices submitting self-nomination statements via the web will be required to 

comply with CMS’ security and system requirements to submit a self-nomination statement via 

the web. However, should a group practice wishing to self-nominate encounter issues doing so, 

the group practice may contact the QualityNet Help Desk for assistance with submitting a selfnomination statement. 

 As for our proposed contingency plan for accepting self-nomination statements via mail 

in the event the web-based functionality was not be available in time to accept self-nomination 

statements for the 2013 PQRS, or in the event we experience issues with accepting selfnomination statements via the web, we are also finalizing that proposal. While we expect that 

we will have the web system operational, we believe it is appropriate to have an alternative 

submission process available as a back-up. Therefore, if the web-based functionality is 

unavailable in time to accept self-nomination statements for the 2013 PQRS, or in the event we 

experience issues with accepting self-nomination statements via the web, in lieu of submitting 

self-nomination statements via the web, a group practice is required to submit its self-nomination 

statement via a letter accompanied by an electronic file submitted in a format specified by CMS 

(such as a Microsoft excel file), and a mailed to the following address: Centers for Medicare & 

Medicaid Services, Center of Clinical Standards and Quality, Quality Measurement and Health 

Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850. 

Although we proposed to require that this self-nomination statement be received by no 
848 

later than 5 PM Eastern Standard Time on January 31 of the year in which the group practice 

wishes to participate in the GPRO, we believe it is appropriate to provide group practices with 

additional time to submit this information and self-nominate under the PQRS. Additional time 

for submissions may also address concerns raised by commenters about the potential for 

increased number of self-nomination statements and efficiency of the web portal with regard to 

avoiding delays. As we discuss in greater detail below in response to comments we received, we 

also believe it would be helpful to afford group practices additional time with regard to selecting 

its reporting mechanism, which group practices must include in the self-nomination statement. 

Therefore, we are finalizing a deadline of October 15 of the year in which the group practice 

wishes to participate in the GPRO. We believe this is an appropriate amount of time for group 

practices under the PQRS. Moreover, we note that this deadline aligns with the final policies we 

are adopting for the value-based payment modifier. For those group practices for whom the 

value-based payment modifier will apply, this extended deadline will provide groups with 

additional time to make decisions with regard to participation under the PQRS. 

 GPRO Selection of Reporting Mechanisms. In the CY 2012 Medicare PFS final rule 

with comment period, we established what information is required to be included in a group 

practice’s self-nomination statement (76 FR 73316). In 2012, the group practice only had one 

reporting mechanism available on which to report data on PQRS quality measures: the GPRO 

web interface. However, beginning 2013, we proposed to allow group practices to report data on 

quality measures using the claims, registry, and EHR-based reporting mechanisms for the PQRS 

incentive and payment adjustment (77 FR 44870). Additionally, we proposed to allow group 

practices to use the proposed administrative claims reporting option. We proposed that a group 

practice wishing to participate in the GPRO for a program year would be required to indicate the 

reporting mechanism the group practice intends to use for the applicable reporting period in its 
849 

self-nomination statement. Furthermore, once a group practice is selected to participate in the 

GPRO and indicates which reporting mechanism the group practice would use, we proposed that 

the group practice would not be allowed to change its selection. Therefore, under this proposal, 

the reporting mechanism the group practice indicates it would use in its self-nomination 

statement for the applicable reporting period would be the only reporting mechanism under 

which CMS would analyze the group practice to determine whether the group practice has met 

the criteria for satisfactory reporting for the PQRS incentive and/or payment adjustment. We 

acknowledged that this proposal would depart from the way we analyze an individual eligible 

professional, as CMS analyzes an individual eligible professional (who is permitted to use 

multiple reporting mechanisms during a reporting period) under every reporting method the 

eligible professional uses. Unfortunately, due to the complexity of analyzing group practices 

under the GPRO, such as having to associate multiple NPIs under a single TIN, it is not 

technically feasible for us to allow group practices using the GPRO to use multiple reporting 

mechanisms or switch reporting mechanisms during the reporting period. 

 We solicited public comment on our proposal to lock-in a group practice’s reporting 

mechanism choice at the time self-nomination. The following is summary of the comments we 

received regarding this proposal. 

 Comment: One commenter stated that group practices should be allowed to change the 

reporting mechanisms through the calendar year in case a more advantageous reporting option is 

available later in the year. For example, a group practice may want to change its reporting 

mechanism during a given reporting period after the list of qualified registries becomes available. 

 Response: We agree that group practices should be provided with some flexibility to 

change their reporting mechanisms. We it is only fair to provide group practices with a window 

to switch their initially chosen reporting mechanisms, as individual eligible professionals are 
850 

allowed to switch reporting mechanisms throughout the year. Therefore, we are allowing group 

practices to switch their chosen reporting mechanism until October 15 of the applicable reporting 

period. We believe this window provides eligible professionals with ample time to make an 

informed decision on which reporting mechanism to use and still provides CMS with advance 

notification of the group practices' chosen reporting mechanism. Based on the comments 

received, we are finalizing a deadline of October 15 of the applicable reporting period (that is, 

October 15, 2013 for reporting periods occurring in 2013) for group practices to elect (via its 

self-nomination statement) the reporting mechanism they will use to submit quality measures 

data for PQRS. Additionally, should a group practice wish to switch the reporting mechanism it 

chose when self-nominating, the group practice will be allowed to do so as long as the group 

practice switches its reporting mechanism prior to the October 15 deadline. 

 Please note that the ability to elect the administrative claims-based reporting mechanism 

will not be available until the summer of the applicable reporting period. Therefore, should a 

group practice self-nominate earlier, if the group practice elects to use the administrative claimsbased reporting mechanism, the group practice would have to visit the web-page to elect the 

administrative claims-based reporting mechanism. 

(3) Process to Participate in the GPRO 

 Please note that, for group practices participating in PQRS through other Medicare 

programs (such as but limited to those group practices participating as Accountable Care 

Organizations (ACOs) under the Medicare Shared Savings Program), certain provisions in this 

section may not apply. For information on how to participate in PQRS through other Medicare 

programs, please refer to the requirements for those respective programs. 

 Determining Group Practice Size. Please note that if a group practice participates in 

PQRS as a group practice, the eligible professionals in the selected group practice cannot 
851 

participate in the PQRS individually. When selecting group practices to participate in the 

GPRO, CMS bases its decision on the information the group practice provides in its selfnomination statement. We believe that changes in a group practice’s size or TIN constitute such 

a significant change in the group practice’s composition that it would cause CMS to reconsider 

its decision to allow the group practice to participate in the GPRO for the applicable program 

year. Specifically, we understand that a group practice’s size may vary throughout the program 

year. For example, we understand that eligible professionals enter into and leave group practices 

throughout the year. Similarly, we understand that group practices may undergo business 

reorganizations during the program year. We note that size fluctuations may affect the criteria 

under which a group practice would use to report after being selected to participate in the GPRO. 

We proposed that groups of varying sizes be subject to different criteria for satisfactory reporting 

for the 2013 and 2014 incentives, as well as for the payment adjustments (77 FR 44822-44833). 

Therefore, we proposed that, for analysis purposes, the size of the group practice must be 

established at the time the group practice is selected to participate in the GPRO. We invited but 

received no public comment on this proposal (77 FR 44807). Therefore, we are finalizing this 

proposal 

 Changes in GPRO TIN. We also understand that, for various reasons, a group practice 

may change TINs within a program year. For example, a group practice may undergo a mid-year 

reorganization that leads to the group practice changing its TIN mid-year. We proposed that, if a 

group practice changes its TIN after the group practice is selected to participate in the GPRO, the 

group practice cannot continue to participate in PQRS as a group practice. We considered the 

changing of a group practice’s TIN a significant change to the makeup of the group practice, as 

the group practice is evaluated under the TIN the group practice provided to CMS at the time the 

group is selected to participate in the GPRO for the applicable year (77 FR 44807). Therefore, 
852 

we viewed a group practice that changes its TIN as an entirely new practice, associated with a 

new TIN. We noted that this proposal may pose a disadvantage for those group practices who 

find it beneficial to report PQRS quality measures using the GPRO. However, we noted that 

eligible professionals in a group practice that has changed its TIN within a year may instead 

participate as individuals. 

We invited public comment on this proposal. The following is summary of the 

comments we received regarding this proposal not to allow group practices who change their 

TINs to continue to participate in the GPRO for the applicable program year. 

Comment: Some commenters urged CMS to allow group practices using the GPRO that 

subsequently change their TIN within a program year to continue participating in PQRS as a 

group practice. One commenter noted that not allowing a group practice to continue to use the 

GPRO should the group practice change their TIN in a program year is a hindrance to practice 

mergers and reorganizations. 

Response: We appreciate the commenters' feedback. It is not our intention to hinder 

group practices from merging with another practice or reorganizing. However, it is not 

operationally feasible to allow a group practice selected to participate in the GPRO that changes 

its TIN within a program year to continue to participate in PQRS under the GPRO. Therefore, 

we are finalizing our proposal to require that a group practice maintain the same TIN throughout 

a given program year to continue to participate in the GPRO. We note that group practices will 

now be given until October 15 to self-nominate and select its reporting mechanism for the 

GPRO, allowing more time within the program year for group practices to organize its 

composition and ultimately its reporting structure. We note that, should a group practice change 

its TIN, eligible professionals within the group practice have the option to participate in PQRS 

individually. 
853 

GPRO Opt-out Period. We understand that a group practice may decide not to participate 

in PQRS using the GPRO after being selected. Therefore, we proposed that group practices be 

provided with an opportunity to opt out of participation in the GPRO after selection (77 FR 

44807). We noted that it is necessary for a group practice to indicate to CMS the group 

practice’s intent not to use the GPRO because, once a group practice is selected to participate in 

the GPRO for the applicable reporting period, CMS will not separately assess the NPIs 

associated with the group practice’s TIN to see if they meet the criteria for satisfactory reporting 

as individual eligible professionals. Therefore, we must be notified of the group practice’s 

decision not to participate in the GPRO so the eligible professionals within the group practice 

could be assessed at the individual TIN/NPI level. We proposed that group practices would have 

until April 1 of the year of the applicable reporting period (for example, by April 1, 2013 for 

reporting periods occurring in 2013) to opt out of participating in the GPRO. 

We invited public comment on the proposed selection process for group practices 

wishing to participate in the GPRO. The following is summary of the comments we received 

regarding this proposed opt-out period for group practices that have elected to participate in 

PQRS under the GPRO. 

Comment: One commenter supported our proposal to provide an opt-out period for those 

group practices who self-nominated to participate in the GPRO but later decide to participate at 

the individual level. 

Response: We appreciate the commenter's feedback. We have historically provided an 

opt-out period, because the deadline for a group practice to submit a self-nomination statement to 

participate in the GPRO has normally been on or about January 31 of the applicable program 

year. We believed it was necessary to provide an opt-out period for group practices, as we 

required group practices to submit a self-nomination statement indicating their intent to 
854 

participate in the GPRO early in the year. However, since, as we discussed above, beginning in 

2013, group practices will have until October 15 of the applicable program year to submit its 

self-nomination statement, we believe that this opt-out period is no longer necessary. Therefore, 

we are not finalizing an opt-out period for group practices that are selected to participate in the 

GPRO for the applicable program year. Once a group practice is selected and approved to 

participate in the GPRO, past the opt-out period, the group practice will be required to participate 

in the GPRO for the applicable program year. 

c. Requirement for Eligible Professionals and Group Practices Electing to Use the 

Administrative Claims-based Reporting Mechanism for the 2015 Payment Adjustment 

 

 Unlike using the traditional PQRS reporting mechanisms (that is, claims, registry, EHRs, 

GPRO web interface) to satisfy the reporting requirements for the 2015 and 2016 payment 

adjustments, we proposed that eligible professionals and group practices wishing to use the 

proposed administrative claims reporting mechanism, available for the 2015 and/or 2016 

payment adjustments, must elect to use the administrative claims reporting mechanism (77 FR 

44805). We believed this election requirement is important because it is necessary for eligible 

professionals to actively engage in quality reporting. By requiring registration, eligible 

professionals and group practices are making an active choice in how they would like their 

quality performance measured. For eligible professionals, we proposed that this election process 

would consist of a registration statement that included: the eligible professional’s name and 

practice name, the eligible professional’s TIN and NPI for analytical purposes, and the eligible 

professional’s contact information (77 FR 44806). For group practices, we proposed that this 

election process would also consist of a registration statement that included: the group practice’s 

business name and contact information, the group practice’s TIN, and contact information of the 
855 

group practice’s contact(s) who will be contacted for program, clinical, and/or technical 

purposes. For the method of submitting this registration statement, we proposed any of the 

following options: 

● If technically feasible, submission of this statement via the web; and 

● If technically feasible, submission of an eligible professional’s or group practice’s 

intent to register to use the administrative claims-based reporting mechanism by placing a Gcode on at least 1 Medicare Part B claim. 

 In the event the two proposed options are not technically feasible, we also considered 

allowing for submission of the registration statement by submitting a mailed letter to CMS at 

Centers for Medicare & Medicaid Services, Center of Clinical Standards and Quality, Quality 

Measurement and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, 

Baltimore, MD 21244-1850. However, we noted that using this mailing option would be a more 

burdensome and time-intensive process for CMS. 

 The eligible professional would be required to complete this election process by January 

31 of the applicable payment adjustment reporting period (for example, by January 31, 2013 for 

the 2015 payment adjustment). However, we noted that we proposed that we may extend this 

deadline based on the submission method that we finalized. For example, because processing 

mailed letters would take the longest to process (out of the 3 methods), we anticipated that if we 

were to include the option of mailed letters, the deadline for submitting a mailed registration 

letter would be January 31 of the applicable payment adjustment reporting period. Since it 

would be more efficient to process registration statements received via the web or via a G-code 

on a claim, we anticipated that we would be able to extend the registration deadline to as late as 

December 31 of the applicable payment adjustment reporting period. Once an eligible 

professional makes an election to participate in PQRS using the administrative claims-based 
856 

reporting mechanism for the PQRS payment adjustments, the eligible professional would be 

assessed under the administrative claims-based reporting mechanism. 

 For group practices participating in the GPRO, we proposed that these group practices 

would use the 3 methods described above (mailed letter, web, or G-code submission) and have 

the same deadline as eligible professionals wishing to elect to use the administrative claimsbased reporting mechanism for an applicable payment adjustment. In the alternative, we 

proposed that a group practice participating in the GPRO would be required to elect to use the 

administrative claims-based reporting mechanism in its self-nomination statement. We proposed 

to provide less time for group practices to elect to use the administrative claims-based reporting 

mechanism because it is necessary for CMS to receive this information in the beginning of the 

applicable reporting period to indicate to CMS how these group practices should be analyzed 

throughout the reporting period. This early notification is especially important for large group 

practices, which may have hundreds or thousands of eligible professionals to track as a group 

practice. Therefore, we felt it was appropriate to request that a group practice elect to use the 

administrative claims-based reporting mechanism when the group practice self-nominates. 

 We further proposed that an eligible professional or group practice would be required to 

make this election for each payment adjustment year the eligible professional or group practice 

seeks to be analyzed under this mechanism. For example, if the eligible professional seeks to 

report under the administrative claims mechanism for the 2015 and 2016 payment adjustments, 

the eligible professional would be required to make this election by the applicable deadline, for 

the 2015 payment adjustment and again by the applicable deadline, for the 2016 payment 

adjustment. We invited public comment on the proposed election requirement for eligible 

professionals and group practices electing to participate in the 2015 and 2016 payment 

adjustments using the administrative claims-based reporting mechanism. 
857 

 We invited public comment on the process for electing the administrative claims-based 

reporting option for eligible professionals and group practices. The following is a summary of 

the comments received on this proposed process and on the proposed election requirement. 

 Comment: Some commenters requested that the deadline for electing the administrative 

claims-based reporting option be extended. The commenters believed eligible professionals and 

group practices needed more time to understand the different reporting options and determine 

whether the administrative claims-based reporting option would be appropriate for their 

respective practices. 

 Response: We agree with the commenters and would like to provide eligible 

professionals and group practices with sufficient time to make an informed decision as to 

whether to elect the administrative claims-based reporting option. Therefore, we are extending 

the timeframe that eligible professionals and group practices have for electing the administrative 

claims-based reporting mechanism. However, as we explain in greater detail below, we are not 

finalizing the administrative claims-based reporting option for the 2016 PQRS payment 

adjustment. For the 2015 payment adjustment, eligible professionals and group practices may 

begin to make an election in the summer of the applicable reporting period. The deadline for 

electing the administrative claims-based reporting mechanism will be October 15 of the 

applicable reporting period for both eligible professionals and group practices. For example, for 

the 2015 payment adjustment, eligible professionals and group practices will be able to elect the 

administrative claims-based reporting mechanism until October 15, 2013. 

 Therefore, based on the comments received, we are finalizing the following election 

process for eligible professionals and group practices wishing to use the administrative claimsbased reporting option for the 2015 PQRS payment adjustment. We note that we are changing 

the name of this process from a registration to an election process. We believe using the term 
858 

election process is more appropriate, as individuals and group practices would be electing to be 

analyzed under a reporting mechanism, not registering to participate in PQRS (as registration is 

not a requirement to participate in PQRS). This election process is the same process as the 

registration process proposed, with the following exceptions: 

● We proposed three methods of accepting this election: via the web, a G-code on 

claims, or, if neither were technically feasible, via U.S. mail. We are finalizing submission of 

the administrative claims election statement via the web, because we believe that this is the most 

efficient method of accepting these elections. However, in the event that we experience issues 

with accepting election statements via the web, we are finalizing a back-up method of accepting 

elections via U.S. mail. In the event the we experience issues with accepting election statements 

via the web, eligible professionals and group practices may elect to be analyzed under the 

administrative claims-based reporting mechanism by submitting a mailed letter to CMS at 

Centers for Medicare & Medicaid Services, Center of Clinical Standards and Quality, Quality 

Measurement and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, 

Baltimore, MD 21244-1850. 

● The final deadline for submitting the administrative claims election statement to 

participate using the administrative claims reporting mechanism for the 2015 PQRS payment 

adjustment for both individual eligible professionals, and group practices is October 15, 2013. 

Group practices will be able to make this election under its self-nomination statement. As we 

discussed above, we are finalizing a later deadline so that eligible professionals and group 

practices have more time to determine which reporting mechanism would be more advantageous 

for their respective practices. We note that, should we encounter issues with accepting election 

statements via the web, we may extend the deadline for submitting these administrative claims 

election statements to account for any time the web may not be properly functioning. 
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We are modifying newly created §414.90(h) to indicate this election requirement for 

individual eligible professionals and group practices who wish to use the administrative claimsbased reporting option for the 2015 PQRS payment adjustment. 

 Please note that, for group practices participating in PQRS through other Medicare 

programs, the administrative claims-based reporting mechanism may not be a reporting option 

for reporting PQRS measures. For example, under the Medicare Shared Savings Program, 

eligible professionals within Accountable Care Organizations (ACOs) must report for purposes 

of the PQRS using the GPRO web interface (77 FR 67870). Therefore, group practices 

participating within ACOs participating in the PQRS under the Medicare Shared Savings 

Program cannot participate in the traditional PQRS or report using the administrative claimsbased reporting mechanism. 

2. Reporting Periods for the PQRS Payment Adjustments 

For the PQRS incentives, we previously established 12 and 6-month reporting periods for 

satisfactorily reporting PQRS quality measures at §414.90(f)(1). Under section 

1848(a)(8)(C)(iii) of the Act, we are authorized to specify the quality reporting period (reporting 

period) for a payment adjustment year. We proposed to modify the regulation to establish the 

reporting periods for the PQRS payment adjustments for 2015 and beyond (77 FR 44808). 

Please note that we are re-designating §414.90(f) as §414.90(g) and making technical changes to 

change the structure of the regulation and to improve the readability of the regulation. Newly 

designated §414.90(g)(1) indicates the reporting periods available for the PQRS incentives. 

Additional Reporting Periods for the 2015 and 2016 PQRS Payment Adjustments. For 

the 2015 payment adjustment, in the CY 2012 Medicare PFS final rule, we established CY 2013 

(that is, January 1, 2013 through December 31, 2013) as the reporting period for the 2015 

payment adjustment (76 FR 73392). We established a 12-month reporting period occurring 2 
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years prior to the application of the payment adjustments for group practices and for individual 

eligible professionals to allow time to perform all reporting analysis prior to applying payment 

adjustments on eligible professionals’ Medicare Part B PFS claims. However, we noted that we 

might specify additional reporting periods for the 2015 payment adjustment. To coincide with 

the 6-month reporting period associated with the 2013 incentive for the reporting of measures 

groups via registry, we proposed to modify the regulation at newly designated §414.90(h) to add 

a 6-month reporting period occurring July 1, 2013—December 31, 2013, for the 2015 payment 

adjustment for the reporting of measures groups via registry (77 FR 44808). 

For the 2016 payment adjustment, to coincide with the reporting periods for the 2014 

incentive, we proposed to modify the regulation at newly designated §414.90(h) to specify a 

12-month (January 1, 2014 – December 31, 2014) and, for individual eligible professionals 

reporting measures groups via registry only, a 6-month (July 1, 2014—December 31, 2014) 

reporting period for the 2016 payment adjustments. 

We invited public comment on our proposed reporting periods for the 2015 and 2016 

payment adjustments. The following is a summary of the comments we received on our 

proposals. 

Comment: Some commenters supported our proposal to establish a 6-month payment 

adjustment reporting period for the 2015 and 2016 PQRS payment adjustments to coincide with 

the 6-month reporting period for the 2013 and 2014 PQRS incentives. Some commenters also 

supported our proposal to establish a 12-month payment adjustment reporting period for the 

2016 PQRS payment adjustment. One commenter believes that a 12-month reporting period 

provides a more accurate assessment of actions performed in a clinical setting than data collected 

based on a 6-month reporting period. Other commenters supported continuing to allow a 6-

month and 12-month reporting period. 
861 

Response: Based on the comments received and to parallel the reporting periods for the 

2013 and 2014 PQRS incentives, we are finalizing the addition of a 6-month reporting period for 

the 2015 and 2016 PQRS payment adjustments as proposed. We are also finalizing the 12-

month reporting period for the 2016 PQRS payment adjustment. We are therefore finalizing 

newly created §414.90(h) to specify 6- and 12-month reporting periods occurring 2 years prior to 

the 2015 and 2016 PQRS payment adjustments. 

With respect to the commenter’s concern that a 6-month reporting period may not 

provide as accurate of a picture of the quality of care provided than the 12-month period, we 

generally agree with the commenter. However, our desire to align the reporting periods of the 

2013 and 2014 PQRS incentive and 2015 and 2016 PQRS payment adjustments, and afford 

additional reporting options, outweighs this interest. We also note that the 6-month reporting 

period will only be available for individual eligible professionals reporting measures groups via 

registry. 

Reporting Periods for the 2017 PQRS Payment Adjustment and Beyond. We believe that 

data on quality measures collected based on 12 months provide a more accurate assessment of 

actions performed in a clinical setting than data collected based on a 6-month reporting period, as 

eligible professionals would report on a larger set of patients. We stated that it was our intention 

to move towards using solely a 12-month reporting period once the reporting periods for the 

2013 and 2014 incentives conclude. Therefore, for payment adjustments occurring in 2017 and 

beyond, we proposed to modify the regulation at newly designated §414.90(h) to specify only a 

12-month reporting period occurring January 1—December 31, that falls 2 years prior to the 

applicability of the respective payment adjustment (for example, January 1, 2015 through 

December 31, 2015, for the 2017 payment adjustment) (77 FR 44808). 
862 

We invited public comment on our proposal to establish a 12-month reporting period for 

payment adjustments occurring in 2017 and beyond. The following is a summary of the 

comments we received on this proposal. 

Comment: One commenter supported our proposal to eliminate the 6-month reporting 

period for 2015 and beyond, because the commenter believes that data collected based on 12 

months provides a more accurate assessment of actions performed in a clinical setting than data 

collected based on a 6-month reporting period. 

Response: We agree with the point raised by the commenter and are therefore not 

finalizing a 6-month period for payment adjustments occurring in 2017 and beyond. However, 

we note that we did not propose to eliminate the 6-month reporting period for 2015 and beyond. 

Rather, we simply did not propose a 6-month reporting period for payment adjustments 

occurring in 2017 and beyond (77 FR 44808). 

Comment: Several commenters opposed our proposal to base the PQRS payment 

adjustment year on a reporting period occurring 2 years prior to the payment adjustment year. 

The commenters believe that the reporting period should occur closer to the payment adjustment 

year. Some commenters urged that the implementation of the PQRS payment adjustment should 

be delayed until the PQRS participation rate increases. 

Response: We understand the commenters' concerns on establishing a reporting period 2 

years prior to the payment adjustment year. However, it is not operationally feasible to create a 

full calendar year reporting period for the PQRS payment adjustment any later than 2 years prior 

to the adjustment year and still avoid retroactive payments or the reprocessing of claims. Section 

1848(a)(8) of the Act requires that a payment adjustment be applied to covered professional 

services furnished by an eligible professional in the particular payment adjustment year. 

Therefore, using 2017 as an example, we believe it is necessary to reduce the PFS amount 
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concurrently for PFS allowed charges for covered professional services furnished in 2017. If we 

do not reduce the PFS amount concurrently with claims submissions in 2017, we would need to 

potentially recoup or provide added payments after the determination is made about whether the 

payment adjustment applies, or alternatively, hold claims until such a determination is made. In 

addition, we note that if such retroactive adjustments were made it may require a reconciliation 

of beneficiary copayments. 

As a result, we need to determine whether eligible professionals have satisfactorily 

reported under the PQRS based on a reporting period that occurs prior to 2017. For the reasons 

stated above, for the PQRS payment adjustments occurring in 2017 and beyond, we are 

finalizing 12-month reporting periods that fall 2 years prior to the application of the respective 

payment adjustment year. For example, the reporting period for the 2017 PQRS payment 

adjustment will be CY 2015 (that is, January 1, 2015 – December 31, 2015). We are finalizing 

newly created §414.90(e) to specify a 12-month reporting period for the 2017 PQRS payment 

adjustments and beyond. 

Comment: One commenter supported our proposal to move towards a 12-month 

reporting period, provided that we continue to offer the administrative claims-based reporting 

option to eligible professionals and group practices. 

Response: We appreciate the commenter's feedback but reiterate that we view the 

administrative claims-based reporting option as a temporary option under PQRS. Therefore, as 

we discuss in section III.G.3, we are only finalizing use of the administrative claims-based 

reporting mechanism for the 2015 PQRS payment adjustment at this time. 

Comment: One commenter opposed our proposal to eliminate the 6-month reporting 

period beginning with the 2017 PQRS payment adjustment, at least until such time as the PQRS 

achieves greater alignment with other CMS quality reporting programs. The commenter believes 
864 

that this alternative reporting period should be maintained to offer greater flexibility in reporting. 

The commenter also noted that the late start of this 6-month reporting period has traditionally 

served as an alternative reporting option for eligible professionals who are new to PQRS. 

Response: We appreciate the commenter's feedback. However, in an effort to streamline 

the satisfactory reporting requirements under PQRS and to align with programs such as the 

Value-based Payment Modifier which utilize a performance period of 12 months, we are not 

adding a 6-month reporting period for payment adjustments occurring in 2017 and beyond. 

3. Requirements for the PQRS Reporting Mechanisms 

This section addresses the following reporting mechanisms: claims, registry, EHR 

(including direct EHR products and EHR data submission vendor), GPRO web interface, and 

administrative claims. We previously established at §414.90(f)(2) that eligible professionals 

reporting individually may use the claims, registry, and EHR-based reporting mechanisms. We 

proposed to modify §414.90 to allow group practices comprised of 2-99 eligible professionals to 

use the claims, registry, and EHR-based reporting mechanisms as well, because we recognized 

the need to provide varied reporting criteria for smaller group practices, particularly since we 

proposed to expand the definition of group practice (77 FR 44808). For example, we noted that 

a smaller group practice may not have a sufficiently varied practice to be able to meet the 

proposed satisfactory reporting criteria for the GPRO web interface that would require a smaller 

group practice to report on all of the PQRS quality measures we proposed. We proposed 

changes to §414.90, which we proposed to re-designate §414.90(g) and §414.90(h). 

We invited public comment on this proposal to make the claims, registry, and EHR-based 

reporting options applicable to group practices of 2-99 eligible professionals. The following is 

summary of the comments we received regarding this proposal. 

 Comment: Several commenters supported our proposal to expand the claims, registry, 
865 

direct EHR, and EHR data submission vendor reporting mechanisms to group practices or 2-99 

eligible professionals using the GPRO. Commenters were pleased that groups that are not able 

to use the GPRO web interface (such as specialty provider group practices for which GPRO 

measures typically do not apply) would still be able to participate in PQRS as a group practice in 

the GPRO. Most of these commenters suggested that we extend use of the claims, registry, 

direct EHR, and EHR data submission vendor reporting mechanisms to group practices of 100 or 

more eligible professionals to allow greater flexibility in reporting for these larger group 

practices. These commenters noted that extending the claims, registry, and EHR-based reporting 

options would be especially beneficial to large specialty groups for which the GPRO measures 

do not apply. 

 Response: We appreciate the commenters’ positive feedback regarding these proposals. 

Although we proposed to expand the claims-based reporting mechanism to group practices of 2-

99 eligible professionals, we have discovered that it will not be technically feasible to accept 

group practice reporting data via the claims-based reporting mechanism at this time. Therefore, 

we are not finalizing that part of our proposal. However, we will work to provide group practice 

reporting via the claims-based reporting mechanism in the future. 

 As for the registry-based reporting mechanism, we are finalizing our proposal to extend 

the registry-based reporting mechanism to groups practices comprised of 2-99 eligible 

professionals participating in PQRS via the GPRO for 2013 and beyond. 

 For groups practices of 2-99 eligible professionals using direct EHR and EHR data 

submission vendor products, we are delaying availability of this option until 2014 to coincide 

with when the EHR Incentive Program introduces its group practice reporting option for 

meeting the clinical quality measures (CQM) objective for achieving meaningful use (77 FR 

54076 through 54078). Therefore, in this final rule, we are adopting the EHR-based reporting 
866 

options for groups of 2-99 eligible professionals participating in PQRS via the GPRO for 2014 

and beyond. 

 As for extending use of the registry and EHR-based reporting mechanisms for GPRO 

group practices of 100 of more eligible professionals, we agree with the commenters that 

extending the registry and EHR-based reporting mechanisms would provide more opportunities 

for large specialty group practices to participate in PQRS. Therefore, based on the comments 

received, we are finalizing the registry-based reporting mechanism for 2013 and beyond and the 

EHR-based reporting mechanisms for 2014 and beyond for groups of 100 or more eligible 

professionals under the GPRO as well as those group practices with 2-99 eligible professionals 

under the GPRO. 

 Therefore, we are finalizing §414.90(g) and §414.90(h) to indicate that the registry-based 

reporting mechanism will be available for use by eligible professionals and group practices 

beginning in 2013 and the EHR-based reporting mechanisms (direct EHR product and EHR data 

submission vendor) will be available for use by eligible professional and group practices 

beginning in 2014 to report for the PQRS incentives and payment adjustments. 

a. Claims-based Reporting: Requirements for Using Claims-based Reporting for 2013 and 

Beyond 

Eligible professionals that wish to report data on PQRS quality measures via claims for 

the incentives and for the payment adjustments must submit quality data codes (QDCs) on claims 

to CMS for analysis. QDCs for the eligible professional’s selected PQRS (individual or 

measures groups) quality measures that are reported on claims may be submitted to CMS at any 

time during the reporting period for the respective program year. However, as required by 

section 1848(m)(1)(A) of the Act, all claims for services furnished during the reporting period, 

would need to be processed by no later than the last Friday occurring 2 months after the end of 
867 

the reporting period, to be included in the program year’s PQRS analysis. For example, all 

claims for services furnished during a reporting period that occur during calendar year 2013 

would need to be processed by no later than the last Friday of the second month after the end of 

the reporting period, that is, processed by February 28, 2014 for the reporting periods that end 

December 31, 2013. In addition, after a claim has been submitted and processed, we proposed at 

re-designated §414.90(g)(2)(i)(A) and newly added §414.90(h)(2)(i)(A) to indicate that EPs 

cannot submit QDCs on claims that were previously submitted and processed (for example, for 

the sole purpose of adding a QDC for the PQRS). 

We invited public comment on our proposed requirements for using the claims-based 

reporting mechanism for the incentives and for the payment adjustments for 2013 and beyond. 

The following is a summary of the comments we received regarding these proposals.

 Comment: Some commenters disagreed with our proposal not to allow the resubmission 

of claims for the sole purpose of attaching a reporting code on a claim. 

Response: We understand that there are instances where Medicare Part B claims are 

resubmitted and reprocessed. However, to avoid unnecessary reprocessing of claims for the sole 

purpose of reporting PQRS quality data, and because it is overly burdensome and costly to 

analyze claims that are resubmitted to identify the submission of additional codes for the PQRS, 

we are finalizing our proposal. We note that this has been a program policy since the inception 

of PQRS in 2007. Therefore, we are finalizing §414.90(g)(2)(i)(A) and §414.90(hg)(2)(i)(A), 

with some technical changes to the language we are making in this final rule, to indicate that if 

an eligible professional re-submits a Medicare Part B claim for reprocessing, the eligible 

professional may not attach a G-code at that time for reporting on individual Physician Quality 

Reporting System measures or measures groups. 

b. Registry-based Reporting 
868 

(1) Proposed Qualification Requirements for Registries for 2013 and Beyond 

For 2013 and beyond, we proposed that registries wishing to submit data on PQRS 

quality measures for a particular reporting period would be required to be qualified for each 

reporting period the registries wish to submit quality measures data (77 FR 44808). This 

qualification process is necessary to verify that registries are able to submit data on PQRS 

quality measures on behalf of eligible professionals and group practices to CMS. Registries who 

wish to become qualified to report PQRS quality measures for a reporting period undergo (1) a 

self-nomination process and (2) a qualification process regardless of whether the registry was 

qualified the previous program year. 

Registry Self-nomination Process. For the self-nomination process, we proposed that the 

self-nomination process would consist of the submission of a self-nomination statement 

submitted via the web by January 31 of each year in which the registry seeks to submit data on 

PQRS quality measures on behalf of eligible professionals and group practices (77 FR 44809). 

For example, registries that wish to become qualified to report data in 2013 under the program, 

that is, to report during all of the reporting periods for the 2013 incentive and the 2015 payment 

adjustment, would be required to submit its self-nomination statement by January 31, 2013. We 

proposed that the self-nomination statement contain all of the following information: 

● The name of the registry. 

● The reporting period start date the registry will cover. 

● The measure numbers for the PQRS quality measures on which the registry is 

reporting. 

We noted that CMS is currently developing the functionality to accept registry selfnomination statements via the web and anticipate development of this functionality to be 

complete for registries to submit their self-nomination statements via the web in 2013. However, 
869 

in the event that it is not technically feasible to collect this self-nomination statement via the 

web, we proposed that registry vendors would submit its self-nomination statement via a mailed 

letter to CMS (77 FR 44809). The self-nomination statement would be mailed to the following 

address: Centers for Medicare & Medicaid Services, Center for Clinical Standards and Quality, 

Quality Measurement and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-

02-01, Baltimore, MD 21244-1850. We proposed that these self-nomination statements must be 

received by CMS by 5:00 p.m. Eastern Standard Time on January 31 of the applicable year. 

We invited public comment on our proposals related to the registry self-nomination 

process. The following is a summary of these comments. 

Comment: One commenter suggested that we extend the proposed self-nomination 

deadline of January 31 for registries who wish to become qualified to submit PQRS measures 

data should we finalize the option to submit this self-nomination statement via U.S. mail. 

Response: Based on our desire to streamline the self-nomination process, we are 

finalizing our proposal to accept the registry self-nomination statements via the web. However, 

we understand that issues may arise with respect to the web-based self-nomination process. 

Therefore, we are finalizing the proposed back-up submission method. Specifically, only in the 

event that we encounter issues accepting registry self-nomination statements via the web, we are 

finalizing our proposal to accept self-nomination statements from registries who wish to become 

qualified to submit PQRS measures data to CMS via U.S. mail. The self-nomination statement 

will be mailed to the following address: Centers for Medicare & Medicaid Services, Center for 

Clinical Standards and Quality, Quality Measurement and Health Assessment Group, 7500 

Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850. 

We are also finalizing the deadline of January 31. Although we agree that submitting a 

self-nomination statement via U.S. mail would require more time to complete than submitting 
870 

the self-nomination statement via the web, we do not believe an extended submission deadline is 

warranted since registries (such as those participating in PQRS in 2012) are familiar with 

submitting self-nomination statements by January 31 via U.S. mail. Beginning 2013, registries 

wishing to indicate their intent to submit PQRS measure data on behalf of eligible professionals 

are required to submit a self-nomination statement for each year in which the registry seeks to 

participate in PQRS. Please note that when submitting self-nomination statements via the web, 

registries are required to meet CMS’ security and system requirements. Should a registry 

wishing to self-nominate encounter issues using the web, the registry may contact the QualityNet 

Help Desk for assistance in submitting a self-nomination statement. 

 

Comment: One commenter suggested that we extend the proposed self-nomination 

deadline of January 31 for registries who wish to become qualified to submit PQRS measures 

data to CMS. The commenter believes that, since we are proposing new criteria for registries, 

the registries should be provided with more time to make any needed changes prior to submitting 

its self-nomination statement. 

Response: We understand that registries need time to decide whether to undergo the 

qualification process to submit PQRS measures data to CMS. However, extending the selfnomination deadline would delay our ability to make the list of qualified registries available to 

eligible professionals and group practices for a particular reporting period. We note that the 

deadline for registries to submit a self-nomination statement has historically been January 31 of 

the year in which the registry seeks to become qualified. The January 31 deadline has provided 

registries with sufficient time to submit self-nomination statements in the past, even when new 

requirements were established for registries, so we do not believe it is necessary to extend the 

self-nomination deadline for registries past January 31 of the year in which the registry seeks to 
871 

become qualified. In addition, as previously stated, beginning 2013, we are accepting registry 

self-nomination statements via the web. We believe this will provide registries with more time 

to submit their self-nomination statements, as registries will not have to account for the time it 

takes for CMS to receive its self-nomination statement via U.S. mail. Please note that the selfnomination statement simply indicates to CMS a registry’s intent to participate in PQRS. The 

process to become a qualified registry, which follows this discussion, occurs after the deadline 

for registries to submit its self-nomination statement. 

Registry Qualification Process. For the qualification process, we proposed that all 

registries, regardless of whether or not they have been qualified to report PQRS quality measures 

in a prior program year, undergo a qualification process to verify that the registry is prepared to 

submit data on PQRS quality measures for the reporting period in which the registry seeks to be 

qualified (77 FR 44809-44810). To become qualified for a particular reporting period, we 

proposed that a registry would be required to: 

● Be in existence as of January 1 the year prior to the program year in which the registry 

seeks qualification (for example, January 1, 2012, to be qualified to submit data in 2013). 

● Have at least 25 participants by January 1 the year prior to the program year in which 

the registry seeks qualification (for example, January 1, 2012, to be qualified for the reporting 

periods occurring in 2013). 

● Provide at least 1 feedback report to participating eligible professionals and group 

practices for each program year in which the registry submits data on PQRS quality measures on 

behalf of eligible professionals and group practices. This feedback reporting would be based on 

the data submitted by the registry to CMS for the applicable reporting period or periods 

occurring during the program year. For example, if a registry was qualified for the reporting 

periods occurring in 2013, the registry would be required to provide a feedback report to all 
872 

participating eligible professionals and group practices based on all 12 and 6-month reporting 

periods for the 2013 incentive and the 12-month reporting period for 2015 payment adjustment. 

Although we proposed to require that qualified registries provide at least 1 feedback report to all 

participating eligible professionals and group practices, we encouraged registries to provide an 

additional, interim feedback report, if feasible, so that an eligible professional may determine 

what steps, if any, are needed to meet the criteria for satisfactory reporting. 

● For purposes of distributing feedback reports to its participating eligible professionals 

and group practices, the registry must collect each participating eligible professional’s e-mail 

address and have documentation from each participating eligible professional authorizing the 

release of his or her e-mail address. 

● Not be owned or managed by an individual, locally-owned, single-specialty group (for 

example, single-specialty practices with only 1 practice location or solo practitioner practices 

would be precluded from becoming a qualified PQRS registry). 

● Participate in all ongoing PQRS mandatory support conference calls and meetings 

hosted by CMS for the program year in which the registry seeks to be qualified. For example, a 

registry wishing to be qualified for reporting in 2013 would be required to participate in all 

mandatory support conference calls hosted by CMS related to reporting in 2013 under the PQRS. 

● Be able to collect all needed data elements and transmit to CMS the data at the 

TIN/NPI level for at least 3 measures. 

● Be able to calculate and submit measure-level reporting rates and/or, upon request, 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 based on a calculation of the measure’s numerator and denominator 
873 

specifications) for each measure on which the eligible professional (as identified by the 

TIN/NPI) or group practice reports and/or, upon request, the Medicare beneficiary data elements 

needed to calculate the reporting rates. 

● Be able to separate out and report on Medicare Part B FFS patients. 

● Report the number of eligible instances (reporting denominator). 

● Report the number of instances a quality service is performed (reporting/performance 

numerator). 

● Report the number of performance exclusions, meaning the quality action was not 

performed for a valid reason as defined by the measure specification. 

● Report the number of reported instances, performance not met, meaning the quality 

action was not performed for any valid reason as defined by the measure specification. Please 

note that an eligible professional receives credit for reporting, not performance. 

● Be able to transmit data on PQRS quality measures in a CMS-approved XML format. 

● Comply with a CMS-specified secure method for data submission, such as submitting 

the registry’s data in an XML file through an identity management system specified by CMS or 

another CMS-approved method, such as use of appropriate Nationwide Health Information 

Network specifications, if technically feasible. 

● Submit an acceptable “validation strategy” to CMS by March 31 of the reporting year 

the registry seeks qualification (for example, if a registry wishes to become qualified for 

reporting in 2013, this validation strategy would be required to be submitted to CMS by 

March 31, 2013). A validation strategy details how the registry will determine whether eligible 

professionals and group practices 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 
874 

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. 

● Perform the validation outlined in the strategy and send the results to CMS by June 30 

of the year following the reporting period (for example, June 30, 2014, for data collected in the 

reporting periods occurring in 2013). 

● 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 

eligible professionals and group practices, as well as the registry’s disclosure of quality measure 

results and numerator and denominator data and/or patient-specific data on Medicare 

beneficiaries on behalf of eligible professionals and group practices who wish to participate in 

the PQRS. 

● 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 measure results and 

numerator and denominator data and/or patient-specific data on Medicare beneficiaries to CMS 

for the purpose of PQRS participation. This documentation would be required to be obtained at 

the time the eligible professional signs up with the registry to submit PQRS quality measures 

data to the registry and would be required to meet any applicable laws, regulations, and 

contractual business associate agreements. 

● Upon request and for oversight purposes, provide CMS access to review the Medicare 

beneficiary data on which PQRS registry-based submissions are founded or provide to CMS a 

copy of the actual data. 

● 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 
875 

provided to CMS are accurate and complete. 

● Use PQRS measure specifications and the CMS provided measure calculation 

algorithm, or logic, to calculate reporting rates or performance rates unless otherwise stated. We 

will provide registries a standard set of logic to calculate each measure and/or measures group 

they intend to report for each reporting period. 

● Provide a calculated result using the CMS-supplied measure calculation logic and 

XML file format for each measure that the registry intends to calculate. The registries may be 

required to show that they can calculate the proper measure results (that is, reporting and 

performance rates) using the CMS-supplied logic and send the calculated data back to CMS in 

the specified format. The registries will be required to send in test files with fictitious data in the 

designated file format. 

● Describe to CMS the cost for eligible professionals and group practices that the 

registry charges to submit PQRS and/or eRx Incentive Program data to CMS. 

● Agree to verify the information and qualifications for the registry prior to posting 

(includes names, contact, measures, cost, etc.) and furnish/support all of the services listed for 

the registry on the CMS Website. 

● Agree that the registry’s data for Medicare beneficiaries may be inspected or a copy 

requested by CMS and provided to CMS under our oversight authority. 

● Be able to report consistent with the satisfactory reporting criteria requirements for the 

PQRS incentives and payment adjustments. 

 In addition to meeting all the requirements specified previously for the reporting of 

individual quality measures via registry, for registries that intend to report on PQRS measures 

groups, we proposed that these registries, regardless of whether or not registries were qualified in 

previous years, would be required to: 
876 

● Indicate the reporting period chosen for each eligible professional who chooses to 

submit data on measures groups. 

● Base reported information on measures groups only on patients to whom services were 

furnished during the relevant reporting period. 

● If the registry is reporting using the measures group option for 20 patients, the registry 

on behalf of the eligible professional may include non-identifiable data for non-Medicare 

beneficiaries as long as these patients meet the denominator of the measure and the eligible 

professional includes a majority of Medicare Part B patients in their cohort of 20 patients for the 

measures group. 

We intend to post the final list of registries qualified for each reporting period by the 

summer of each year in which the reporting periods occur on the CMS website at 

http://http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. For example, we intend to post the list of registries qualified for 

2013 reporting periods by summer 2013. For each reporting period, the list of qualified 

registries would contain the following information: the registry name, registry contact 

information, the measures and/or measures group(s) for which the registry is qualified and 

intends to report for the respective reporting period. 

The registry qualification process we proposed was largely the same process we 

established to qualify registries for the reporting periods occurring in 2012. We proposed a 

similar process to the 2012 qualification process because, registries are already familiar with this 

qualification process, so we felt there would be a greater likelihood that registries wishing to be 

qualified to report quality measures data for a particular reporting period would be able to pass 

the qualification process. We felt this would provide eligible professionals with more qualified 

registry products from which to choose. 
877 

We invited public comment on our proposals related to the qualification process for 

registries. The following is a summary of the comments we received regarding these proposals. 

Comment: One commenter asked for clarification on our proposal to have a validation 

strategy. 

 Response: Please note that we do not provide requirements or guidelines for a validation 

strategy. Registries must adopt a strategy in the manner the registry chooses. Therefore, the 

specifics of the validation strategy are dependent on the registry. However, we are finalizing the 

requirement that a registry seeking to be qualified to submit PQRS quality measures data have a 

validation strategy. As we discuss in further detail in the following response, although we 

strongly encourage registries to test their validation strategies with CMS, we are not finalizing 

this testing requirement. 

 Comment: One commenter requested that the requirement for registries to provide data to 

CMS should contain the stipulation that it be de-identified at the patient level. 

 Response: We have historically reserved the right to request patient identifiable data if 

we so choose. We understand the security concerns around patient-identified data and will work 

with the registry to receive the data in a secure manner. 

 Comment: One commenter recommended that the final list of qualified PQRS registries 

be available earlier than the summer of each reporting period. 

Response: We realize that it may be challenging for eligible professionals to choose 

among the numerous registries. Due to the commenter’s concerns as well as concerns we have 

heard from other stakeholders regarding the timing of the availability of the qualified registry 

list, we are not finalizing the following proposed registry qualification requirement: perform the 

validation outlined in the strategy and send the results to CMS by June 30 of the year following 

the reporting period (for example, June 30, 2014, for data collected in the reporting periods 
878 

occurring in 2013). We note that the delay in posting the list of qualified registries was mainly 

due to our desire to test a registry’s validation strategy prior to qualifying the registry to report 

PQRS quality measures data for the applicable year. Since we are not requiring that this 

validation strategy be tested, we will be able to post the list of qualified registries sooner. We 

anticipate that we will post the list of qualified registries in the Spring of the applicable year the 

registries are qualified submit quality measures data on behalf of eligible professionals (for 

example, Spring 2013 for reporting periods occurring in 2013). 

We note that, although we are not requiring that a registry’s validation strategy be tested 

to become qualified to submit PQRS quality measures data on behalf of its eligible professionals, 

this testing process will still be available for registries to test their respective validation 

strategies. It is important for registries to undergo this testing process to check whether they will 

be able to submit quality measures data accurately to CMS after the applicable reporting period. 

Comment: One commenter sought clarification on our proposal to, "upon request and for 

oversight purposes, provide CMS access to review the Medicare beneficiary data on which 

PQRS registry-based submissions are founded or provide to CMS a copy of the actual data." 

Specifically, the commenter sought clarification as to whether this requirement would require 

that CMS have access to more data than is already required for PQRS. 

Response: This requirement would not require that CMS have access to more data than 

is already required for PQRS. Rather, this requirement is necessary in order for CMS to verify 

the accuracy of the data submitted by the respective registry. As stated previously, CMS will 

work with registries to accept data in a secure manner. 

Based on the comments received and for the reasons stated previously, we are finalizing 

the registry qualification process for 2014 and beyond, as proposed, with the exception that we 

are not finalizing the requirement that a registry perform the validation outlined in its strategy 
879 

and send the results to CMS by June 30 of the year following the reporting period. 

Registry Audit and Disqualification Process. Lastly, in the CY 2012 Medicare PFS 

proposed rule, we raised the issue of disqualifying registries that submit inaccurate data (76 FR 

42845). We did not adopt a disqualification process but noted the importance of such a process, 

as well as our intention to provide detailed information regarding a disqualification process in 

future rulemaking (76 FR 73322). In an effort to ensure that registries provide accurate reporting 

of quality measures data, we proposed to modify §414.90(b) to indicate that we would audit 

qualified registries (77 FR 45044-45045). If, during the audit process, we find that a qualified 

registry has submitted grossly inaccurate data, we proposed, under §414.90(b), to indicate that 

we would disqualify such a registry from the subsequent year under the program, meaning that a 

registry would not be allowed to submit PQRS quality measures data on behalf of eligible 

professionals and group practices for the next year. Under this proposal, a disqualified registry 

would not be included in the list of qualified registries that is posted for the applicable reporting 

periods under which the registry attempted to qualify (77 FR 44810). We further proposed to 

post a registry’s disqualification status on the CMS website at 

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. For example, if a qualified registry submits quality measures 

data for the reporting periods occurring in 2013 but is then audited and later disqualified, the 

registry would not be allowed to submit PQRS quality measures data on behalf of participating 

eligible professionals and group practices to CMS for the reporting periods occurring in 2014 or 

later. One example of submitting grossly inaccurate data that CMS has encountered in the past is 

if a registry reports inaccurate TIN/NPIs on 5 percent or more of the registry’s submissions. As 

CMS calculates data on a TIN/NPI level, it is important for registries to provide correct TIN/NPI 

information. 
880 

In proposing registry disqualification, we considered other alternatives, such as placing 

registries in a probationary status. However, we believed it is important for registries to submit 

correct data once it is qualified to submit data on behalf of its eligible professionals and 

therefore, find that immediate disqualification to be appropriate. This becomes especially 

important particularly as the program moves from the use of incentives to payment adjustments 

(77 FR 44811). 

We invited public comment as to the threshold of grossly inaccurate data for the purpose 

of disqualifying a registry. The following is a summary of the comments we received regarding 

this proposal. 

Comment: One commenter generally supported the establishment of a process to audit 

qualified registries, but advised CMS to exercise caution when using their authority to disqualify 

registries, thereby preventing these registries from submitting data on PQRS measures. 

Response: We understand the consequences of disqualifying a previously qualified 

registry and will therefore use this authority with caution. It is our intention that disqualification 

be used only for those registries submitting grossly inaccurate data. However, we stress the 

importance of having registries provide correct data to ensure that eligible professionals and 

group practices are correctly provided with incentive payments or payment adjustments. 

Comment: Should CMS discover that a registry has submitted inaccurate data, one 

commenter requested that the registry be allowed an opportunity to correct their mistakes and 

rectify any processes leading to data submission errors. 

Response: We appreciate the commenter's feedback. However, due to the time it takes to 

perform data analysis for payment determination, it is not technically feasible to allow registries 

to another opportunity resubmit data that is found to be inaccurate. We note that the registries 

have until the last Friday of February following the applicable reporting period (for example, 
881 

February 28, 2014 for reporting periods occurring in 2013). After this data submission period, 

CMS must perform its analysis to determine whether eligible professionals have met the criteria 

for satisfactory reporting for the PQRS incentives or payment adjustments. In order to perform 

this analysis in time to issue payment adjustments beginning January 1 of the applicable payment 

adjustment year (for example, January 1, 2015 for the 2015 PQRS payment adjustment), CMS 

cannot provide for an additional opportunity to resubmit data that is found to be inaccurate. 

We note that, although no longer required, registries have an opportunity during the year 

to test its validation and submission strategy with CMS prior to submitting the data that CMS 

will use to determine whether its eligible professionals or group practices have met the criteria 

for satisfactory reporting for the PQRS incentives and/or payment adjustments. We strongly 

encourage registries to undergo this testing process, as it will help to alleviate issues that may 

occur when submitting PQRS quality measures data to CMS. 

Comment: Some commenters oppose disqualifying registries because of inaccuracies in 

TIN/NPI information provided to CMS by the registries. One commenter states that registries do 

not gather TIN/NPI information; rather, outside reporting sites provide TIN/NPI information. 

Since the registries do not have access to this information provided by these outside sites, 

registries have no way of verifying the accuracy of TIN/NPI information. Another commenter 

stated that submission of inaccurate data should be shared by those generating the data, that is, 

the responsibility of submitting inaccurate data should be shared with the registry, its eligible 

professionals and group practices, as well as other entities involved in submitting quality 

measures data to CMS via a qualified registry. 

Response: We recognize that registries are limited to the data they receive from their 

eligible professionals. It is not our intention to seek to disqualify registries who, through no fault 

of their own, submit inaccurate data. However, we believe it is necessary to eliminate or, at a 
882 

minimum, drastically reduce instances where mismatches in TIN/NPI information would result 

in nonpayment of an incentive or conversely the application of the payment adjustment when it 

appears that the eligible professional or group practice would otherwise be eligible to receive an 

incentive. While we understand that registries are reliant on the data they receive from their 

eligible professionals or group practices, CMS discovered numerous instances where registries 

have failed to correct data inaccuracies within the purview of a registry's calculations. We 

understand that registry vendors undergo costs associated with qualifying their products to 

submit data on PQRS measures. We also understand that it would place an added burden on 

registries who were previously qualified to repeat the qualification process should CMS 

disqualify the registry. Therefore, as proposed, it is our intention to limit disqualification of 

registries to those who submit grossly inaccurate data to CMS. 

Comment: One commenter suggested that registries in their first year of PQRS 

participation be provided with leniency with regard to disqualification. 

Response: We note that CMS typically works with registries during the data submission 

period following a PQRS reporting period to help avoid the reporting of inaccurate data. One 

example of this is providing the testing process whereby registries may test its validation and 

submission strategy. In addition, during the submission process occurring immediately after the 

PQRS reporting periods, CMS provides help and guidance to those registries who encounter 

issues submitting PQRS quality measures data to CMS. Therefore, we do not believe that 

registries participating in PQRS for the first time are disadvantaged to the point that they should 

be provided greater leniency. The need for CMS to receive accurate data to determine PQRS 

incentive and/or payment adjustment applicability outweighs the need to afford newly qualified 

registries leniency should these registries submit grossly inaccurate data. 

Comment: One commenter sought clarification on the following questions: (1) What 
883 

happens to the registry participants’ respective data? Are their submissions also “disqualified”? 

(2) Does a finding of a submission with “grossly inaccurate data” by a registry mean that all data 

collected and submitted by that registry is to be considered “grossly inaccurate”? 

Response: We appreciate the commenter’s questions. With respect to the first question, 

if we find that a registry has submitted grossly inaccurate data, the data submitted by its registry 

participants those reporting periods will be disregarded. For example, if a registry submits 

grossly inaccurate data to CMS in 2014 for reporting periods occurring in 2013, the data 

submitted by the registry on behalf of its eligible professionals and group practices for reporting 

periods occurring in 2013 will not be accepted by CMS. With respect to the second question, 

should we find that a registry has submitted grossly inaccurate data, the data submitted will be 

considered inaccurate, and CMS will not accept the data provided. 

Based on the comments received and for the reasons stated, we are modifying §414.90(b) 

to indicate that we are finalizing the proposed disqualification process for registries. Should 

CMS decide to disqualify a registry, please note that our decision to disqualify a registry is final. 

Collection of Registry Data via the NwHIN. The Nationwide Health Information 

Network (NwHIN) is an initiative developed by the Department of Health and Human Services 

that provides for the exchange of healthcare information. Traditionally, CMS has not collected 

data received via a registry through NwHIN. However, we strive to encourage the collection of 

data via the NwHIN and intend to do so when it is technically feasible to do so (as early as 

2014). Therefore, we solicited public comment on collecting data via registry for PQRS via 

NwHIN. We received no comments on this proposal. However, since we believe the NwHIN 

must be further developed in order to be able to collect registry data via the NwHIN, we are not 

finalizing any policy to collect data via the NwHIN at this time. 

c. EHR-based Reporting 
884 

(1) Requirements for a Vendor’s Direct EHR Products for 2014 and Beyond 

Definition of Direct EHR Product. We proposed to modify §414.90(b) to define a direct 

electronic health record (EHR) product as “an electronic health record vendor’s product and 

version that submits data on Physician Quality Reporting System measures directly to CMS” (77 

FR 45053). Please note that the self-nomination and qualification requirements for a vendor’s 

direct EHR products for 2012 and 2013 were established in the CY 2012 Medicare PFS final rule 

(76 FR 73323). 

We did not receive public comment on our proposal to modify the definition of a direct 

electronic health record (EHR) product (77 FR 44811). Therefore, we are modifying §414.90(b) 

to define a direct electronic health record (EHR) product as “an electronic health record vendor’s 

product and version that submits data on Physician Quality Reporting System measures directly 

to CMS,” as proposed. 

Discontinuation of the Qualification Process for Direct EHR Products. In the CY 2012 

PFS final rule, we established the requirement that direct EHR products that submit PQRS 

quality measures data to CMS for reporting periods occurring in 2013 be qualified (77 FR 

77323). We proposed to no longer require qualification of direct EHR products beginning in 

2014 (77 FR 44811). Although we would still allow EHR vendors to submit test files to the 

PQRS and continue to provide support calls, we would no longer require vendors to undergo this 

testing process. Although vendors and their products would no longer be required to undergo 

this testing or qualification process, we proposed that CMS would only accept the data if the data 

are: 

• Transmitted in a CMS-approved XML format utilizing a Clinical Document Architecture 

(CDA) standard such as Quality Reporting Data Architecture (QRDA) level 1 and 
885 

• In compliance with a CMS-specified secure method for data submission, such as submitting 

the direct EHR vendor’s data (for testing) through an identity management system specified 

by CMS or another approved method. 

CMS would therefore no longer post a list of qualified EHR vendors and their products 

on the CMS website. Therefore, eligible professionals would need to work with their respective 

EHR vendor to determine whether their specific EHR product has undergone any testing with the 

PQRS and/or whether their EHR product can produce and transmit the data in the CMS-specified 

form and manner. While we no longer believe that this process is necessary, we invited public 

comment as to whether CMS should continue to require that direct EHR products undergo selfnomination and qualification processes prior to being authorized to submit quality measures data 

to CMS for PQRS reporting purposes. 

We proposed to not continue the qualification requirement (that is, no longer propose this 

process for future years of the program) because we believe adequate checks are in place to 

ensure that a direct EHR product is able to submit quality measures data for the PQRS. For 

example, to the extent possible, we intend to align with the Medicare EHR Incentive Program for 

our criteria for satisfactory reporting and measures available for reporting under the EHR-based 

reporting mechanism. The Medicare EHR Incentive Program requires that an eligible 

professional submit clinical quality measures using EHR technology certified under the program 

established by the Office of the National Coordinator for Health Information Technology (ONC). 

We anticipated that ONC’s certification process could include testing related to the reporting of 

the proposed PQRS EHR measures indicated in Tables 32 and 33, since we proposed to align the 

PQRS EHR-based measures with the measures available for reporting under the EHR Incentive 

Program. We invited public comment as to whether, in lieu of qualification, CMS should require 

that direct EHR products that would be used to submit data on PQRS quality measures for a 
886 

respective reporting period be classified as certified under the program established by ONC. 

The following is summary of the comments we received regarding our proposal to 

discontinue the qualification process for direct EHR products as well as our proposal to require 

CEHRT in lieu of PQRS qualification. 

 Comment: Several commenters supported our proposal to discontinue qualification of 

direct EHR products. The commenters believe that this proposal moves towards our goal of 

aligning PQRS and the EHR Incentive Program. The commenters also believe discontinuing 

qualification of direct EHR vendor products helps to encourage use of the EHR-based reporting 

mechanism for reporting under PQRS. 

 Response: We appreciate the commenters’ feedback and, based on the support we 

received for this proposal and the reasons we discussed above, we are finalizing our proposal to 

discontinue qualifying direct EHR products beginning in 2014. 

 Comment: Should CMS discontinue the qualification process, one commenter requested 

that CMS continue to allow EHR vendors the opportunity to submit test files when needed. 

Response: Although CMS is discontinuing qualifying EHR products, vendors will be able 

to continue to submit test files. We believe that allowing submission of test files is an important 

tool for providers and provides an adequate check to determine whether the vendor products are 

able to successfully submit data to CMS. 

Comment: Some commenters opposed our proposal to discontinue qualification of direct 

EHR products. The commenters believed that discontinuing qualification will increase burden 

on providers, who will have no guide to determine whether a direct EHR product is qualified to 

report PQRS measures. One commenter therefore urged CMS to continue to qualify direct EHR 

products until the ONC’s certification process can be used for PQRS in addition to the EHR 

Incentive Program. Another commenter expressed concern that, should CMS discontinue the 
887 

qualification process for direct EHR products, eligible professionals and group practices would 

simply assume that their CEHRT are able to submit data on measures under PQRS. 

Response: We understand that our decision to discontinue the qualification process for 

direct EHR products puts the onus on eligible professionals and group practices to determine 

whether a direct EHR product meets the requirements for reporting PQRS measures. However, 

we have received much stakeholder feedback requested that we discontinue the requirement that 

an eligible professional select a "qualified" direct EHR product; the stakeholders believe that the 

qualified designation is confusing, because there is already certification process in place 

administered by ONC that tests EHR products. Therefore, we are finalizing our proposal to 

discontinue the qualification process for direct EHR products under the PQRS beginning in 

2014. 

Nonetheless, we share the commenter's concern to provide guidance to eligible 

professionals on choosing EHR products. Therefore, based on the comments received, we are 

also finalizing to the requirement that a direct EHR product be certified by ONC as Certified 

EHR Technology (CEHRT), and therefore meet the definition of CEHRT in ONC’s regulations 

(see 45 CFR 170.102), to submit PQRS measures. (For the 2014 Edition EHR certification 

criteria, please refer to 77 FR 54163). While the process for certifying EHR technology may not 

be distinctly tailored for reporting PQRS quality measures, we note that we are making efforts to 

align, to the maximum extent possible, the measures and reporting criteria with the EHR 

Incentive Program, which requires eligible professionals to use CEHRT. For example, it is our 

intention to further align the EHR measures available for reporting by eligible professionals and 

group practices under PQRS and the EHR Incentive Program, so that the specifications of these 

measures will be the same. Therefore, beginning in 2014, ONC’s certification process would 

test the submission of data on CQMs available for reporting under the EHR Incentive Program 
888 

and, consequently, since the measures would be the same, data on PQRS quality measures that 

are reportable via an EHR. 

We understand that CEHRT may provide more capabilities than needed to report PQRS 

quality measures. However, we note that most of these capabilities are intertwined with the 

direct EHR product’s ability to capture data on quality measures and therefore necessary. The 

certified health information technology product list (CHPL) includes all EHR technology that 

has been certified, and it can be found at http://oncchpl.force.com/ehrcert?q=CHPL. 

Comment: While one commenter generally supported requiring direct EHR products to 

be ONC certified as CEHRT to report PQRS measures, the commenter stated that the ONC 

certification process should only be used for the PQRS and EHR Incentive Programs if the 

measures are identical, particularly in specifications and reporting format. 

Response: We note the commenter's concern regarding use of the ONC certification 

process and the alignment of EHR-based measures in PQRS and the EHR Incentive Program. 

As we noted in the previous response, it is our intention to align, to the maximum extent 

possible, the measures and reporting criteria for eligible professionals to meet the criteria for 

satisfactory reporting under PQRS and the criteria for meeting the CQM component of 

meaningful use under the EHR Incentive Program. By 2014, we expect that the measures and 

reporting criteria available under both programs will be sufficiently aligned to justify requiring 

that an EHR product used to report PQRS quality measures data undergo the ONC certification 

process. Therefore, we believe that requiring a direct EHR product to be CEHRT in order to be 

eligible to report measures under PQRS beginning in 2014 is appropriate. 

Comment: One commenter recommended that a certified quality reporting module be 

considered as a direct EHR product for purposes of submitting PQRS measures to CMS. 

Response: We are discontinuing the qualification process and requiring that a direct 
889 

EHR product be CEHRT beginning in 2014. A certified quality reporting module may be part of 

CEHRT, but CEHRT as a whole is more comprehensive. Please refer to ONC’s standards and 

certification criteria final rule for additional information on requirements for CEHRT (77 FR 

54163). The Certified HIT Product List CHPL, which is the listing of all certified products, is 

available at http://oncchpl.force.com/ehrcert?q=CHPL. 

Other Requirements for Direct EHR Products. Although we proposed that direct EHR 

products would no longer be required to undergo this testing or qualification process, we 

proposed that CMS would only accept the data if the data are: 

● Transmitted in a CMS-approved XML format utilizing a Clinical Document 

Architecture (CDA) standard such as Quality Reporting Data Architecture (QRDA) level 1 and 

● In compliance with a CMS-specified secure method for data submission, such as 

submitting the direct EHR vendor's data (for testing) utilizing an identity management system 

specified by CMS or another approved method (77 FR 44811). 

In addition, upon request and for oversight purposes, we proposed that the vendor would 

still be expected to provide CMS access to review the Medicare beneficiary data on which PQRS 

direct EHR-based submissions are founded or provide to CMS a copy of the actual data. 

We invited public comment on these additional proposed requirements for direct EHR 

products. The following is a summary of comments we received on this proposal. 

Comment: One commenter opposed our proposed requirement that direct EHR vendors 

would be expected to provide CMS access to review to Medicare beneficiary data on which 

PQRS direct EHR-based submissions are founded or provide to CMS a copy of the actual data. 

Under the direct EHR submission method, healthcare organizations are submitting data directly 

to CMS. The vendor does not come into possession of the data being submitted during this 

process and does not have a copy of the data to provide to CMS. Responsibility for providing 
890 

access to such data must remain with the healthcare organization. Another commenter expressed 

HIPAA concerns regarding our proposed requirement that EHR vendors would be expected to 

provide CMS access to review to Medicare beneficiary data on which PQRS direct EHR-based 

submissions are founded or provide to CMS a copy of the actual data. 

Response: We agree with the concerns the commenters have raised. Therefore, we are 

not finalizing the requirement that direct EHR products provide CMS access to review the 

Medicare beneficiary data upon which the direct vendor's submissions are founded or a copy of 

the actual data. 

In summary, we are finalizing the requirements for submitting quality measures data via a 

direct EHR product, as proposed, with the following exception: we are not finalizing our 

proposal to allow CMS access to review the Medicare beneficiary data on which PQRS direct 

EHR-based submissions are founded or provide to CMS a copy of the actual data. In addition, 

we note that the EHR Incentive Program has provided an additional format for transmitting 

quality measures data to CMS from CEHRT. In addition to finalizing the submission of quality 

measures data using the QRDA Category I format, the EHR Incentive Program also finalized the 

QRDA Category III transmission format (77 FR 54075). In our proposal, we proposed to require 

that eligible professionals and group practices using CEHRT transmit quality measures data in a 

CMS-approved XML format utilizing a Clinical Document Architecture (CDA) standard, and 

used QRDA Category I as an example. Since it was our intent to align with the EHR Incentive 

Program, who finalized transmission of quality measures data using the QRDA Category I and 

QRDA Category III formats, we are requiring that quality measures data submitted via CEHRT 

for purposes of reporting for PQRS beginning in 2014 be transmitted using the QRDA Category 

I and QRDA Category III formats. We note that, although we are requiring that products be able 

to transmit data using the QRDA Category I and III formats, for purposes of reporting PQRS 
891 

quality measures data to CMS, eligible professionals need only submit data via their EHR using 

1 (either QRDA Category I or III) of these formats. For those eligible professionals who wish to 

participate in both PQRS and the EHR Incentive Program using an EHR product that is CEHRT 

beginning in 2014, we refer readers to Option 2 for the submission of CQMs under the EHR 

Incentive Program (77 FR 54058). 

Collection of EHR data via the NwHIN. The Nationwide Health Information Network 

(NwHIN) is an initiative developed by the Department of Health and Human Services that 

provides for the exchange of healthcare information. Traditionally, CMS has not collected data 

received via a direct EHR product through NwHIN, but we would like to encourage this method 

with EHR-based reporting. However, we strive to encourage the collection of data via the 

NwHIN and intend to do so when it is technically feasible to do so (as early as 2014). Therefore, 

we solicited public comment on collecting data via an EHR for PQRS via NwHIN. The 

following is a summary of the comments we received. 

Comment: One commenter opposed collection of data received via a direct EHR product 

through the Nationwide Health Information Network (NwHIN). The commenter believes 

collecting data through NwHIN is premature and believes that development of the NwHIN is 

necessary prior to collecting data through the NwHIN. 

Response: We appreciate the commenter's feedback and agree with the commenter. 

Therefore, we are not finalizing any policy to collect data received via a direct EHR product 

through the NwHIN at this time. 

(2) Requirements for a Vendor’s EHR Data Submission Vendor Products for 2013 and Beyond 

Definition of EHR Data Submission Vendors. The EHR data submission vendor product 

was a reporting mechanism that was newly established in the CY 2012 Medicare PFS final rule 

(76 FR 73324). EHR products from an EHR data submission vendor were products that are able 
892 

to receive and transmit clinical quality data extracted from an EHR to CMS. We proposed to 

modify §414.90(b) to define an electronic health record (EHR) data submission vendor product 

as “an electronic health record vendor’s product and version that acts as an intermediary to 

submit data on Physician Quality Reporting System measures on behalf of an eligible 

professional or group practice” (77 FR 45053). 

We invited public comment but received no comments on this proposed definition of 

EHR data submission vendor product. However, we are modifying this definition to indicate that 

a data submission vendor is not necessarily an EHR product. Rather, according to stakeholder 

feedback, an EHR data submission vendor is any entity that is able to receive and transmit to 

CMS quality measures data extracted from an EHR product on behalf of the eligible 

professional. Therefore, we are modifying§414.90(b) to define an “electronic health record 

(EHR) data submission vendor” as “an entity that receives and transmits data on Physician 

Quality Reporting System measures from an EHR product to CMS.” 

Qualification process for EHR Data Submission Vendors for 2013. Please note that the 

qualification requirements for a vendor’s EHR data submission vendor products for 2013 were 

established in the CY 2012 Medicare PFS final rule (76 FR 73327). Specifically, we established 

that a qualification and testing process would occur in 2012 to qualify EHR data submission 

vendor products to submit PQRS quality measures data for reporting periods occurring in CY 

2013. Operationally, we were unable to establish a qualification and testing process in 2012 to 

qualify EHR data submission vendor products for reporting periods occurring in CY 2013. 

Therefore, we proposed to perform, in 2013, the qualification and testing process established in 

the CY 2012 Medicare PFS final rule (76 FR 73327) that was supposed to occur in 2012 (77 FR 

44812). We invited but received no public comment on this proposal. Therefore, we are 

finalizing our proposal to perform this qualification and testing process for EHR data submission 
893 

vendor products in 2013. 

 Discontinuation of Qualification Process for EHR Data Submission Vendors. For 2014 

and beyond, we proposed to no longer qualify EHR data submission vendor products to use such 

products under the PQRS for the same reasons we have articulated in our proposal not to 

continue qualifying direct EHR products (77 FR 44812). Although we would still allow EHR 

data submission vendors to submit test files to the PQRS and continue to provide support calls, 

we would no longer require vendors to undergo this testing process. CMS, however, would no 

longer post a list of qualified EHR data submission vendors on the CMS website. Therefore, 

eligible professionals would need to work with their respective EHR data submission vendor to 

determine whether the vendor has undergone any testing with the PQRS and/or whether EHR 

data submission vendor can produce and transmit the data in the CMS-specified form and 

manner. 

We invited public comment on our proposal to, beginning 2014, not require qualification 

of EHR data submission vendor products. We also invited public comment as to whether CMS 

should continue to require that EHR data submission vendors undergo these self-nomination and 

qualification processes prior to being authorized to submit quality measure data to CMS on an 

eligible professional’s behalf for PQRS reporting purposes. 

We proposed to not continue the qualification requirement (that is, no longer propose this 

process for 2014 and future years of the program) because we felt adequate checks were in place 

to ensure that an EHR data submission vendor is able to submit quality measures data for the 

PQRS. For example, to the extent possible, we intend to align with the Medicare EHR Incentive 

Program for our criteria for satisfactory reporting and measures available for reporting under the 

EHR-based reporting mechanism. The Medicare EHR Incentive Program requires that an 

eligible professional submit clinical quality measures using EHR technology certified under the 
894 

program established by the Office of the National Coordinator for Health Information 

Technology (ONC). We anticipated that the ONC’s certification process could include testing 

related to the reporting of the proposed PQRS EHR measures indicated in Table 95, since we 

proposed to align the PQRS EHR-based measures with the measures available for reporting 

under the EHR Incentive Program. We invited public comment as to whether, in lieu of 

qualification, CMS should require that direct EHR products that would be used to submit data on 

PQRS quality measures for a respective reporting period be classified as CEHRT under the 

program established by the ONC. 

The following is a summary of comments we received regarding our proposals to 

discontinue the qualification process for EHR data submission vendors and/or requiring that a 

vendor’s EHR product be CEHRT. 

Comment: Several commenters supported our proposal to discontinue qualification of 

EHR data submission vendors. The commenters believed that this proposal moves towards our 

goal of aligning PQRS and the EHR Incentive Program. The commenters also believed 

discontinuing qualification of EHR data submission vendors helps to encourage use of the EHRbased reporting mechanism for reporting under PQRS. 

Response: Based on the comments received and for the reasons stated previously, we are 

finalizing our proposal to discontinue qualifying EHR data submission vendors beginning in 

2014. 

Comment: Some commenters opposed our proposal to discontinue qualification of EHR 

data submission vendors. The commenters believe that discontinuing qualification will increase 

burden on providers, who will have no guide to determine whether an EHR data submission 

vendor is qualified to report PQRS measures. One commenter therefore urged CMS to continue 

to qualify EHR data submission vendors until the Office of the National Coordinator (ONC) for 
895 

Health Information Technology certification process can be used for PQRS to certify its EHR 

products in addition to the EHR Incentive Program. Another commenter expressed concern that, 

should CMS discontinue the qualification process for EHR data submission vendors, eligible 

professionals and group practices would simply assume that their CEHRT are able to submit data 

on measures under PQRS. 

Response: We understand that our decision to discontinue the qualification process for an 

EHR data submission vendor’s EHR products puts the onus on eligible professionals and group 

practices to determine whether a product meets the requirements for reporting PQRS measures. 

However, we have received much stakeholder feedback requested that we discontinue the 

requirement that an eligible professional select a "qualified" EHR product; the stakeholders 

believe that the qualified designation is confusing, because there is already a certification 

program in place established by ONC that tests and certifies certain EHR products. Therefore, 

we are finalizing our decision to discontinue the qualification process for EHR data submission 

vendor’s EHR products under the PQRS beginning in 2014. 

Nonetheless, we share the commenter's concern that discontinuing the qualification 

process would place additional burden on providers when trying to determine which EHR data 

submission vendor to enter into an agreement with. Therefore, based on the comments received 

and for the reasons we are requiring that direct EHR products be CEHRT beginning in 2014, we 

are also finalizing a requirement that a vendors EHR product be certified under the program 

established by ONC as Certified EHR Technology (CEHRT), and therefore meet the definition 

of CEHRT in ONC’s regulations (see 45 CFR 170.102), to submit PQRS measures. We 

understand that CEHRT may provide more capabilities than needed to report PQRS quality 

measures. However, we note that most of these capabilities are intertwined with the EHR 

product’s ability to capture data on quality measures and therefore necessary. 
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Comment: While one commenter generally supported requiring that EHR data 

submission vendor products be ONC certified as CEHRT to report PQRS measures, the 

commenter stated that the ONC certification process should only be used for the PQRS and EHR 

Incentive Programs if the measures are identical, particularly in specifications and reporting 

format. 

Response: We note the commenter's concern regarding use of the ONC certification 

process and the alignment of EHR-based measures in PQRS and the EHR Incentive Program. 

As we noted in the response to this comment regarding requiring CEHRT and direct EHR 

products, it is our intention to align, to the maximum extent possible, the measures and reporting 

criteria for eligible professionals to meet the criteria for satisfactory reporting under PQRS and 

the criteria for meeting the CQM component of meaningful use under the EHR Incentive 

Program. By 2014, we expect that the measures and reporting criteria available under both 

programs will be sufficiently aligned to justify requiring that an EHR product undergo the ONC 

certification process. Therefore, we believe that requiring a direct EHR product to be CEHRT in 

order to be eligible to report measures under PQRS beginning in 2014 is appropriate. 

Other Requirements for Data Submission Vendors’ EHR Products. Although EHR data 

submission vendor products are no longer be required beginning in 2013 to undergo this testing 

or qualification process, we proposed that CMS would only accept the data if the data are: 

● Transmitted in a CMS-approved XML format utilizing a Clinical Document 

Architecture (CDA) standard such as Quality Reporting Data Architecture (QRDA) level 1 and 

for EHR data submission vendor products that intend to report for purposes of the proposed 

PQRS-Medicare EHR Incentive Program Pilot, if the aggregate data are transmitted in a CMSapproved XML format 

● In compliance with a CMS-specified secure method for data submission (77 FR 
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44812). 

 In addition, upon request and for oversight purposes, we proposed that the vendor would 

still be expected to provide CMS access to review the Medicare beneficiary data on which PQRS 

direct EHR-based submissions are founded or provide to CMS a copy of the actual data. 

We invited public comment on these proposed requirements for EHR data submission 

vendors. The following is a summary of the comments we received on this proposal. 

Comment: One commenter generally supported our proposal to require that data 

submitted follow the proposed format, regardless of whether the qualification process is 

discontinued. The commenter also specifically supported use of a standard reporting structure in 

XML. The commenter further believes that QRDA Level 1 should adequately capture measure 

information for patients and types of measures where the analysis is something other than the 

patient. 

Response: We appreciate the commenter's support and are finalizing these proposed 

requirements, as proposed. 

In addition, we note that in addition to finalizing the submission of quality measures data 

using the QRDA Category I format, the EHR Incentive Program also finalized the QRDA 

Category III transmission format (77 FR 54075). In our proposal, we proposed to require that 

eligible professionals and group practices using CEHRT transmit quality measures data in a 

CMS-approved XML format utilizing a Clinical Document Architecture (CDA) standard, and 

used QRDA Category I as an example. Since it was our intent to align with the EHR Incentive 

Program, who finalized transmission of quality measures data using the QRDA Category I and 

QRDA Category III formats, we are also requiring that quality measures data submitted via 

CEHRT for purposes of reporting for PQRS beginning in 2014 be transmitted using the QRDA 

Category I and QRDA Category III formats. We note that, although we are requiring that 
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products be able to transmit data using the QRDA Category I and III formats, for purposes of 

reporting PQRS quality measures data to CMS, eligible professionals need only submit data via 

their EHR using 1 (either QRDA Category I or III) of these formats. For those eligible 

professionals who wish to participate in both PQRS and the EHR Incentive Program using an 

EHR product that is CEHRT beginning in 2014, we refer readers to Option 2 for the submission 

of CQMs under the EHR Incentive Program (77 FR 54058). 

Collection of EHR Data via the NwHIN. The Nationwide Health Information Network 

(NwHIN) is an initiative developed by the Department of Health and Human Services that 

provides for the exchange of healthcare information. Traditionally, CMS has not collected data 

received via an EHR data submission vendor through NwHIN, but we would like to encourage 

this method with EHR-based reporting. However, we strive to encourage the collection of data 

via the NwHIN and intend to do so when it is technically feasible to do so (as early as 2014). 

Therefore, we solicited public comment on collecting data via an EHR for PQRS via NwHIN. 

The following is a summary of comments we received. 

Comment: One commenter opposed collection data received via a direct EHR product 

through the Nationwide Health Information Network (NwHIN). The commenter believes 

collecting data through NwHIN is premature and believes that development of the NwHIN is 

necessary prior to collecting data through the NwHIN. 

Response: We appreciate the commenter's feedback and agree with the commenter. 

Therefore, we are not finalizing any plan to collect data received via an EHR data submission 

vendor through the NwHIN at this time. 

d. GPRO Web interface: Requirements for Group Practices Using the GPRO Web interface for 

2013 and Beyond 
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The GPRO web interface is a reporting mechanism established by CMS that is used by 

group practices that are selected to participate in the GPRO. For 2013 and beyond, we proposed 

to modify newly designated §414.90(g) and §414.90(h) to identify the GPRO web interface as a 

reporting mechanism available for reporting under the PQRS by group practices comprised of 25 

or more eligible professionals (77 FR 45055). Consistent with the GPRO satisfactory reporting 

criteria we established for the 2012 PQRS (76 FR 73338), as well as the GPRO satisfactory 

reporting criteria we proposed for 2013 and beyond, we proposed to limit reporting via the 

GPRO web interface during a respective reporting period to group practices composed of at least 

25 eligible professionals (that is, this reporting option would not be available to group practices 

that contain 2-24 eligible professionals) and selected to participate in the GPRO for the year 

under which the reporting period occurs (77 FR 44812). For example, a group practice wishing 

to submit quality measure data via the GPRO web interface for 2013 must be a group practice 

selected to participate in the GPRO for the 2013 program year. We believe it is necessary to limit 

use of the GPRO web interface to group practices comprised of at least 25 eligible professionals 

selected to participate in the GPRO because the 18 measures (including 2 composite measures, 

for a total of 22 measures) that are proposed to be reportable via the GPRO web interface (as 

specified in Table 33 of the proposed rule) reflect a variety of disease modules: patient/ caregiver 

experience, care coordination/patient safety, preventive health, diabetes, hypertension, ischemic 

vascular disease, heart failure, and coronary artery disease. 

We believe that the reporting of the 18 proposed measures spanning across various 

settings would lend this reporting mechanism to larger group practices that are more likely to be 

multi-specialty practices (which are typically group practices consisting of more than 24 eligible 

professionals). The GPRO web interface was modeled after the CMS Physician Group Practice 

(PGP) demonstration, and this demonstration was originally intended for large group practices. 
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From our experience with the PGP demonstration, we believe a group practice comprised of 25 

eligible professionals is the smallest group practice that could benefit from use of the GPRO web 

interface as a reporting mechanism. We also do not believe that excluding group practices 

comprised of 2-24 eligible professionals from using the GPRO web interface as a reporting 

mechanism would harm these smaller group practices because we proposed to expand the 

reporting options for small group practices by proposing to allow groups composed of 2-99 

eligible professionals to report using the claims, qualified registry, EHR, and administrative 

claims-based reporting mechanisms. 

We proposed to provide group practices that are selected to participate in the GPRO 

using GPRO web interface reporting option with access to the GPRO web interface by no later 

than the first quarter of the year following the end of the reporting period under which the group 

practice intends to report (77 FR 44813). For example, for group practices selected for the 

GPRO for the 2013 incentive using the GPRO web interface tool, we proposed to provide group 

practices selected to participate in the GPRO with access to the GPRO web interface by no later 

than the first quarter of 2014 for purposes of reporting for the applicable 2013 reporting period 

for the incentive. In addition, we noted that if CMS encountered operational issues with the use 

of the GPRO web interface, we reserved the right to use a similar tool for group practices to use 

in lieu of reporting via the GPRO web interface. 

We invited public comment on our proposed requirements for group practices using the 

GPRO web interface for 2013 and beyond. We received the following comment on these 

proposals:

Comment: One commenter supported our proposal to limit availability of the GPRO web 

interface to group practices of 25 or more eligible professionals and agreed with our reasoning. 
901 

Response: We appreciate with the commenter's feedback and, therefore, we are finalizing 

our proposal to limit the availability of the GPRO web interface to group practices comprised of 

25 or more eligible professionals. In the future, CMS will try to develop ways by which smaller 

group practices could be able to use the GPRO web interface. 

Based on the comments received, we are finalizing, as proposed, requirements for group 

practices using the GPRO web interface for 2013 and beyond. We are also modifying 

§414.90(g)(3) and §414.90(h)(3) to indicate that the GPRO web interface will be a reporting 

mechanism available for use by group practices for the PQRS incentives and payment 

adjustments. 

Collection of GPRO Web interface Data via the NwHIN. The Nationwide Health 

Information Network (NwHIN) is an initiative developed by the Department of Health and 

Human Services that provides for the exchange of healthcare information. Traditionally, CMS 

has not collected data received via the GPRO web interface through NwHIN. However, we 

strive to encourage the collection of data via the NwHIN and intend to do so when it is 

technically feasible to do so (as early as 2014). Therefore, we solicited public comment on 

collecting data via the GPRO web interface for PQRS via NwHIN. We received no public 

comment on this proposal. However, since we believe collecting data via the NwHIN would be 

premature, we are not finalizing any policy to collect data received via the GPRO web interface 

in the NwHIN. 

e. Administrative Claims 

 For purposes of reporting for the 2015 and 2016 PQRS payment adjustments only, we 

proposed to modify §414.90(h) to allow eligible professionals and group practices to use an 

administrative claims reporting mechanism (77 FR 45056). The administrative claims reporting 

mechanism builds off of the traditional PQRS claims-based reporting mechanism. Under the 
902 

traditional PQRS claims-based reporting mechanism, eligible professionals and group practices 

wishing to report data on PQRS quality measures via claims for the incentives and for the 

payment adjustments must submit quality data codes (QDCs) on claims to CMS for analysis. 

Under the proposed administrative claims reporting mechanism, unlike the traditional claimsbased reporting option, an eligible professional or group practice would not be required to submit 

QDCs on claims to CMS for analysis (77 FR 44813). Rather, CMS would analyze every eligible 

professional’s or group practice’s patient’s Medicare claims to determine whether the eligible 

professional or group practice has performed any of the clinical quality actions indicated in the 

proposed PQRS quality measures in Table 63 of the CY 2013 PFS proposed rule. We proposed 

that, for purposes of assessing claims for quality measures under this option, all claims for 

services furnished that occur during the 2015 and/or 2016 PQRS payment adjustment reporting 

period would need to be processed by no later than 60 days after the end of the respective 2015 

and 2016 payment adjustment reporting periods (that is, December 31, 2013 and December 31, 

2014). 

We invited public comment on our proposed requirements for using the administrative 

claims-based reporting mechanism for the 2015 and 2016 payment adjustments. The following 

is summary of the comments we received regarding these proposals.

 Comment: Several commenters supported the addition of the administrative claims-based 

reporting mechanism for the 2015 and 2016 PQRS payment adjustments. The commenters noted 

that this addition of the administrative claims-based reporting mechanism would relieve the 

reporting burden on eligible professionals. 

 Response: We appreciate the commenters' feedback and are finalizing the administrative 

claims-based reporting mechanism for the 2015 payment adjustment. Since it is our intention 

that this reporting option be temporary, we will consider having the administrative claims-based 
903 

reporting mechanism available for the 2016 PQRS payment adjustment in the future, but we are 

not finalizing our proposal to have the administrative claims-based reporting option for eligible 

professionals and group practices for the 2016 PQRS payment adjustment at this time. As 

participation in PQRS increases and eligible professionals and group practices become more 

familiar with the traditional claims, registry, direct EHR, EHR data submission vendor-based, or 

GPRO web interface reporting mechanisms, it is our intention to move away from use of the 

administrative claims-based reporting mechanism to allow for more proactive reporting by 

eligible professionals and group practices. 

 Comment: One commenter suggested that eligible professionals be allowed to choose the 

administrative claims-based reporting option to meet the criteria for satisfactory reporting for the 

2013 and 2014 PQRS incentives. 

 Response: We respectfully disagree. We believe that eligible professionals and group 

practices should be required to use the traditional reporting mechanisms (claims, registry, EHR, 

or GPRO web interface) to report for the PQRS incentive as we believe that reporting via these 

traditional reporting mechanisms produce more meaningful data. As noted previously, while the 

administrative claims-based reporting mechanism still satisfies PQRS requirements by 

submitting quality measures data to CMS, we agree with other commenters that the 

administrative claims-based reporting option may not provide data that is as meaningful as data 

collected through other mechanisms. We are finalizing the addition of the administrative claimsbased reporting option only as a means to report for the 2015 PQRS payment adjustments to ease 

eligible professionals into reporting PQRS measures. Since we see this option as temporary, 

only a limited set of measures were proposed for use under the administrative claims-based 

reporting option. We believe that more meaningful data will be collected using the traditional 

claims, registry, EHR, or GPRO web interface reporting mechanisms, where eligible 
904 

professionals or group practices may choose measures from a broad set that may be more 

relevant to their practice. Therefore, eligible professionals will not be able to use the 

administrative claims-based reporting mechanism for the 2013 and 2014 PQRS incentives. 

 Based on the comments received, we are finalizing, as proposed, the administrative 

claims-based reporting mechanism for reporting for the 2015 payment adjustment only. We are 

not finalizing the administrative claims-based reporting mechanism for the 2016 PQRS payment 

adjustment, as we will revisit the necessity of having this reporting option available for the 2016 

PQRS payment adjustment next year. We are modifying §414.90(h)(2) and §414.90(h)(3) to 

indicate that the administrative claims-based reporting mechanism is available for use by eligible 

professionals and group practices for the 2015 PQRS payment adjustment. 

4. Criteria for Satisfactory Reporting for the 2013 and 2014 Incentives 

For 2013 and 2014, in accordance with §414.90(c)(3), eligible professionals that 

satisfactorily report data on PQRS quality measures are eligible to receive an incentive equal to 

0.5 percent of the total estimated Medicare Part B allowed charges for all covered professional 

services furnished by the eligible professional or group practice during the applicable reporting 

period. This section contains the criteria for satisfactory reporting for the 2013 and 2014 

incentives, which are the last two incentives authorized under the PQRS. 

a. Criteria for Satisfactory Reporting for Individual Eligible Professionals 

(1) Criteria for Satisfactory Reporting on Individual PQRS Quality Measures via Claims 

According to the “2010 Physician Quality Reporting System and eRx Reporting 

Experience and Trends,” available for viewing in the “downloads” section of the main page the 

PQRS website (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html), reporting via the claims-based reporting mechanism was the 

most commonly used reporting method. We believe that this trend would continue, so we 
905 

anticipated that, for the 2013 and 2014 incentives, the criteria for satisfactory reporting for the 

claims-based reporting mechanism would be the method most widely used by individual eligible 

professionals. So as not to change reporting criteria that a large number of individual eligible 

professionals are familiar with using, we established the same reporting criteria for the 2011 and 

2012 incentives (76 FR 73330). Therefore, for the respective 12-month reporting periods for the 

2013 and 2014 incentives, based on our authority under section 1848(m)(3)(D) of the Act to 

revise the reporting criteria for satisfactory reporting specified under the statute and our desire to 

maintain the same reporting criteria we established for individual eligible professionals for the 

2012 PQRS incentive (76 FR 73330), we proposed the following criteria for satisfactory 

reporting of PQRS individual measures for individual eligible professionals using the claimsbased reporting mechanism: Report at least 3 measures, OR, if less than 3 measures apply to the 

eligible professional, report 1—2 measures, AND report each measure for at least 50 percent of 

the eligible professional’s Medicare Part B FFS patients seen during the reporting period to 

which the measure applies (77 FR 44813). Measures with a 0 percent performance rate would 

not be counted. For an eligible professional who reports fewer than 3 measures via the claimsbased reporting mechanism, we proposed that the eligible professional be subject to the 

Measures Applicability Validation (MAV) process, which would allow us to determine whether 

an eligible professional should have reported quality data codes for additional measures. We felt 

the MAV process was necessary 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 eligible professional). Under the MAV process, if an eligible 

professional who reports on fewer than 3 measures reports on a measure that is part of an 

identified cluster of closely related measures, then the eligible professional would not qualify as 

a satisfactory reporter for the 2013 and/or 2014 incentives. We proposed this MAV process for 
906 

the claims-based reporting mechanism only because it is more likely for EPs to report on more 

than 3 measures under the registry and EHR-based reporting mechanisms, as a registry or EHR 

product will typically automatically report on all measures that apply to the eligible 

professional’s practice. We note that, consistent with section 1848(m)(3)(A)(i) of the Act, this 

proposed claims-based reporting criteria would be the only proposed criteria where an eligible 

professional could report on fewer than 3 measures. 

We invited public comment on the proposed criteria for satisfactory reporting of 

individual measures by individual eligible professionals via claims for the 2013 and 2014 

incentives. The following is a summary of the comment we received regarding these proposed 

criteria: 

Comment: One commenter supported our proposed criteria for satisfactory reporting for 

individual eligible professionals via claims. The commenter stated that the 3-measure threshold 

allows small practices that participate individually treating multi-morbid patients to participate in 

PQRS. 

Response: Based on the comments received and for the reasons stated previously, we are 

finalizing, as proposed, the criteria for satisfactory reporting for individual eligible professionals 

via claims for the 2013 and 2014 PQRS incentives. These criteria are specified in Tables 25 and 

26 below. 

(2) Criteria for Satisfactory Reporting on Individual PQRS Quality Measures via Registry 

We note that section 1848(m)(3)(A)(ii) of the Act provides that, to meet the criteria for 

satisfactory reporting under PQRS, an eligible professional would be required to report on at 

least 3 measures for at least 80 percent of the cases in which the respective measure is reportable 

under the system. Although we have the authority under section 1848(m)(3)(D) of the Act to 

revise the criteria for satisfactory reporting, for registry-based reporting, we have largely 
907 

followed these reporting criteria for the PQRS incentives. According to the “2010 Physician 

Quality Reporting System and eRx Reporting Experience and Trends,” eligible professionals are 

more likely to meet the requirements for a PQRS incentive using the satisfactory reporting 

criteria for the registry-based reporting mechanism than claims. In fact, in 2010, approximately 

87 percent of the eligible professionals reporting individual PQRS quality measures via registry 

were eligible and met the criteria for satisfactory reporting for the 2010 incentive. Since eligible 

professionals have had success with using these satisfactory reporting criteria, we believe such 

criteria are appropriate and see no reason to change the criteria for satisfactory reporting via 

registry that has been in place since 2010. Therefore, for those reasons and our desire to 

maintain the same reporting criteria we established for individual eligible professionals for the 

2012 PQRS incentive (76 FR 73331), we proposed the following criteria for satisfactory 

reporting of PQRS individual measures for individual eligible professionals using the registrybased reporting mechanism for the 12-month reporting periods for the 2013 and 2014 incentives, 

respectively: report at least 3 measures AND report each measure for at least 80 percent of the 

eligible professional’s Medicare Part B FFS patients seen during the reporting period to which 

the measure applies (77 FR 44814). Measures with a zero percent performance rate will not be 

counted. 

We invited but received no public comment on the proposed criteria for satisfactory 

reporting of individual measures by individual eligible professionals via a registry for the 2013 

and 2014 incentives. Therefore, we are finalizing these criteria as proposed. These criteria are 

specified in Tables 25 and 26 below. 

(3) Criteria for Satisfactory Reporting on Individual PQRS Quality Measures via EHR 

 Satisfactory Reporting Criteria of Individual PQRS Quality Measures via EHR for the 

2013 PQRS Incentive. As stated previously, section 1848(m)(7) of the Act requires us to 
908 

develop a plan to integrate reporting requirements for PQRS and the EHR Incentive Program. 

Therefore, for EHR-based reporting, it is our main goal to align our EHR reporting requirements 

with the reporting requirements an eligible professional must meet to satisfy the clinical quality 

measure (CQM) component of meaningful use (MU) under the EHR Incentive Program. To 

align with the EHR Incentive Program, we based our proposals on the EHR Incentive Program – 

Stage 2 NPRM (77 FR 13698). Also to align with the EHR Incentive Program, for the EHR 

reporting periods in CY 2013, we proposed (77 FR 13745) to continue the CQM reporting 

requirements that were established for eligible professionals for CYs 2011 and 2012 in the EHR 

Incentive Program – Stage 1 final rule (75 FR 44398-44411). Therefore, to align with the 

reporting requirements for meeting the CQM component of meaningful use, and based on our 

authority under section 1848(m)(3)(D) of the Act to revise the reporting criteria for satisfactory 

reporting identified under the statute, we proposed the following criteria for the 12-month 

reporting period for the 2013 incentive (77 FR 44814): 

● As required by the Stage 1 final rule, eligible professionals must report on three 

Medicare EHR Incentive Program core or alternate core measures, plus three additional 

measures. The EHR Incentive Program’s core, alternate core, and additional measures can be 

found in Table 6 of the EHR Incentive Program’s Stage 1 final rule (75 FR 44398) or in Tables 

32 and 33 of the CY 2013 PFS proposed rule. We referred readers to the discussion in the Stage 

1 final rule for further explanation of the requirements for reporting those CQMs (75 FR 44398 

through 44411). 

 Under this proposal, eligible professionals using these reporting criteria would be 

required to report on 6 measures. For the proposed PQRS EHR measures that are also Medicare 

EHR Incentive Program core, alternate core, or additional measures that the eligible professional 

reports (75 FR 44398 through 44411), an eligible professional would be required to report the 
909 

applicable measure for 100 percent of the eligible professionals Medicare Part B FFS patients. 

 In addition, we noted that section 1848(m)(3)(A)(ii) of the Act provides that, to meet the 

criteria for satisfactory reporting under PQRS, an eligible professional would be required to 

report on at least 3 measures for at least 80 percent of the cases in which the respective measure 

is reportable under the system. Although we have the authority under section 1848(m)(3)(D) of 

the Act to revise the criteria for satisfactory reporting, for EHR-based reporting, we noted that 

we have largely kept these reporting criteria for the 2010—2012 incentives. As some eligible 

professionals succeeded with these criteria, we proposed the following similar criteria for the 

12-month reporting period for the 2013 incentive: report at least 3 measures AND report each 

measure for at least 80 percent of the eligible professional’s Medicare Part B FFS patients seen 

during the reporting period to which the measure applies (77 FR 44814). Measures with a zero 

percent performance rate will not be counted. 

 We received no public comment on the satisfactory reporting criterion we proposed for 

individual PQRS measures using a direct EHR or EHR data submission vendor product for the 

2013 PQRS incentive: Report at least 3 measures for at least 80 percent of the cases in which the 

respective measure is reportable under the system. Therefore, for the reasons previously stated, 

we are finalizing the criterion. 

We invited public comment on the proposed criteria for the satisfactory reporting of 

individual PQRS measures using a direct EHR or EHR data submission vendor product for the 

2013 PQRS incentive. The following is a summary of those comments. 

 Comment: Several commenters generally supported our proposals to align the EHR 

reporting criteria with the criteria established for meeting the CQM component of achieving 

meaningful use under the EHR Incentive Program. 

 Response: We appreciate the commenters’ positive feedback. 
910 

 Comment: Several commenters supported our proposed criteria for the satisfactory 

reporting of PQRS measures via direct EHR or EHR data submission vendor products for the 

2013 PQRS incentive, as the proposed criteria aligns with the CQM criteria of meaningful use 

for the EHR Incentive Program. 

 Response: We appreciate the commenters' feedback. Based on the support received for 

this proposed criterion and for the reasons we discussed above, we are finalizing the following 

criterion for the satisfactory reporting of individual PQRS measures using a direct EHR or EHR 

data submission vendor product for the 2013 PQRS incentive: As required by the Stage 1 final 

rule, eligible professionals must report on three Medicare EHR Incentive Program core or 

alternate core measures, plus three additional measures. The EHR Incentive Program’s core, 

alternate core, and additional measures can be found in Tables 6 and 7 of the EHR Incentive 

Program’s Stage 1 final rule (75 FR 44398 through 44411) or in Table 95 of this section. We 

refer readers to the discussion in the Stage 1 final rule for further explanation of the requirements 

for reporting those CQMs (75 FR 44398 through 44411). 

 Comment: Several commenters encouraged us to accept the reporting of measures with a 

zero percent performance rate using the EHR-based satisfactory reporting criteria that aligns with 

the EHR Incentive Program. Under Stage 1, many of the core and alternate core measures are 

not applicable to specialties. The commenter believes that allowing the reporting of measures 

with a zero percent performance rate will achieve our goal of having eligible professionals report 

one set of data for PQRS and the EHR Incentive Program. 

 Response: We understand the commenter's concerns. We have stressed the importance of 

collecting data that is applicable to the eligible professional’s practice. Therefore, or PQRS, we 

are only concerned with the reporting of measures that are relevant to an eligible professional’s 

practice. An eligible professional may still report on the same number of measures he/she is 
911 

reporting for the EHR Incentive Program. However, for purposes of PQRS, we will only analyze 

the measures that are applicable to the eligible professional’s practice. If using this reporting 

criterion, an eligible professional should be able to report on at least one applicable measure. 

 Satisfactory Reporting Criteria of Individual PQRS Quality Measures via EHR for the 

2014 PQRS Incentive. At the time of the CY 2013 PFS proposed rule, we noted that we had 

proposed under the Medicare EHR Incentive Program options for meeting the CQM component 

of achieving meaningful use beginning with CY 2014 (77 FR 13746—13748). To align our 

EHR-based reporting requirements with those proposed under the Medicare EHR Incentive 

Program, we proposed the following criteria for satisfactory reporting using the EHR-based 

reporting mechanism for the 12-month reporting period for the 2014 incentive: 

● Option 1a: Select and submit 12 clinical quality measures available for EHR-based 

reporting from Tables 32 and 33 of the proposed rule, including at least 1 measure from each of 

the following 6 domains – (1) patient and family engagement, (2) patient safety, (3) care 

coordination, (4) population and public health, (5) efficient use of healthcare resources, and (6) 

clinical process/effectiveness. 

● Option 1b: Submit 12 clinical quality measures composed of all 11 of the proposed 

Medicare EHR Incentive Program core clinical quality measures specified in Table 95 plus 1 

menu clinical quality measure from Tables 32 and 33 of the proposed rule. We noted it was our 

intention to finalize the reporting criteria that aligns with the criteria that would be established 

for meeting the CQM component of meaningful use beginning with CY 2014 for the Medicare 

EHR Incentive Program. Furthermore, to the extent that the final criteria for meeting the CQM 

component of achieving meaningful use differ from what was proposed, we noted that our 

intention was to align with the reporting criteria the EHR Incentive Program ultimately 

established (77 FR 44814). Therefore, eligible professionals who participate in both PQRS and 
912 

the EHR Incentive Program would be able to use one reporting criterion, during overlapping 

reporting periods, to satisfy the satisfactory reporting criteria under PQRS and the CQM 

component of meaningful use under the Medicare EHR Incentive Program. 

 In addition to this proposed criterion, we had proposed under the Medicare EHR 

Incentive Program that, beginning with CY 2014, eligible professionals who participate in both 

the Physician Quality Reporting System and the Medicare EHR Incentive Program may satisfy 

the CQM component of meaningful use if they submit and satisfactorily report PQRS clinical 

quality measures under the PQRS EHR reporting option using Certified EHR Technology (77 

FR 13748). Since this language suggested that the Medicare EHR Incentive Program may defer 

to the satisfactory reporting criteria for the EHR-based reporting mechanism that we will 

establish for 2014, we proposed the following reporting criteria for the 12-month reporting 

period for the 2014 incentive that largely conform to the criteria set forth under section 

1848(m)(3)(A)(ii) of the Act that we established for the 2012 incentive and that we proposed for 

the 2013 incentive: report at least 3 measures AND report each measure for at least 80 percent of 

the eligible professional’s Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. Measures with a zero percent performance rate will not be counted. 

 We received no comments regarding the following proposed criteria using a direct EHR 

or EHR data submission vendor product for the 2014 incentive: Report at least 3 measures AND 

report each measure for at least 80 percent of the eligible professional’s Medicare Part B FFS 

patients seen during the reporting period to which the measure applies. However, in an effort to 

streamline reporting requirements for the 2014 PQRS incentives, we only wish to finalize one 

reporting criterion to meet the criteria for satisfactory reporting for the 2014 PQRS incentive 

using an EHR-based reporting mechanism. Therefore, since the EHR Incentive Program did not 

finalize this proposed reporting criterion, we are not finalizing this proposed criterion. We 
913 

understand that not finalizing this criterion would eliminate a reporting option previously 

available to eligible professionals. We note however, that this EHR-based reporting criterion 

was not widely used by eligible professionals. In fact, according to the 2010 PQRS and eRx 

Experience Report, less than 1% of eligible professionals participating in PQRS did so using the 

EHR-based reporting mechanism. Therefore, we do not believe eligible professionals will be 

harmed by our decision not to finalize this criterion. Furthermore, we believe that eligible 

professionals that have used the EHR-based reporting mechanism in the past will gravitate 

towards using reporting criterion that aligns with the EHR Incentive Program, as eligible 

professionals using aligned criterion will have the ability to submit one set of quality measures 

data to achieve the requirements under both PQRS and the EHR Incentive Program. 

Nonetheless, we are streamlining the criteria in 2014, and not 2013, in order to give eligible 

professionals an additional year to adjust their practice workflows to account for this change. 

We invited public comment on the proposed criteria for satisfactory reporting on PQRS 

measures via EHR for the 2014 PQRS incentive that were proposed under the EHR Incentive 

Program for 2014. The following is summary of the comments we received regarding these 

proposals. 

 Comment: Several commenters generally supported our proposals to align the EHR 

reporting criteria with the criteria established for meeting the CQM component of achieving 

meaningful use under the EHR Incentive Program. 

 Response: We appreciate the commenters’ positive feedback. 

 Comment: Some commenters suggested an alternative criterion for the satisfactory 

reporting of individual PQRS measures via EHR: For the 2014 PQRS incentive, report six 

measures, covering at least two domains. If no individual measures available for EHR-based 
914 

reporting are relevant to the eligible professional, the eligible professional may submit measures 

with a zero percent performance rate. 

 Response: We appreciate the commenter's suggestion. However, as previously stated, it 

is our intention to adopt satisfactory reporting criteria that closely aligns with the criteria 

established for achieving meaningful use for the EHR Incentive Program. Since the alternative 

criterion proposed by the commenter does not align with the criteria established for the EHR 

Incentive Program, we respectfully decline to establish this alternative criterion for the 

satisfactory reporting of individual measures via EHR for the 2014 PQRS incentive. 

 Comment: For the proposed option 1a for EHR-based reporting for the 2014 PQRS 

incentive, one commenter believed that the requirement to report 12 CQMs is too high. The 

commenter believed that because many measures are focused towards primary care and 

preventive medicine, it may be difficult for sub-specialists to meet the 12 CQM threshold, 

leading these eligible professionals to potentially report a zero percent performance rate on most 

measures. Commenters were also concerned that the proposal to report at least 1 measure from 

each of the six proposed domains would add to difficulty in reporting, as some of the domains 

have limited measure sets. 

 Response: We understand and agree with the commenter's arguments against option 1a. 

Indeed, the EHR Incentive Program did not finalize these criteria for reporting CQMs to achieve 

meaningful use under the EHR Incentive Program. Therefore, we are not finalizing this proposal 

for the PQRS. 

 Comment: For the proposed option 1b for EHR-based reporting for the 2014 PQRS 

incentive, one commenter believed that the requirement to report 12 CQMs is too high. Because 

many measures are focused towards primary care and preventive medicine, the commenter was 

concerned that it may be difficult for sub-specialists to meet the 12 CQM threshold, leading these 
915 

eligible professionals to potentially report a zero percent performance rate on most measures. 

Commenters also believed that the additional proposed requirement to reporting on 11 core 

CQM measures may have the negative consequence of forcing eligible professionals to report on 

measures that are not fully relevant to their respective practice, as there may not be 12 CQMs 

relevant to their practice. 

 Response: We understand and agree with the commenter's arguments against option 1b. 

Indeed, the EHR Incentive Program did not finalize these criteria for reporting CQMs to achieve 

meaningful use under the EHR Incentive Program. Therefore, we are not finalizing this proposal 

for the PQRS. 

 Comment: Several commenters encouraged us to accept the reporting of measures with a 

zero percent performance rate using the EHR-based satisfactory reporting criteria that aligns with 

the EHR Incentive Program. The commenter believes that allowing the reporting of measures 

with a zero percent performance rate will achieve our goal of having eligible professionals report 

one set of data for PQRS and the EHR Incentive Program. 

 Response: We understand the commenter's concerns. For PQRS, we are only concerned 

with the reporting of measures that are relevant to an eligible professional’s practice. Therefore, 

we will only analyze the measures for which there is Medicare patient data. 

 We note that, despite this distinction in the way the eligible professional’s submitted data 

is analyzed, we are still achieving our goal of aligning the criteria for satisfactory reporting under 

PQRS with the criteria for meeting the CQM component of achieving meaningful use under the 

EHR Incentive Program. Eligible professionals will still be able to report the same set of data in 

the same form and manner to satisfy the requirements for both programs. The only distinction 

lies in the analysis performed by the two programs. For example, let’s pretend an eligible 

professional, in 2014, uses CEHRT to report 9 measures covering 3 domains, and only 1 measure 
916 

applies to the eligible professional’s practice (that is, the eligible professional has patients that 

are eligible for inclusion in only 1 measure’s denominator). The eligible professional will have 

met the criteria for meeting the CQM component of achieving meaningful use in 2014, because 

the eligible professional would have reported 9 measures covering at least 3 domains and 

reported the measures (1 measure, in this example) for which there is patient data and the 

remaining required measures as "zero denominators" as displayed by the eligible professional's 

CEHRT. The eligible professional will have also met the criteria for satisfactory reporting under 

PQRS for the 2014 PQRS incentive, because we will assume that by receiving data for only 1 

measure with a denominator greater than zero that the eligible professional did not have any 

other applicable measures on which to report.. 

 We understand that there may be instances where no measures apply to an eligible 

professional. For those eligible professionals for which no measures available for reporting used 

the EHR-based reporting mechanisms apply, for 2014, we strongly encourage those eligible 

professionals to meet the criteria for satisfactory reporting using an alternative reporting option. 

 Based on the comments received and for the reasons we stated above, we are finalizing 

the following criteria for satisfactory reporting of individual PQRS measures using direct EHR 

or EHR data submission vendor products for the 2014 PQRS incentive: Report 9 measures 

covering at least 3 domains, as specified in Table 95. If an eligible professional's CEHRT does 

not contain patient data for at least 9 measures covering at least 3 domains, then the eligible 

professional must report the measures for which there is patient data. 

 We note that the EHR Incentive Program established the requirements, should an eligible 

professional’s CEHRT not contain patient data for at least 9 measures covering at least 3 

domains, the eligible professional must report the measures for which there is patient data and 
917 

report the remaining required measures as "zero denominators" as displayed by the eligible 

professional's CEHRT. If there are no measures applicable to the eligible professional's scope of 

practice and patient population, eligible professionals must still report 9 measures even if zero is 

the result in either the numerator or denominator of the measure. If all applicable measures have 

a value of zero from their CEHRT, then eligible professional must report any 9 measures (77 FR 

54058). For PQRS, we are only concerned with the reporting of measures that are relevant to an 

eligible professional’s practice. Therefore, we are not accepting the reporting of “zero 

denominators.” Therefore, to meet the criteria for satisfactory reporting for the 2014 PQRS 

incentive using this criterion, an eligible professional must report on at least 1 applicable 

measure (that is, at least 1 of the 9 measures that the eligible professional reports using an EHRbased reporting mechanism must not have a “zero denominator”) . 

 (4) Criteria for Satisfactory Reporting on PQRS Measures Groups via Claims 

 In the CY 2012 Medicare PFS final rule, we established the following criteria for 

satisfactorily reporting PQRS measures groups for the 12-month reporting period for the 2012 

incentive (76 FR 73335): 

● Report at least 1 PQRS measures group, AND report each measures group for at least 

30 Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent 

performance rate will not be counted; OR 

● Report at least 1 PQRS measures group, AND report each measures group for at least 

50 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting 

period to whom the measures group applies; BUT report each measures group on no less than 15 

Medicare Part B FFS patients seen during the reporting period to which the measures group 

applies. Measures groups containing a measure with a 0 percent performance rate will not be 

counted. 
918 

 We received stakeholder feedback that it is difficult for some specialties to meet the 30 

Medicare Part B FFS patient threshold. Therefore, based on our authority under section 

1848(m)(3)(D) of the Act to revise the reporting criteria for satisfactory reporting, we proposed 

the following criteria for the satisfactorily reporting PQRS measures groups for individual 

eligible professionals using the claims-based reporting mechanism for the 12-month reporting 

periods for the 2013 and 2014 incentives: Report at least 1 measures group AND report each 

measures group for at least 20 Medicare Part B FFS patients. Measures groups containing a 

measure with a zero percent performance rate will not be counted (77 FR 44815). 

 We invited public comment on the proposed criterion for satisfactory reporting of 

measures groups via claims for the 2013 and 2014 incentives. The following is summary of the 

comments we received regarding this proposal. 

 Comment: Several commenters supported our proposal to lower the minimum patient 

count for reporting measures groups from 30 to 20. Commenters noted that lowering the 

reporting threshold would ease the reporting burden of reporting measures groups for eligible 

professionals. 

 Response: We appreciate the commenters' feedback and are finalizing our proposed 

criteria for individual eligible professionals reporting measures groups via claims for the 2013 

and 2014 PQRS incentives. The criteria are specified in Tables 25 and 26 below. 

(5) Criteria for Satisfactory Reporting on PQRS Measures Groups via Registry 

In the CY 2012 Medicare PFS final rule, we established the following criteria for 

satisfactorily reporting PQRS measures groups for the 12-month reporting period for the 2012 

incentive (76 FR 73337): 

● Report at least 1 PQRS measures group AND report each measures group for at least 

30 Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent 
919 

performance rate will not be counted; OR 

● Report at least 1 PQRS measures group, AND report each measures group for at least 

80 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting 

period to whom the measures group applies; BUT report each measures group on no less than 15 

Medicare Part B FFS patients seen during the reporting period to which the measures group 

applies. Measures groups containing a measure with a 0 percent performance rate will not be 

counted. 

In addition, we established the following criteria for satisfactorily reporting PQRS 

measures groups for the 6-month reporting period for the 2012 incentive (76 FR 73337): Report 

at least 1 PQRS measures group, AND report each measures group for at least 80 percent of the 

eligible professional’s Medicare Part B FFS patients seen during the reporting period to whom 

the measures group applies; BUT report each measures group on no less than 8 Medicare Part B 

FFS patients seen during the reporting period to which the measures group applies. Measures 

groups containing a measure with a 0 percent performance rate will not be counted. 

We received stakeholder feedback that it is difficult for some specialties to meet the 30 

Medicare Part B FFS patient threshold. Therefore, based on our authority under section 

1848(m)(3)(D) of the Act to revise the reporting criteria for satisfactory reporting, we proposed 

the following criteria for satisfactory reporting of PQRS measures groups for individual eligible 

professionals using the registry-based reporting mechanism for the 2013 and 2014 incentives: 

(1) For the 12-month reporting periods for the respective 2013 and 2014 incentives, 

report at least 1 measures group, AND report each measures group for at least 20 patients, a 

majority of which must be Medicare Part B FFS patients. Measures groups containing a measure 

with a 0 percent performance rate would not be counted. 

(2) For the 6-month reporting period for the respective 2013 and 2014 incentives, report 
920 

at least 1 measures group, AND report each measures group for at least 20 patients, a majority of 

which must be Medicare Part B FFS patients. Measures group containing a measure with a zero 

percent performance rate will not be counted. We noted that this is the same criterion 

established for the 12-month reporting period. We proposed the same criterion for both 

reporting periods in an effort to simplify the reporting criteria for satisfactory reporting (77 FR 

44815). 

We noted that, while we still proposed to require that an eligible professional report on at 

least 20 patients, we understood that a patient’s personal identification information may be 

stripped when data is collected via a qualified registry. Therefore, we understood that it may be 

difficult to distinguish Medicare and non-Medicare patients. Given this difficulty and that the 

eligible professionals generally would be attempting to report data on Medicare patients, we felt 

the reporting of some non-Medicare patients could serve as a proxy for the reporting of Medicare 

patients whose data is not easily distinguishable as data on Medicare patients under this reporting 

mechanism. 

Finally, we noted that our proposals would satisfy the requirement under section 

1848(m)(5)(F) of the Act that we provide for alternative reporting periods and criteria for 

satisfactory reporting with regard to measures groups and registry-based reporting. 

We invited public comment on the proposed criteria for satisfactory reporting of 

measures groups by individual eligible professionals via registry for the 2013 and 2014 

incentives. The following is summary of the comments we received regarding these proposals. 

Comment: One commenter opposed our proposed satisfactory reporting criteria for 

reporting measures groups via registry for the 6-month reporting period for the 2013 and/or 2014 

PQRS incentives because the commenter was concerned that eligible professionals who are 

satisfactory reporters using this criteria would only receive half the allowed amount for the 2013 
921 

and/or 2014 PQRS incentives. 

Response: We appreciate the commenter's feedback. Please note that all eligible 

professionals who satisfactorily report PQRS measures under the criteria for satisfactory 

reporting via registry for the 6-month reporting period for the 2013 and/or 2014 PQRS incentives 

will receive the 2013 and/or 2014 incentive of 0.5% of our estimate of the group practice’s PFS 

allowed charges furnished during the applicable reporting period. Therefore, an eligible 

professional would earn the same incentive amount regardless of which reporting period the 

eligible professional chooses to use. In an effort to streamline our criteria for satisfactory 

reporting, this satisfactory reporting criterion is identical to the satisfactory reporting criterion for 

the 12-month reporting period. 

Comment: Several commenters supported our proposal to lower the minimum patient 

count for reporting measures groups from 30 to 20. Commenters noted that lowering the 

reporting threshold would ease the reporting burden of reporting measures groups for eligible 

professionals. Several commenters also supported our proposal to allow for the reporting of data 

on non-Medicare patients. 

Response: We appreciate the commenters' feedback and are finalizing, as proposed, the 

criteria for satisfactory reporting of measures groups by individual eligible professionals via 

registry for the 2013 and 2014 incentives. We note that, with respect to the requirement that an 

eligible professional report on at least a majority (11) of the 20 patients on which the eligible 

professionals report, to the extent that an eligible professional reports on more than 20 patients, 

for purposes of the 2013 and 2014 PQRS incentives, an eligible professional need only ensure 

that he/she has reported on 11 Medicare patients. 

Tables 90 and 91 provide a summary of the final criteria for the satisfactory reporting of 

PQRS quality measures for the 2013 and 2014 incentives. 
922 

Table 90: Summary of Criteria for Satisfactory Reporting by Individual Eligible 

Professionals of Data on PQRS Quality Measures for the 2013 Incentive 

Reporting 

Period 

Measure 

Type 

Reporting 

Mechanism 

Proposed Reporting Criteria 

Jan 1, 

2013—

Dec 31, 

2013* 

Individual 

Measures 

Claims Report at least 3 measures, OR, 

If less than 3 measures apply to the eligible professional, report 1—2 

measures*; AND 

Report each measure for at least 50 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

Jan 1, 

2013—

Dec 31, 

2013 

Individual 

Measures 

Qualified 

Registry 

Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

Jan 1, 

2013—

Dec 31, 

2013 

Individual 

Measures 

Qualified 

Direct EHR 

Product 

Option 1: Report on ALL three PQRS EHR measures that are also 

Medicare EHR Incentive Program core measures. 

If the denominator for one or more of the Medicare EHR Incentive 

Program core measures is 0, report on up to three PQRS EHR measures 

that are also Medicare EHR Incentive Program alternate core measures; 

AND 

Report on three additional PQRS EHR measures that are also measures 

available for the Medicare EHR Incentive Program 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

Jan 1, 

2013—

Dec 31, 

2013 

Individual 

Measures 

Qualified 

EHR Data 

Submission 

Vendor 

Option 1: Report on ALL three PQRS EHR measures that are also 

Medicare EHR Incentive Program core measures. 

If the denominator for one or more of the Medicare EHR Incentive 

Program core measures is 0, report on up to three PQRS EHR measures 

that are also Medicare EHR Incentive Program alternate core measures; 

AND 

Report on three additional PQRS EHR measures that are also measures 

available for the Medicare EHR Incentive Program 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

Jan 1, 

2013—

Dec 31, 

2013 

Measures 

Groups 

Claims Report at least 1 measures group, AND 

Report each measures group for at least 20 Medicare Part B FFS 

patients. Measures groups containing a measure with a 0 percent 

performance rate will not be counted. 

Jan 1, 

2013—

Dec 31, 

2013 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted 

Jul 1, 

2013—

Dec 31, 

2013 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 
923 

Reporting 

Period 

Measure 

Type 

Reporting 

Mechanism 

Proposed Reporting Criteria 

rate will not be counted 

* Subject to the measure applicability validation (MAV) process. 

Table 91: Summary of Criteria for Satisfactory Reporting by Individual Eligible 

Professionals of Data on PQRS quality measures for the 2014 Incentive 

Reporting 

Period 

Measure 

Type 

Reporting 

Mechanism Proposed Reporting Criteria 

Jan 1, 

2014—

Dec 31, 

2014* 

Individual 

Measures 

Claims Report at least 3 measures, OR, 

If less than 3 measures apply to the eligible professional, report 1—2 

measures*; AND 

Report each measure for at least 50 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

Jan 1, 

2014—

Dec 31, 

2014 

Individual 

Measures 

Qualified 

Registry 

Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

Jan 1, 

2014—

Dec 31, 

2014 

Individual 

Measures 

Direct EHR 

product that 

is CEHRT 

Report 9 measures covering at least 3 domains. If an eligible 

professional's CEHRT does not contain patient data for at least 9 

measures covering at least 3 domains, then the eligible professional 

must report the measures for which there is patient data. 

 

Jan 1, 

2014—

Dec 31, 

2014 

Individual 

Measures 

EHR data 

submission 

vendor’s 

product that 

is CEHRT 

Report 9 measures covering at least 3 domains. If an eligible 

professional's CEHRT does not contain patient data for at least 9 

measures covering at least 3 domains, then the eligible professional 

must report the measures for which there is patient data. 

Jan 1, 

2014—

Dec 31, 

2014 

Measures 

Groups 

Claims Report at least 1 measures group, AND 

Report each measures group for at least 20 Medicare Part B FFS 

patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted. 

Jan 1, 

2014—

Dec 31, 

2014 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted. 

Jul 1, 

2014—

Dec 31, 

2014 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted. 

* Subject to the measure applicability validation (MAV) process. 

b. Criteria for Satisfactory Reporting for Group Practices Participating in the GPRO 

This section addresses the criteria for satisfactory reporting for group practices 

participating in the GPRO for the 2013 and 2014 incentives, which are the last two incentives 
924 

authorized under the Physician Quality Reporting System. Please note that, in addition to 

offering the GPRO web interface that we’ve previously included under the program, we 

proposed new criteria for group practices under the GPRO that allow group practices to use the 

claims, registry, and EHR-based reporting mechanisms (77 FR 44819). In prior program years, 

large group practices have been successful in reporting quality measures data via the GPRO web 

interface. We proposed new criteria under the claims, qualified registry, and EHR-based 

reporting mechanisms because we felt that smaller groups may benefit from different reporting 

criteria and also other reporting mechanisms. Since the introduction of smaller group practices 

composed of 25-99 eligible professionals under the GPRO was fairly recent, and given that we 

proposed to modify the definition for group practice such that the PQRS GPRO would include, 

beginning in 2013, group practices composed of 2-24 eligible professionals, we proposed 

additional criteria for reporting because we felt it might be more practicable for smaller group 

practices to report on PQRS quality measures via claims, qualified registry, or direct EHR or 

EHR data submission vendor versus the GPRO web interface, which was designed for use by 

larger group practices. 

(1) Beneficiary Assignment Methodology and Criteria for Satisfactory Reporting on PQRS 

Quality Measures via the GPRO Web interface 

GPRO Beneficiary Assignment Methodology. To populate the GPRO web interface, we 

must first assign beneficiaries to each group practice and then from those assigned beneficiaries 

draw a sample of beneficiaries for the disease and patient care modules in the GPRO web 

interface. 

 In the proposed rule we discussed how we are assigning beneficiaries in 2012 to group 

practices for purposes of reporting on the PQRS quality measures via the GPRO web interface. 

We proposed to continue using this same assignment methodology for 2013 and subsequent 
925 

years because it is already in place operationally. 

 However, as an alternative way to assign beneficiaries to groups for the GPRO web 

interface, in the proposed rule we also discussed and invited comments on using the assignment 

and sampling methodology utilized under the more recently implemented Medicare Shared 

Savings Program (76 FR 6700). The Medicare Shared Savings Program uses an approach that is 

generally similar to and is based on the approach previously used by the PGP Transition 

demonstration, but that was revised to reflect both our experiences under the demonstration and 

specific statutory requirements for the Medicare Shared Savings Program. In particular, the 

attribution method used by the Medicare Shared Savings Program emphasizes primary care 

services furnished by physicians. More information regarding the assignment methodology that 

is used in the Shared Savings Program can be found on the program website at 

https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/. To more closely 

align with the Medicare Shared Savings Program, we invited comments on whether it would be 

preferable to modify the assignment method PQRS uses to assign beneficiaries to a group 

practice to be more consistent with the two-step assignment method specified in §425.402 that is 

used under the Medicare Shared Savings Program to assign beneficiaries to an ACO. 

 Consistent with that two-step methodology, in order for a beneficiary to be eligible for 

assignment to a group practice, the beneficiary must have received at least one primary care 

service from a physician within the group practice during the reporting period. Accordingly, we 

would identify beneficiaries who received at least one primary care service from any group 

practice physician (regardless of specialty) participating in the group practice during the 

reporting period. Under the first assignment step, we would assign the beneficiary to the group 

practice if the beneficiary had at least one primary care service furnished by a primary care 
926 

physician at the participating group practice, and more primary care services (measured by 

Medicare allowed charges) furnished by primary care physicians in the participating group 

practice than furnished by primary care physicians at any other group or solo practice. 

 The second step applies only for those beneficiaries who do not receive any primary care 

services from a primary care physician during the reporting period. We would assign the 

beneficiary to the participating group practice in this step if the beneficiary had at least one 

primary care service furnished by a group practice physician regardless of specialty, and more 

primary care services were furnished by group practice eligible professionals (measured by 

Medicare allowed charges) at the participating group practice than at any other group or solo 

practice We would then pull samples of beneficiaries for the relevant measures/modules from 

this population of assigned beneficiaries to populate the GPRO web interface. In other words, 

the GPRO web interface would be populated based on a sample of the group practice assigned 

beneficiary population. Group practices would need to complete the tool for the first 411 or 218 

consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s 

sample for each domain, measures set, or individual measure if a separate denominator is 

required such as in the case of preventive care measures which may be specific to one sex. If the 

pool of eligible assigned beneficiaries is less than 411 or 218, the group practice would report on 

100 percent of assigned beneficiaries for the domain, measure set, or individual measure. The 

GPRO web interface would need to be completed for all domains, measure sets, and measures 

described in Table 96. 

 We considered making this change to the assignment method beginning with the 2013 

PQRS GPRO web interface so that the rules used to assign beneficiaries to group practices 

participating in PQRS and ACOs participating in the Medicare Shared Savings Program would 

be more consistent. Since both group practices that are participating in the PQRS GPRO and 
927 

ACOs participating in the Medicare Shared Savings Program would be using the same GPRO 

web interface to report the same set of quality measures to CMS, we believe that applying 

consistent assignment methods across the two programs would allow us to streamline our 

processes and could potentially reduce confusion among group practices considering 

participation in the PQRS GPRO or ACOs considering participation in the Medicare Shared 

Savings Program. 

 We invited public comment whether to continue to use the PQRS-established 

methodology for assigning beneficiaries, or, in the alternative, to use the assignment and 

sampling methodology utilized under the Medicare Shared Savings Program. The following is 

summary of the comments we received regarding these proposals. 

 Comment: One commenter supported our proposal to continue the assignment and 

sampling methodology currently being used to populate the GPRO web interface. However, 

another commenter urged CMS to adopt an assignment and sampling methodology that is more 

focused on primary care, as the commenter believes that medical colleges participating in the 

GPRO will experience more success in reporting via the GPRO web interface with this change. 

 Response: We appreciate the commenters’ feedback. We appreciate the commenters’ 

feedback. In an effort to align with the Medicare Shared Savings Program, we are adopting the 

beneficiary assignment and sampling methodology used under the Medicare Shared Savings 

Program, which, unlike the current methodology to populate the GPRO web interface, requires 

that the beneficiary being assigned had at least one primary care service furnished by a group 

practice physician. We understand that as a result of this requirement, there could be some group 

practices (such as groups consisting only of non-physician practitioners) that would not be able 

to report PQRS quality measures using the GPRO web interface because no beneficiaries would 

be assigned to them. However, we do not expect this would affect many group practices 
928 

reporting PQRS quality measures using the GPRO web interface. We offer a number of other 

options for participating in PQRS. We note that the assignment and sampling methodology does 

not depart drastically from the assignment and sampling methodology currently used to populate 

the GPRO web interface as both methods were based off of the assignment and sampling 

methodology used under the PGP demonstration. Therefore, we are modifying 414.1240 to 

reflect the final decision to apply the same assignment and sampling methodology as is currently 

used under the Medicare Shared Savings Program. 

 Criteria for Satisfactory Reporting on PQRS Quality Measures via the GPRO Web 

interface. Consistent with the group practice reporting requirements under section 

1848(m)(3)(C) of the Act, we proposed the following criteria for the satisfactory reporting of 

PQRS quality measures for group practices participating- in the GPRO for the 12-month 

reporting periods for the 2013 and 2014 incentives, respectively, using the GPRO web interface 

for groups practices of 25-99 eligible professionals: Report on all measures included in the web 

interface; AND populate data fields for the first 218 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 (77 FR 44820). If the pool of eligible assigned beneficiaries is less than 

218, then report on 100 percent of assigned beneficiaries. In other words, we understand that, in 

some instances, the sampling methodology CMS provides will not be able to assign at least 218 

patients on which a group practice may report, particularly those group practices on the smaller 

end of the range of 25-99 eligible professionals. If the group practice is assigned less than 218 

Medicare beneficiaries, then the group practice would report on 100 percent of its assigned 

beneficiaries. In addition, we proposed the following criteria for the satisfactory reporting of 

PQRS quality measures for group practices participating in the GPRO for the 2013 and 2014 

incentives, respectively, using group practices of 100 or more eligible professionals: Report on 
929 

all measures included in the web interface; AND populate data fields 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 percent of assigned beneficiaries. 

The satisfactory reporting criteria we proposed for the GPRO web interface for groups of 

25-99 eligible professionals and for large group practices for the 2013 and 2014 incentives were 

consistent with the reporting criteria we established for the 2012 PQRS incentive (76 FR 73339). 

We proposed these same criteria because the thresholds proposed for these criteria were based on 

analysis performed on group reporting based on the Medicare Care Management Performance 

(MCMP) and PGP demonstrations used to determine reasonable thresholds for group practice 

reporting. We also note that there are the same criteria used for ACOs participating in the 

Medicare Shared Savings Program. Therefore, we believed the satisfactory reporting criteria that 

for the GPRO web interface for the 2013 and 2014 incentives were appropriate criteria and 

reasonable for groups to meet. 

 Furthermore, we proposed using Medicare Part B claims data for dates of service on or 

after January 1 and submitted and processed by approximately the last Friday in October of the 

applicable 12-month reporting period under which the group practice participates in the GPRO to 

assign Medicare beneficiaries to each group practice. For example, for a group practice 

participating under the GPRO for the reporting periods occurring in 2013, for the sampling 

model, we proposed that we would assign beneficiaries on which to report based on Medicare 

Part B claims with dates of service beginning January 1, 2013 and processed by October 25, 

2013 (77 FR 44820). 

 We invited but received no public comment on the proposed satisfactory reporting 

criteria on PQRS quality measures via the GPRO web interface. Therefore, we are finalizing 
930 

these proposals as proposed. These criteria are specified in Tables 27 and 28. 

(2) Criteria for Satisfactory Reporting on Individual PQRS Quality Measures for Group 

Practices Participating in the GPRO via Claims, Registry, and EHR 

 We proposed to have the claims, registry, and EHR reporting mechanisms available for 

group practices of 2-99 eligible professionals to use to report PQRS quality measures (77 FR 

44820). For these group practices, we proposed alternative criteria to those proposed under the 

GPRO web interface for satisfactory reporting for the 2013 and 2014 incentives using the claims, 

registry, and EHR-based reporting mechanisms that mirror the criteria we proposed for 

individual reporting for the claims, registry, and EHR-based reporting mechanisms from the 

2013 and 2014 incentives. We noted that the criteria we proposed for the 2013 and 2014 

incentives using the claims, registry, and EHR-based reporting mechanisms are similar to the 

criteria for individual reporting, because we believe smaller group practices are more akin to 

individuals for practice scope. We believed that the larger the group practice, the more likely 

that the group practice would benefit using the reporting options under the GPRO web interface. 

 Therefore, based on our authority under section 1848(m)(3)(C) of the Act, we proposed 

the following satisfactory reporting criteria via claims for group practices comprised of 2-99 

eligible professionals under the GPRO for the 2013 and 2014 incentives via claims: Report at 

least 3 measures AND report each measure for at least 50 percent of the group practice’s 

Medicare Part B FFS patients seen during the reporting period to which the measure applies. 

Measures with a zero percent performance rate will not be counted. 

For those group practices that chose to report using a qualified registry, we proposed the 

following satisfactory reporting criteria via qualified registry for group practices comprised of 2-

99 eligible professionals under the GPRO for the 2013 and 2014 incentives: Report at least 3 

measures AND report each measure for at least 80 percent of the group practice's Medicare Part 
931 

B FFS patients seen during the reporting period to which the measure applies. Measures with a 

zero percent performance rate will not be counted. 

For group practices comprised of 2-99 eligible professionals that chose to report PQRS 

quality measures via EHR, we proposed the following 2 options for the satisfactory reporting 

criteria via a direct EHR product or EHR data submission vendor for group practices comprised 

of 2-99 eligible professionals under the GPRO for the 2013 incentive: 

 Option 1: Eligible professionals in a group practice must report on three Medicare EHR 

Incentive Program core or alternate core measures, plus three additional measures. We noted 

that the EHR Incentive Program’s core, alternate core, and additional measures could be found in 

Table 6 of the EHR Incentive Program’s Stage 1 final rule (75 FR 44398) or in Tables 32 and 33 

of the proposed rule (77 FR 44821). We also referred readers to the discussion in the Stage 1 

final rule for further explanation of the requirements for eligible professionals reporting those 

CQMs (75 FR 44398 through 44411). 

Option 2: Report at least 3 measures AND report each measure for at least 80 percent of 

the eligible professional’s Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. Measures with a zero percent performance rate will not be counted. 

 We noted that at the time of the CY 2013 PFS proposed rule, that we had proposed under 

the Medicare EHR Incentive Program 2 options for meeting the CQM component of achieving 

meaningful use beginning with CY 2014 (see 77 FR 13746—13748). To align our EHR-based 

reporting requirements with those proposed under the Medicare EHR Incentive Program at the 

time, we proposed the following criteria for satisfactory reporting using the EHR-based reporting 

mechanism for the 12-month reporting period for the 2014 incentive: 

● Option 1a: Select and submit 12 clinical quality measures available for EHR-based 

reporting from Tables 32 and 33, including at least 1 measure from each of the following 6 
932 

domains – (1) patient and family engagement, (2) patient safety, (3) care coordination, (4) 

population and public health, (5) efficient use of healthcare resources, and (6) clinical 

process/effectiveness (77 FR 44821). 

● Option 1b: Submit 12 clinical quality measures composed of all 11 of the proposed 

Medicare EHR Incentive Program core clinical quality measures specified in Tables 32 and 33 of 

the proposed rule plus 1 menu clinical quality measure from Tables 32 and 33 of the proposed 

rule. We proposed to adopt the group reporting criteria that aligns with the criteria that would be 

established for meeting the CQM component under CY 2014 for the Medicare EHR Incentive 

Program. Furthermore, to the extent that the final group reporting criteria for meeting the CQM 

component of achieving meaningful use differ from what was proposed, our intention was to 

align with the group reporting criteria the EHR Incentive Program ultimately established. We 

invited public comment on this proposal. 

We also considered proposing the following satisfactory reporting criteria for the 2014 

PQRS incentive for groups of 2-99 that was similar to the satisfactory reporting criteria being 

proposed for the 2013 PQRS incentive via EHR: report at least 3 measures, AND report each 

measure for at least 80 percent of the group practice’s Medicare Part B FFS patients seen during 

the reporting period to which the measure applies. Measures with a zero percent performance 

rate will not be counted (77 FR 44821). We invited public comment on this alternative 

considered. 

We invited public comment on the proposed criteria for satisfactory reporting of 

individual measures by group practices via claims, registry, or EHR for the 2013 and 2014 

incentives. The following is a summary of general comments we received. 

Comment: Several commenters supported our proposal to expand the reporting 

mechanisms and satisfactory reporting criteria for group practices participating in the GPRO. 
933 

The commenters believe that establishing these proposals would lead to greater overall program 

participation. 

Response: We appreciate the commenters' positive feedback. We are finalizing all 

proposed criteria for the satisfactory reporting of PQRS quality measures via the GPRO using the 

registry-based reporting mechanisms for groups of 2-99 eligible professionals for the 2013 and 

2014 PQRS incentives, as proposed. In addition, to align with the EHR Incentive Program, 

which will introduce a group practice reporting option in 2014, we are delaying implementing 

criteria for satisfactory reporting for group practices of 2-99 eligible professionals to 2014. The 

details of the EHR reporting criterion for group practices are discussed in greater detail below. 

However, since we have determined that it is not technically feasible to accept group reporting 

via the claims-based reporting mechanism at this time, we are not finalizing our proposed 

reporting criteria for group practices using the claims-based reporting mechanism for the 2013 

and 2014 PQRS incentives at this time. 

Comment: One commenter opposes offering varying reporting criteria, depending on 

group size and reporting method. The commenter believes that these varying methods of 

reporting unnecessarily complicates the program and provide a strong disincentive for 

participation. 

Response: We understand the commenter’s concern regarding the complexity of 

reporting under PQRS. Therefore, we have made an effort to streamline reporting criteria 

wherever possible. For example, the criteria we are establishing for satisfactory reporting using 

the registry and EHR-based reporting mechanisms are similar whether an eligible professional is 

reporting PQRS measures as part of a group in a GPRO or as an individual. However, we 

believe it is necessary to offer different reporting options and varying criteria to provide 

flexibility in reporting as well as ensure that the reporting threshold we are establishing is 
934 

appropriate given a particular group practice's size and resources. We also note that it is not 

necessary for eligible professionals and group practices to meet the criteria for satisfactory 

reporting for the PQRS incentives or payment adjustments using multiple criteria and reporting 

mechanisms. Eligible professionals and group practices need only chose one criterion under 

which to report. 

Comment: One commenter sought clarification on how many eligible professionals 

within the group practice would be required to report PQRS measures using the proposed GPRO 

satisfactory reporting criteria for the claims, registry, and EHR-based reporting mechanisms for 

the 2013 and 2014 PQRS incentives. The commenter suggests that CMS not focus on requiring 

a certain amount of eligible professionals within the group practice to report but, instead, focus 

on a group practice's aggregate patients. 

Response: We clarify that the criteria we establish for reporting using the registry and 

EHR-based reporting mechanisms does not require every eligible professional in the group 

practice to report PQRS measures. Rather, we note that the criteria we establish focuses on the 

group reporting on a certain percentage of its applicable patients, regardless of how many of the 

group practice's eligible professionals participate in reporting the PQRS measures. For example, 

if a group practice comprised of 10 eligible professionals participating in the GPRO chooses to 

report PQRS measures using the registry-based reporting mechanism, the group practice must 

report on at least 3 measures for 80 percent of the group practice's aggregate applicable patients. 

A measure is applicable to a patient if the service provided to the patient and billed to Medicare 

under the Physician Fee Schedule is contained in the denominator of a measure. For more 

information on the PQRS measures, including what types of services are contained in the 

denominator of certain measures, please visit the PQRS website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
935 

Instruments/PQRS/index.html to view the PQRS Measures List and Implementation Guide for 

the relevant year. It is irrelevant whether 5 or all 10 of the group practice's eligible professionals 

report. We would imagine, however, that a group practice would have to report on a larger set of 

patients the larger the group size. 

Comment: One commenter urged CMS to expand the proposed satisfactory reporting 

criteria of individual PQRS measures under the GPRO using the claims, registry, and EHR based 

reporting mechanisms to groups of 100 or more eligible professionals. The commenter notes 

that the measures available for reporting using the GPRO web interface are limited, so expanding 

the proposed claims, registry, and EHR-based reporting options under the GPRO would allow 

greater flexibility for large specialty practices to report on PQRS measures. 

Response: We agree with the commenter's feedback. Our desire to encourage specialties 

to submit meaningful measure data outweighs our desire to restrict the GPRO registry and EHRbased reporting options to smaller groups of 2-99 eligible professionals. We provided our 

reasons for limiting our proposal to restrict the registry and EHR-based reporting mechanisms to 

groups of 2-99 eligible professionals in the CY 2012 PFS proposed rule (76 FR 44821). 

Specifically, we stated that the reporting behavior of these smaller group practices would be 

more akin to individual reporting. However, we have received stakeholder feedback, such as the 

commenter’s, that large groups (mainly large single specialty groups) find it more beneficial to 

report via registry or EHR as the measures available under these reporting mechanisms are more 

applicable to the group’s practice. Stakeholders have also expressed concern that it is difficult 

for their billing departments to keep track of the reporting activities of each individual eligible 

professional. Providing a group practice reporting option for these groups would reduce the 

administrative burden these large single specialty practices incur from having to keep track of the 

group practice’s reporting activity by each individual TIN/NPI combination. Therefore, we will 
936 

expand the GPRO qualified registry and EHR-based reporting options to groups of 100 or more 

eligible professionals. 

Comment: One commenter stressed the importance of allowing eligible professionals to 

still report as individuals despite these newly proposed group reporting options under the GPRO. 

The commenter noted that requiring eligible professionals to participate in PQRS under their 

respective group practices would have a negative impact on registries. The commenter noted 

that, historically, eligible professionals choosing to participate in PQRS independent of their 

group practice have used the registry-based reporting mechanism. The commenter believed that 

the registries have been particularly successful in collecting data relevant for measuring quality 

of care furnished to patients. 

Response: CMS understands the need to establish reporting criteria for eligible 

professionals who wish to participate in PQRS independent of the other eligible professionals in 

their group practice. We note that the proposal to establish satisfactory reporting criteria using 

the claims, registry, and EHR-based reporting mechanisms for group practices using the GPRO 

was not intended to eliminate reporting options for eligible professionals who wish to participate 

in PQRS as individuals. These options are still available for individual reporting. Please note, 

however, that should an eligible professional fall under a TIN that elects to participate in PQRS 

using the GPRO, the eligible professional must participate in PQRS as part of the group practice. 

The eligible professional can no longer participate as an individual. 

Comment: With regard to the satisfactory reporting criteria we proposed for groups in the 

GPRO using direct EHR products or EHR data submission vendor, one commenter noted that, 

should we finalize these proposed reporting criteria, the PQRS would be out of sync with Stage 1 

of the Medicare EHR Incentive Program, which did not establish a group practice reporting 

option. The commenter did note, however, that the EHR Incentive Program established an EHR-
937 

based reporting option for group practices under Stage 2, which begins in 2014. 

Response: We agree with the commenter that our proposed Options 1 and 2 for the 

satisfactory reporting of measures using the EHR-based reporting mechanism under the GPRO 

for the 2013 PQRS Incentive do not align with the requirements for meeting the CQM 

component of meaningful use in 2013 of the EHR Incentive Program, as there is no group 

reporting option for CQMs for the Medicare EHR Incentive Program until 2014. Therefore, we 

are not finalizing the following proposed satisfactory reporting criteria for the 2013 PQRS 

Incentive: (1) Option 1: Eligible professionals in a group practice must report on three Medicare 

EHR Incentive Program core or alternate core measures, plus three additional measures and (2) 

Option 2: Report at least 3 measures, AND report each measure for at least 80 percent of the 

group practice's Medicare Part B FFS patients seen during the reporting period to which the 

measure applies. Measures with a zero percent performance rate will not be counted. 

However, we finalized for the EHR Incentive Program two group reporting options 

beginning in 2014 for the CQM component of achieving meaningful use, one of which is the 

following: Medicare EPs who satisfactorily report PQRS CQMs using CEHRT under the PQRS 

GPRO would be considered to have satisfied their CQM reporting requirement as a group for the 

Medicare EHR Incentive Program (77 FR 54076 through 54078). In the proposed rule, we 

proposed 3 GPRO options for the satisfactory reporting of PQRS individual measures. However, 

we also indicated that it was our intent to finalize reporting criterion that aligns with the CQM 

requirements for achieving meaningful use in the EHR Incentive Program. Following the criteria 

we finalized for the satisfactory reporting of individual PQRS quality measures using a direct 

EHR product or EHR data submission vendor for individual eligible professionals, we are 

finalizing the following criteria for the satisfactory reporting of data on PQRS quality measures 

via the GPRO for the 2014 Incentive: Report 9 measures covering at least 3 domains specified in 
938 

Table 95. If the group practice’s CEHRT does not contain Medicare patient data for at least 9 

measures covering at least 3 domains, then the group practice must report the measures for which 

there is Medicare patient data. A group practice must report on at least 1 measure for which 

there is Medicare patient data. 

Although we proposed three reporting criteria for the satisfactory reporting of PQRS 

measures via an EHR-based reporting mechanism under the GPRO for the 2014 PQRS incentive, 

we are only finalizing one GPRO EHR reporting criterion. Similar to the reasoning we provided 

to streamline the reporting criteria for reporting measures groups via registry for the 2013 and 

2014 PQRS incentives, it is our desire to provide one streamlined reporting option via EHR for 

group practices participating in the GPRO. 

We note that we believe these proposed criteria meet the requirements for group practice 

reporting specified in section 1848(m)(3)(C) of the Act. Section 1848(m)(3)(C) requires that the 

criterion for group reporting use a statistical sampling model, such as the model used in the PGP 

demonstration. We note that, although these criteria depart from the model used in the PGP 

demonstration, we believe that these criteria still meet the statistical sampling model requirement 

in that the group practices would still be required to report the measures on a sample of their 

patients. Rather than CMS choosing which sample of patients the group practice must report, 

with these criteria, the group practice decides to submit quality measures data on a sample of 100 

percent of its patients. We note that although reporting on 100 percent of patients is not a 

sample, for data collection purposes, CMS would only collect data on the group practice’s 

patients to which the EHR measures apply. Therefore, even though a group practice would 

report on 100 percent of patients to which the measure applies, not all of the EHR measures 

would necessarily apply to all of the group practice’s patients. Since the group practice is then 

only providing information on its patients to whom the measure is applicable, we believe the 
939 

proposed EHR reporting criteria would still meet the statistical sampling model requirement. 

A summary of the final criteria for satisfactory reporting for group practices selected to 

participate in the GPRO for the 2013 and 2014 incentives is specified in Tables 92 and 93: 

TABLE 92: Criteria for Satisfactory Reporting of Data on PQRS Quality Measures via the 

GPRO for the 2013 Incentive 

Reporting 

Period 

Reporting 

Mechanism 

Group 

Practice Size Proposed Reporting Criterion 

12-month 

(Jan 1 — 

Dec 31) 

GPRO Web 

interface 

25-99 eligible 

professionals 

Report on all measures included in the web interface in Table 

96; AND 

Populate data fields for the first 218 consecutively ranked and 

assigned beneficiaries in the order in which they appear in the 

group’s sample for each module or preventive care measure. If 

the pool of eligible assigned beneficiaries is less than 218, then 

report on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31) 

GPRO Web 

interface 

100+ eligible 

professionals 

Report on all measures included in the web interface in Table 

96; AND 

Populate data fields for the first 411 consecutively ranked and 

assigned beneficiaries in the order in which they appear in the 

group’s sample for each module or preventive care measure. If 

the pool of eligible assigned beneficiaries is less than 411, then 

report on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31) 

Qualified 

Registry 

2+ eligible 

professionals 

Report at least 3 measures, AND 

Report each measure for at least 80 percent of the group 

practice’s Medicare Part B FFS patients seen during the 

reporting period to which the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

* Subject to the measure applicability validation (MAV) process. 

Table 93: Criteria for Satisfactory Reporting of Data on PQRS Quality Measures via the 

GPRO for the 2014 Incentive 

Reporting 

Period 

Reporting 

Mechanism 

Group Practice 

Size Proposed Reporting Criterion 

12-month 

(Jan 1 — 

Dec 31) 

GPRO Web 

interface 

25-99 eligible 

professionals 

Report on all measures included in the web interface in Table 96; 

AND 

Populate data fields for the first 218 consecutively ranked and 

assigned beneficiaries in the order in which they appear in the 

group’s sample for each module or preventive care measure. If the 

pool of eligible assigned beneficiaries is less than 218, then report 

on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31) 

GPRO Web 

interface 

100+ eligible 

professionals 

Report on all measures included in the web interface in Table 96; 

AND 

Populate data fields for the first 411 consecutively ranked and 

assigned beneficiaries in the order in which they appear in the 

group’s sample for each module or preventive care measure. If the 

pool of eligible assigned beneficiaries is less than 411, then report 

on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31) 

Qualified 

Registry 

2+ eligible 

professionals 

Report at least 3 measures, AND 

Report each measure for at least 80 percent of the group practice’s 

Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. 

Measures with a 0 percent performance rate will not be counted. 

12-month Direct EHR 2+ eligible Report 9 measures covering at least 3 domains. If the group 
940 

Reporting 

Period 

Reporting 

Mechanism 

Group Practice 

Size Proposed Reporting Criterion 

(Jan 1 — 

Dec 31) 

product that 

is CEHRT 

or EHR 

Data 

Submission 

Vendor’s 

Product that 

is CEHRT 

professionals practice’s CEHRT does not contain patient data for at least 9 

measures covering at least 3 domains, then the group practice must 

report the measures for which there is patient data. 

* Subject to the measure applicability validation (MAV) process. 

c. Analysis of the Criteria for Satisfactory Reporting for the 2013 and 2014 Incentives 

For the proposed criteria for satisfactory reporting for the 2013 and 2014 incentives 

described in this section, we proposed that eligible professionals and group practices may not 

combine different satisfactory reporting criteria under different reporting mechanisms to meet 

the requirements of satisfactory reporting for the 2013 and 2014 incentives (77 FR 44824). For 

example, an eligible professional may not meet the requirements for the 2013 incentive by 

reporting on 2 applicable PQRS quality measures via EHR and 1 applicable PQRS quality 

measure via qualified registry, because the eligible professional did not meet the criteria for 

satisfactory reporting under at least one reporting mechanism. Similarly, a group practice would 

be required to select a single reporting mechanism for the entire group practice. For example, for 

a group practice consisting of 4 eligible professionals, the group practice would not be able to 

meet the requirements for the 2014 incentive by reporting 2 individual measures via qualified 

registry and 1 measure via the direct EHR submission method. 

For individual eligible professionals and group practices reporting on individual measures 

and/or measures groups, we noted that, although an eligible professional or group practice could 

meet more than one criterion for satisfactory reporting, only one incentive payment will be made 

to the eligible professional or group practice. For example, if an eligible professional meets the 

criteria for satisfactory reporting of individual measures via claims and measures groups via 

claims for the 2013 incentive, the eligible professional would nonetheless only be entitled to one 
941 

incentive payment. CMS would consider the eligible professional to be incentive eligible under 

whichever reporting criterion yields the greatest bonus. 

We invited but received no public comment on our proposed analysis of the criteria for 

satisfactory reporting for the 2013 and 2014 incentives. Therefore, we are finalizing this analysis 

rule. 

5. Criteria for Satisfactory Reporting for the Payment Adjustments 

Section 1848(a)(8) of the Social Security Act, as added by section 3002(b) of the 

Affordable Care Act, provides that for covered professional services furnished by an eligible 

professional during 2015 or any subsequent year, if the eligible professional does not 

satisfactorily report 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 professional 

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. For 2016 and 

subsequent years, the applicable percent is 98.0 percent. 

This section contains the final criteria for satisfactory reporting for purposes of the 2015 

and 2016 payment adjustments for eligible professionals and group practices, as well as some 

discussion of what we are considering for the payment adjustments for 2017 and beyond. 

 As stated previously, the majority of eligible professionals currently are not participating 

in the PQRS. Yet, the payment adjustment will apply to all eligible professionals who are not 

satisfactory reporters during the reporting period for the year. Therefore, we noted that in 

implementing the PQRS payment adjustment, we seek to achieve two overarching policy goals. 

First, and foremost, we sought to increase participation in the PQRS and to implement the 

payment adjustment in a manner that will allow eligible professionals who have never 

participated in the program to familiarize themselves with the program. Second, we sought to 
942 

align the reporting requirements under the PQRS with the quality reporting requirements of 

various CMS programs, such as the physician value-based payment modifier discussed in section 

III.K of this final rule with comment period. 

a. Criteria for Satisfactory Reporting for the 2015 and 2016 Payment Adjustments for Eligible 

Professionals and Group Practices using the Claims, Registry, EHR, and GPRO web interface 

Reporting Mechanisms 

 This section addresses the criteria for satisfactory reporting for the 2015 and 2016 

payment adjustments using the claims, registry, EHR-based, and GPRO web interface reporting 

mechanisms. First, we proposed that for purposes of the 2015 and 2016 payment adjustments 

(which would be based on data reported during 12 and 6-month reporting periods that fall within 

2013 and 2014, respectively), an eligible professional or group practice would meet the 

requirement to satisfactorily report data on quality measures for covered professional services for 

the 2015 and 2016 payment adjustments by meeting the requirement for satisfactory reporting 

for the 2013 and 2014 incentives respectively (77 FR 44824). That is, we proposed the exact 

same criteria for satisfactory reporting for the 2015 and 2016 payment adjustments that we 

proposed for the 2013 and 2014 incentives, described in Tables 25 and 26 of the proposed rule, 

with the exception of two additional alternative criteria. Since we had already proposed 

satisfactory reporting criteria for the 2013 and 2014 incentives and the reporting periods for the 

respective 2013 and 2014 incentives and 2015 and 2016 payment adjustments coincide, we felt it 

was appropriate that the proposed criteria for the 2013 and 2014 incentives apply to satisfy the 

satisfactory reporting requirements for the 2015 and 2016 payment adjustments, respectively. 

We noted that these proposed criteria for the 2013 and 2014 PQRS incentives were the only 

criteria we proposed to establish for the respective 2015 and 2016 PQRS payment adjustments 

for group practices using the GPRO web interface. 
943 

 For individual eligible professionals also participating in the EHR Incentive Program, we 

noted that it is our intention to align our proposed criteria for satisfactory reporting for the 2015 

and 2016 PQRS payment adjustments with the criteria for meeting the CQM component of 

meaningful use applicable during the 2015 and 2016 PQRS payment adjustment reporting 

periods. For eligible professionals participating in PQRS and the EHR Incentive Program using 

a direct EHR product or EHR data submission vendor that is CEHRT, we noted that since we 

proposed to align our proposed EHR criteria for satisfactory reporting for the 2013 and 2014 

PQRS incentives with the proposed criteria for meeting the CQM component of meaningful use 

for CYs 2013 and 2014if these proposals were established and we meet our goal of aligning the 

two programs, an eligible professional that met the CQM component of meaningful use during 

the PQRS 2015 and 2016 payment adjustment reporting periods occurring in CYs 2013 and 2014 

respectively using a direct EHR product or EHR data submission vendor that is CEHRT would 

meet the requirements for satisfactory reporting for the 2015 and 2016 PQRS payment 

adjustments by submitting a single set of data. 

 We invited public comment on our proposals related to applying the satisfactory 

reporting criteria established for the 2013 and 2014 PQRS incentives for eligible professionals 

and group practices using the GPRO to the respective 2015 and 2016 PQRS payment 

adjustments. The following is a summary of the comments we received on these proposals. 

 Comment: Several commenters supported applying the satisfactory reporting criteria 

established for the 2013 and 2014 PQRS incentives for eligible professionals and group practices 

using the GPRO to the respective 2015 and 2016 PQRS payment adjustments. 

 Response: We appreciate the commenters’ support for these proposals and are, therefore, 

finalizing these proposals, as proposed. 

 In addition, as a result of the overarching goals we have articulated above about 
944 

encouraging participation and concern about eligible professionals’ familiarity and experience 

with the program, we proposed the following alternative criteria for satisfactory reporting during 

the 12-month reporting periods for the 2015 and 2016 payment adjustments for eligible 

professionals and group practices: report 1 (applicable) measure or measures group using the 

claims, registry or EHR-based reporting mechanisms. We noted that this particular proposed 

alternative criterion for satisfactory reporting was significantly less stringent that the satisfactory 

reporting criteria we have proposed for the 2013 and 2014 incentives. However, we stressed that 

we were proposing less stringent criteria only to ease eligible professionals and group practices 

who have not previously participated in PQRS into reporting into the mechanics of reporting 

quality measures under PQRS. As indicated in the proposed rule, for the 2017 PQRS payment 

adjustment and beyond, we anticipate eliminating these alternative proposed criteria and 

establishing criteria that more closely resemble the proposed satisfactory reporting criteria for the 

2013 and 2014 incentives (77 FR 44826). 

 For group practices, section 1848(m)(3)(C) requires that the criterion for group reporting 

use a statistical sampling model, such as the model used in the PGP demonstration, we noted that 

we believed that the proposed reporting criteria met this standard, as the group practice would 

decide on which sample of patients to report (77 FR 44825). Under the proposed criteria, the 

group practice would select the sample number, meaning the group could choose to report on all 

applicable patients or a certain number of patients to which the particular measure applied. We 

noted that, although the group practice could choose the sample, we expected that the sample the 

group practice selects would represent a sufficient picture of the beneficiaries the group practice 

sees. 

 We invited public comments on these proposed criteria for satisfactory reporting for the 

2015 and 2016 payment adjustments for eligible professionals and group practices using the 
945 

claims, registry, EHR-based reporting mechanisms. The following is a summary of the 

comments we received regarding these proposed criteria. 

 Comment: Realizing the need to increase participation in PQRS, several commenters 

generally supported our proposed phased approach of introducing more lenient satisfactory 

reporting criteria for the 2015 and 2016 PQRS payment adjustments with the intention of moving 

towards more stringent satisfactory reporting criteria, such as the satisfactory reporting criteria 

established for the 2013 and 2014 PQRS incentives, for future payment adjustments. 

 Response: We appreciate the commenters' positive feedback on our proposals for 

satisfactory reporting for the 2015 and 2016 PQRS payment adjustments. 

 Comment: Several commenters supported our proposed criteria for satisfactory reporting 

for the 2015 and 2016 PQRS payment adjustments: Reporting 1 measure or measures group. 

These commenters believed that these proposed criteria would help ensure that an eligible 

professional who makes a good faith effort to report PQRS measures would avoid the 2015 and 

2016 PQRS payment adjustments. In fact, some commenters suggested that we establish these 

criteria for the 2017 PQRS payment adjustment and beyond. 

 Response: We are not finalizing these reporting criteria for the 2017 PQRS payment 

adjustment and beyond. We note that we proposed these criteria to help eligible professionals 

and group practices who are participating in PQRS for the first time to become familiar with the 

PQRS reporting requirements. We believe that, by the reporting period for the 2017 PQRS 

payment adjustment, eligible professionals and group practices should be held to satisfactory 

reporting criteria that are identical or similar to the satisfactory reporting criteria we are 

establishing for the 2013 and 2014 PQRS incentives. 

 Based on the comments received and for the reasons previously stated, we are finalizing 

the proposed criteria for satisfactory reporting for the 2015 PQRS payment adjustment -- Report 
946 

1 measure or measures group during the applicable payment adjustment reporting period. 

Therefore, an individual eligible professional will meet the criteria for satisfactory reporting for 

the 2015 payment adjustment if the eligible professional reports 1 measure or, for eligible 

professionals only, measures group using a claims, qualified registry, or EHR-based reporting 

mechanism during the applicable payment adjustment reporting period. Unlike the criteria for 

satisfactory reporting for the 2013 and 2014 PQRS incentives, which requires an eligible 

professional to report on measures based on a percentage of applicable patients or patient count, 

this criterion only requires that an eligible professional or group practice report on 1 measure or, 

for individual eligible professionals only, 1 measures group for at least 1 applicable patient. 

However, we strongly encourage eligible professionals and group practices to report on as many 

applicable patients as possible. For group practices, please note that since we are not finalizing 

the claims-based reporting option for group practices, we are not finalizing this reporting 

criterion for satisfactory reporting for the claims-based reporting mechanism for group practices. 

 Although we did not propose using the GPRO web interface as a reporting mechanism to 

report 1 measure to meet the criteria for satisfactory reporting for the 2015 PQRS payment 

adjustment, we did propose this criterion for the other three traditional reporting mechanisms 

(claims, registry, and EHR). We anticipated that it would be sufficient to establish this criterion 

for these three other reporting mechanisms (claims, registry, and EHR) for the 2015 PQRS 

payment adjustment. However, as we previously stated, we are not finalizing the claims-based 

reporting mechanism for group practices participating in the GPRO. We are also not finalizing 

the EHR-based reporting mechanism for group practices participating in the GPRO until 2014. 

Therefore, since the registry-based reporting mechanism will be the only reporting mechanism 

under which group practices would be able to use this criterion, we are expanding this criterion 

for use under the GPRO web interface. Therefore, a group practice will not be subject to the 
947 

2015 payment adjustment if the group practice meets the criteria for satisfactory reporting by 

reporting 1 applicable measure using a qualified registry or the GPRO web interface reporting 

mechanism during the CY 2013 payment adjustment reporting period. 

 We are not finalizing these proposed criteria for the 2016 payment adjustment at this 

time, as we intend to revisit whether we should establish more stringent satisfactory reporting 

criteria beginning with the 2016 payment adjustment. We believe that, rather than maintaining 

this criterion for the 2016 PQRS payment adjustment, it may be more preferable to adopt a 

phased approach to moving towards reporting criteria that is identical to or similar to the criteria 

for satisfactory reporting for the 2013 and 2014 PQRS incentives. However, as we explained 

above, we are finalizing one criterion for satisfactory reporting for the 2016 PQRS payment 

adjustment: meet the criteria for satisfactory reporting for the 2014 PQRS incentive. 

 Comment: Some commenters sought clarification on how the PQRS payment adjustment 

will be applied to specialties for which little to no relevant measures exist in the PQRS measures 

set, such as audiologists and endocrinologists. One commenter is concerned that 

endocrinologists who specialize in thyroid conditions will be unable to meet the proposed criteria 

for satisfactory reporting, as the commenter believes there are no proposed PQRS measures 

specific to the treatment of thyroid disease. 

 Response: Although the proposed PQRS measures set contains a broad set of measures, 

we understand that, in rare cases, there remains certain sub-specialties that may not be able to 

find relevant PQRS measures on which to report. However, please note that the PQRS measure 

set contains a broad set of measures that may in fact be applicable to these sub-specialties and 

relevant to their specific practice area. Many measures have broad denominator codes and code 

sets that apply to the majority of eligible professionals. Therefore, we urge these eligible 

professionals and group practices to contact our QualityNet Help Desk for advice on reporting 
948 

and determining whether applicable measures can be found in the PQRS measure set. 

Meanwhile, to the extent possible, we will continue to work with stakeholders to ensure that the 

PQRS measure set addresses gaps for future program years. 

b. Criteria for Satisfactory Reporting for the 2015 Payment Adjustment for Eligible 

Professionals and Group Practices using the Administrative Claims-based Reporting Mechanism 

(1) Criteria for Satisfactory Reporting for the 2015 Payment Adjustment for Eligible 

Professionals and Group Practices using the Administrative Claims-based Reporting Mechanism 

 Unlike the traditional PQRS claims-based reporting mechanism, the administrative 

claims-based reporting mechanism we proposed does not require an eligible professional to 

submit quality data codes (QDCs) on Medicare Part B claims (77 FR 44825). Rather, using the 

administrative claims-based reporting mechanism only requires that an eligible professional or 

group practice submit Medicare claims to CMS. Since CMS, rather than the eligible professional 

or group practice, is performing the analysis and collecting the data provided in an eligible 

professional’s or group practice’s Medicare claims for an eligible professional’s or group 

practice’s Medicare beneficiaries, we believe it is appropriate to propose a reporting threshold 

that is more stringent than that proposed for the 2013 and 2014 incentives that use traditional 

PQRS reporting mechanisms. Therefore, we proposed the following criteria for satisfactory 

reporting for the 12-month reporting periods for the 2015 and 2016 payment adjustments (that 

occur in 2013 and 2014 respectively) for eligible professionals and group practices using the 

administrative claims-based reporting mechanism: Report ALL measures in Table 63 of the 

proposed rule for 100 percent of the cases in which the measures apply. 

 Section 1848(m)(3)(C) requires that the criterion for group reporting use a statistical 

sampling model, such as the model used in the PGP demonstration. We noted that, although 

these criteria depart from the model used in the PGP demonstration, similar to our arguments for 
949 

the satisfactory reporting criteria we proposed for group practices using the claims, registry, and 

EHR-based reporting mechanisms, we believe that these criteria would still meet the statistical 

sampling model requirement in that the group practices would still be required to report the 

measures on a sample of their patients. We noted that, with these proposed criteria, the group 

practice would provide claims data to CMS on 100 percent of its patients for which the measure 

applies. We note that although reporting on 100 percent of patients is not a sample, for data 

collection purposes, CMS would only collect data on the group practice’s patients to which the 

administrative claims measures apply. Therefore, the applicable measures will determine the 

sample size for which the group would report. Since the group practice is then only providing 

information on its applicable patients, we believe these reporting criteria would still meet the 

statistical sampling model requirement. 

 We invited public comment on these proposed criteria for eligible professionals and 

group practices using the administrative claims-based reporting mechanism. The following is a 

summary of comments received on these proposed criteria. 

 Comment: Several commenters supported our proposed criteria for the administrative 

claims-based reporting option for the 2015 and 2016 PQRS payment adjustments. 

 Response: We thank the commenters for their feedback. For the reasons we stated for not 

finalizing availability of the administrative claims-based reporting mechanism for the 2016 

PQRS payment adjustment, we are finalizing the satisfactory reporting criteria for the 

administrative claims-based reporting option for the 2015 PQRS payment adjustment only. 

 Comment: One commenter sought clarification on the reporting threshold for eligible 

professionals and group practices using the administrative claims-based reporting option. 

Specifically, the commenter sought clarification on how eligible professionals and group 

practices would be assessed under the proposed requirement to report on all measures available 
950 

under the administrative claims-based reporting option, particularly for those patients for whom 

not all of the administrative claims measures apply. 

 Response: Unlike the traditional claims, registry, EHR, or GPRO web interface reporting 

mechanisms, where an eligible professional or group practice is not required to submit reporting 

G-codes to submit data on quality measures, CMS will calculate the administrative claims 

measures on behalf of the eligible professional or group practice, therefore reducing the chance 

that a reporting error would occur. For those eligible professionals and group practices for which 

not all of the administrative claims measures apply to the patients of the eligible professionals or 

group practices, CMS would report zero percent performance rates for these measures, meaning 

that a certain clinical quality action was not performed because it did not apply to a certain 

patient. Please note that this administrative claims reporting option will be analyzed in the same 

manner as it will be analyzed under the Value-based Payment Modifier. 

 Comment: One commenter recommended that eligible professionals be allowed to choose 

the administrative claims-based reporting option to meet the criteria for satisfactory reporting for 

the 2013 and 2014 PQRS incentives. 

 Response: We respectfully disagree. We believe that eligible professionals and group 

practices should be held to a higher standard of reporting for the PQRS incentive vs. the PQRS 

payment adjustment. As noted previously, we agree with other commenters that the 

administrative claims-based reporting option may not always provide data that is as relevant to a 

practice as the data that would otherwise be provided from reporting measures using the 

traditional reporting mechanisms. We proposed the administrative claims-based reporting option 

primarily as a means to report for the 2015 and 2016 PQRS payment adjustments to ease eligible 

professionals into reporting PQRS measures. In fact, we are not finalizing the administration 

claims-based reporting option for the 2016 PQRS payment adjustment at this time. Since we see 
951 

this option as temporary, only a limited set of measures were proposed for use under the 

administrative claims-based reporting option. We believe that more meaningful data will be 

collected using the traditional claims, registry, EHR, or GPRO web interface reporting 

mechanisms, where eligible professionals or group practices may choose measures from a broad 

set that may be more relevant to their practice and where we are able to collect richer data than 

what is routinely submitted for billing purposes. Therefore, eligible professionals and group 

practices will not be able to use the administrative claims-based reporting mechanism for the 

2013 and 2014 PQRS incentives. However, should an eligible professional or group practice 

elect to use the administrative claims-based reporting mechanism for the 2015 PQRS payment 

adjustment, please note the eligible professional or group practice may use the traditional 

reporting mechanisms for the 2013 PQRS incentive. 

 Comment: One commenter stated that the administrative claims-based reporting option 

may not produce meaningful data. However, the commenter understands the need to balance our 

goal of increasing participation with our goal to collect meaningful data. 

 Response: We agree with the commenter that data collected using our traditional PQRS 

reporting options (using the claims, registry, EHR, and GPRO web interface reporting 

mechanisms) would provide more meaningful data. As such, we believe the administrative 

claims-based reporting option should be temporary, and we intend to move away from the 

administrative claims-based reporting option. Therefore, we are only finalizing it for the 2015 

PQRS payment adjustment. We believe that providing this option for eligible professionals 

during the first year of the implementation of the PQRS payment adjustment will provide eligible 

professionals with enough time to transition into using a traditional PQRS reporting mechanism. 

 In addition, when developing proposals for reporting criteria for the 2015 and 2016 

PQRS payment adjustments, we considered satisfactory reporting options that would encourage 
952 

eligible professionals and group practices to report for the 2013 and/or 2014 incentives but, 

should eligible professionals or group practices come up shy of meeting the 2013 and/or 2014 

incentive reporting criteria, would still allow an eligible professional to meet the criteria for 

satisfactory reporting for the 2015 and/or 2016 payment adjustments (77 FR 44825). In lieu of 

more lenient satisfactory reporting criteria we proposed for the 2015 and 2016 payment 

adjustment, for example, to report at least 1 measure or measures group or to elect the 

administrative claims-based reporting option, we considered the option of defaulting those 

eligible professionals who report but fail to meet the criteria for satisfactory reporting using the 

proposed criteria for the 2013 and/or 2014 incentives to the administrative claims-based 

reporting option. We would therefore analyze the claims of all eligible professionals who report 

at least 1 measure under a traditional reporting method during the respective 2015 and 2016 

payment adjustment reporting periods under the administrative claims-based reporting option. 

We considered this proposal because it is our intention to encourage eligible professionals to 

report PQRS measures using the proposed reporting criteria for the 2013 and 2014 PQRS 

incentives. However, given our concern about new eligible professionals’ familiarity and 

experience with the program, we stated that we felt it was necessary to propose an alternative, 

less stringent reporting option. 

 We invite public comment on this alternative, and the following is a summary of the 

comments we received. 

 Comment: One commenter opposed defaulting eligible professionals who do not meet the 

criteria for satisfactory reporting for the 2013 and/or 2014 PQRS incentives to the administrative 

claims-based reporting option. The commenter notes that the proposed measures under the 

administrative claims-based reporting option are not broadly applicable to all medical specialties 

and do not encourage the reporting of PQRS measures that are applicable to their patients. 
953 

 Response: We understand the limitations of the proposed administrative claims-based 

reporting option, particularly as it applies to certain specialties. Based on the comments received 

and our desire to encourage eligible professionals to report measures applicable to the eligible 

professionals' practice, we are not finalizing a policy to default eligible professionals who do not 

meet the criteria for satisfactory reporting for the 2013 and/or 2014 PQRS incentives to the 

administrative claims-based reporting option. 

 Comment: One commenter supported defaulting eligible professionals who do not meet 

the criteria for satisfactory reporting for the 2013 and/or 2014 PQRS incentives to the 

administrative claims-based reporting option. The commenter noted that should CMS default 

eligible professionals to the administrative claims-based reporting option, registration would not 

be necessary. 

 Response: Although we disagree, we appreciate the commenter’s feedback. As eligible 

professionals and group practices choose the traditional reporting mechanisms under which they 

report PQRS quality measures, we are requiring eligible professionals to affirmatively choose 

whether or not to elect the administrative claims reporting option. We emphasize our preference 

towards the traditional claims, registry, EHR, and GPRO web interface PQRS reporting 

mechanisms. 

 In summary, eligible professionals and group practices have 3 options for meeting the 

criteria for satisfactory reporting for the 2015 PQRS payment adjustment: 

• Meet the criteria for the 2013 PQRS incentive;; 

• Report 1 applicable measure or, for eligible professionals only, measures group; or 

• Elect to be analyzed under the administrative claims-based reporting mechanism. 

 Eligible professionals and group practices have 1 option for meeting the criteria for 

satisfactory reporting for the 2016 PQRS payment adjustment: meet the criteria for satisfactory 
954 

reporting for the 2016 PQRS payment adjustment. 

c. Analysis of Eligible Professionals and Group Practices who will be Assessed a PQRS 

Payment Adjustment 

 As noted in §414.90(b), an eligible professional is assessed at the TIN/NPI level and a 

group practice selected to participate in the GPRO is assessed at the TIN level. As there is a 1-

year lapse in time between the end of a proposed respective payment adjustment reporting period 

and when an eligible professional is expected to receive a PQRS payment adjustment for not 

meeting the requirements for satisfactory reporting for the respective payment adjustment, we 

understand that an eligible professional may change his or her TIN/NPIs during this lapse of 

time. Likewise, a group practice selected to participate in the GPRO may change its TIN during 

this lapse in time. In the proposed rule (77 FR 44825-44826). We noted that we believed this 

could raise issues with regard to the subsequent application of the payment adjustment and 

concerns about the potential for abuse (for example, “gaming the system”). 

 Accordingly, we invited public comment this issue, including what parameters, if any, 

CMS should impose regarding the changes in TIN/NPIs and compositions of group practices 

with regard to the payment adjustment. We received the following comment regarding this 

issue. 

 Comment: One commenter disagreed with our concern for potential abuse for allowing 

changes in an eligible professional's TIN/NPI composition for applying the PQRS payment 

adjustment. The commenter stated that actual reporting of PQRS measures is typically 

documented by the practice's administrative staff, not the eligible professional. Therefore, 

should an eligible professional decide to enter a new practice, the eligible professional should not 

be held accountable for errors that occurred in his or her previous practice. The commenter 

stated that having a PQRS payment follow the eligible professional into a potential new practice 
955 

could affect the eligible professional's ability to seek new employment. 

 Response: It is not CMS' intention to affect the employment opportunities of eligible 

professionals by establishing parameters concerning changes in an eligible professional's 

TIN/NPI composition for applying the PQRS payment adjustment. Rather, CMS' concern 

regarding changes in an eligible professionals TIN/NPI combination lie in the potential that an 

eligible professional may change his/her TIN/NPI composition solely for the purpose of avoiding 

application of the PQRS payment adjustment. After taking into consideration the comment 

received, at this point, we are not placing any parameters around the changing of an eligible 

professional's TIN/NPI composition for purposes of the payment adjustment. However, we may 

place such parameters in the future should the need arise. 

6. PQRS Quality Measures for 2013 and Beyond 

This section focuses on the PQRS quality measures we are making available for reporting 

under PQRS using the claims, registry, EHR (direct EHR or EHR data submission vendor 

product), GPRO web interface, and/or administrative claims-based reporting mechanisms. 

Below, we address the comments we received regarding these measures. We note, however, that 

many commenters provided comments related to measure specifications and suggestions for 

additional measures. For the measure specifications for these proposed PQRS measures, please 

note that we do not use the rulemaking process to change measure specifications. Measure 

specifications are determined by the measure developers and owners. Therefore, suggestions on 

changes to measure specifications should be addressed to the respective measure developer 

and/or owner. 

In addition, we note that we received some comments in which commenters suggested 

additional measures. However, as we have noted in prior program years, we do not generally 

adopt measures in the final measure set that were not proposed in the proposed rule (though we 
956 

do taken them in consideration for possible use in future years of the program). In addition, we 

note that we undergo a pre-rulemaking process – including the requirement that measure owners 

and developers submit these measures for inclusion in the PQRS measure set in our annual 

PQRS Call for Measures and have these measures subsequently reviewed by the MAP – prior to 

proposing measures in rulemaking. Since these proposed measures have not gone through our 

various vetting channels, we cannot include these newly suggested measures that arise from the 

comments provided. 

We also received comments asking whether PQRS measures applied to certain 

specialties. Please note that these questions are not typically addressed in rulemaking. We urge 

the commenters to contact the QualityNet Help Desk for assistance with finding applicable 

measures. 

a. Statutory Requirements for the Selection of PQRS Quality Measures for 2013 and Beyond 

Under section 1848(k)(2)(C)(i) of the Act, the PQRS 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 (currently, 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 PQRS quality measure must be endorsed by the NQF. Additionally, section 

1848(k)(2)(D) of the Act requires that for each PQRS quality measure, "the Secretary shall 
957 

ensure that eligible professionals have the opportunity to provide input during the development, 

endorsement, or selection of measures applicable to services they furnish." 

The statutory requirements under section 1848(k)(2)(C) of the Act, subject to the 

exception noted previously, 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 for how the measures that are submitted to the NQF for endorsement were 

developed. The basic steps for developing measures applicable to physicians and other eligible 

professionals 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 process of 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 for purposes of the PQRS. 

In addition to section 1848(k)(2)(C) of the Act, section 1890A of the Act, which was 

added by section 3014(b) of the Affordable Care Act, requires that the entity with a contract with 

the Secretary under subsection 1890(a) of the Act (currently that, is the NQF) convene multistakeholder groups to provide input to the Secretary on the selection of certain categories of 

quality and efficiency measures. These categories are described in section 1890(b)(7)(B) of the 

Act, and include such measures as the quality measures selected for reporting under the PQRS. 

Pursuant to section 3014 of Affordable Care Act, the NQF convened multi-stakeholder groups by 

creating the Measure Applications Partnership (MAP). Section 1890(A)(a) of the Act requires 

that the Secretary establish a pre-rulemaking process in which the Secretary must make publicly 

available by December 1st of each year a list of the quality and efficiency measures that the 
958 

Secretary is considering for selection through rulemaking for use in the Medicare program. 

Once we have made this list available to the public, the NQF must provide CMS with the MAP’s 

input on selecting measures by February 1st of each year. The list of measures the under 

consideration for 2012 is available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.a

spx. 

We received the following comments regarding these statutory requirements for the 

selection of PQRS quality measures: 

Comment: One commenter was concerned with the requirement that all measures 

included in PQRS be NQF-endorsed. 

Response: As we discussed above, section 1848(k)(2)(C)(i) of the Act generally requires 

that the PQRS quality measures be NQF endorsed. However, we note that section 

1848(k)(2)(C)(ii) of the Act authorizes CMS to include measures in PQRS that are not NQFendorsed. PQRS gives preference to measures that have been endorsed by NQF. However, there 

are cases where no NQF measures exist which address an identified quality area. Additionally, 

PQRS measures undergo yearly revisions based on NQF and measure owner direction, which 

incorporate new evidence and clinical recommendations. 

Comment: Some commenters believed that only measures that are NQF-endorsed should 

be available for reporting in PQRS. 

Response: We understand the importance of NQF endorsement. While we appreciate the 

commenters' feedback, we believe there are circumstances (such as when a measure addresses a 

gap in the PQRS measure set) where we may believe that it is important to include a non-NQF 

endorsed measure to be available for reporting under PQRS. Section 1848(k)(2)(C)(ii) of the 

Act authorizes the Secretary to include measures available for reporting under PQRS that are not 
959 

NQF endorsed. We believe that the measures we finalize under PQRS undergo a vetting 

process. For example, prior to rule making, CMS reviews input from the Measure Applications 

Partnership (MAP). Among other factors, utility, feasibility, and analytics are assessed during 

this process. The Secretary has contracted with the National Quality Forum (NQF), as the 

consensus-based entity for a number of reasons, as described in section 1890 of the Act, 

including for the specific purpose of convening multi-stakeholder groups to provide input to 

CMS on the identification of the best available performance measures and the selection of these 

measures for PQRS (amongst other purposes). 

Comment: One commenter stressed its concern with prioritizing measures that are NQFendorsed. The commenter notes that NQF endorsement is not achievable for all measures as 

staff and financial resources are limited for many measure developers, both of which are needed 

to deploy large testing projects to support reliability and validity. Moreover, the commenter 

believed the method of measure development for primary care differs vastly from that of 

specialty care due to dissimilarities in patient populations and target diseases which may be more 

amenable to qualitative vs. quantitative research. 

Response: We understand the commenter's concerns regarding the limitations of NQFendorsement and have historically included measures that are not NQF-endorsed for inclusion in 

the PQRS measure set based on our exception authority under section 1848(k)(2)(C)(ii) of the 

Act. We continue to include measures that are not NQF-endorsed to address gaps in the PQRS 

measure set when appropriate. 

Comment: One commenter requested that, in the future, CMS include more information 

regarding measure recommendations from the Measure Applications Partnership (MAP) to allow 

the public to more meaningfully comment on proposed PQRS measures. 
960 

Response: We understand the need to provide the public with adequate information to 

meaningfully comment on our proposals. Therefore, in the future, we will seek to provide more 

information regarding measure recommendations from the MAP. 

b. Other Considerations for the Selection of Proposed PQRS Quality Measures for 2013 and 

Beyond 

 As we noted above, 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). We may select measures under this 

exception if there is a specified area or medical topic for which a feasible and practical measure 

has not been endorsed by the entity. Under this exception, aside from NQF endorsement, we 

requested that stakeholders apply the following considerations when submitting measures for 

possible inclusion in the PQRS measure set: 

● High impact on healthcare. 

● Measures that are high impact and support CMS and HHS priorities for improved 

quality and efficiency of care for Medicare beneficiaries. 

● Measures that address gaps in the quality of care delivered to Medicare beneficiaries. 

● Address Gaps in the PQRS measure set. 

● Measures impacting chronic conditions (chronic kidney disease, diabetes mellitus, 

heart failure, hypertension and musculoskeletal). 

● Measures applicable across care settings (such as, outpatient, nursing facilities, 

domiciliary, etc.). 

● Broadly applicable measures that could be used to create a core measure set required 

of all participating eligible professionals. 
961 

● Measures groups that reflect the services furnished to beneficiaries by a particular 

specialty. 

On October 7, 2011, we ended a Call for Measures that solicited new measures for 

possible inclusion in the PQRS for 2013 and beyond. During the Call for Measures, we solicited 

measures that were either NQF-endorsed or fell under the exception specified in section 

1848(k)(2)(C)(ii) of the Act. 

Although the deadline to submit measures for consideration for the 2013 PQRS program 

year has ended, we invited public comment on future considerations related to the selection of 

new PQRS quality measures. The following is a summary of the comments received. 

Comment: One commenter emphasized the need that measures selected for reporting 

under PQRS be vetted by multi-stakeholder entities from development to endorsement, 

particularly by physicians who are ultimately the end-users of the measures. Another commenter 

stressed the importance of providing a better review and vetting process of measures. 

Response: We appreciate the commenter's feedback and understand the importance of 

ensuring that stakeholders review measures prior to being included in PQRS, particularly during 

our annual PQRS Call for Measures and subsequently through use of the MAP’s input. 

Comment: One commenter strongly supports the continued development of risk-adjusted 

measures versus process measures as true measures of physician quality. 

Response: CMS agrees and will strive to include and implement robust outcomes 

measures in the PQRS measure set as appropriate measures. 

Comment: One commenter urges CMS to bolster the current PQRS requirements, which 

rely too heavily on measures of basic competencies and other processes that are not necessarily 

close to or related to an outcome. The commenter believes that many measure gaps (particularly 

in the area of outcomes) must be filled for PQRS to effectively and accurately assess physician 
962 

performance. Therefore, the commenter urges CMS to fill these gaps at the earliest opportunity 

by working with medical societies and other measure developers. 

Response: We agree with the commenter's feedback and are actively working with 

stakeholders to address measure gaps in the PQRS measure set. 

Comment: One commenter urged CMS to continue to develop risk adjustment 

methodologies as there is not a clear method to adjust many quality measures. The commenter 

asked CMS to support the development of measures that better address multi-morbidity and 

patient centeredness. 

Response: We appreciate the commenter's feedback and encourage the submission of risk 

adjusted measures for consideration for inclusion in the PQRS measures set. 

c. PQRS Quality Measures 

This section focuses on the proposed PQRS individual Measures available for reporting 

via claims, registry, and/or EHR-based reporting for 2013 and beyond. To align with the 

proposed measure domains provided in the EHR Incentive Program (77 FR 13743), we classify 

all proposed measures against six domains based on the National Quality Strategy’s six 

priorities, as follows (77 FR 44827): 

 (1) Patient and Family Engagement. These are measures that reflect the potential to 

improve patient-centered care and the quality of care delivered to patients. They emphasize the 

importance of collecting patient-reported data and the ability to impact care at the individual 

patient level as well as the population level through greater involvement of patients and families 

in decision making, self-care, activation, and understanding of their health condition and its 

effective management. 

 (2) Patient Safety. These are measures that reflect the safe delivery of clinical services in 

both hospital and ambulatory settings and include processes that would reduce harm to patients 
963 

and reduce burden of illness. These measures should enable longitudinal assessment of 

condition-specific, patient-focused episodes of care. 

 (3) Care Coordination. These are measures that demonstrate appropriate and timely 

sharing of information and coordination of clinical and preventive services among health 

professionals in the care team and with patients, caregivers, and families to improve appropriate 

and timely patient and care team communication. 

(4) Population and Public Health. These are measures that reflect the use of clinical and 

preventive services and achieve improvements in the health of the population served and are 

especially focused on the leading causes of mortality. These are outcome-focused and have the 

ability to achieve longitudinal measurement that will demonstrate improvement or lack of 

improvement in the health of the US population. 

(5) Efficient Use of Healthcare Resources. These are measures that reflect efforts to 

significantly improve outcomes and reduce errors. These measures also impact and benefit a 

large number of patients and emphasize the use of evidence to best manage high priority 

conditions and determine appropriate use of healthcare resources. 

 (6) Clinical Processes/Effectiveness. These are measures that reflect clinical care 

processes closely linked to outcomes based on evidence and practice guidelines. 

 We invited but received no public comment on these domains. 

Please note that the PQRS quality measure specifications for any given proposed PQRS 

individual quality measure may differ from specifications for the same quality measure used in 

prior years. For example, for the proposed PQRS quality measures that were selected for 

reporting in 2012, please note that detailed measure specifications, including the measure’s title, 

for the proposed individual PQRS quality measures for 2013 and beyond may have been updated 

or modified during the NQF endorsement process or for other reasons. In addition, due to our 
964 

desire to align measure titles with the measure titles that were proposed for 2013, 2014, 2015, 

and potentially subsequent years of the EHR Incentive Program, we note that the measure titles 

for measures available for reporting via EHR may change. To the extent that the EHR Incentive 

Program updates its measure titles to include version numbers (77 FR 13744), we intend to use 

these version numbers to describe the PQRS EHR measures that will also be available for 

reporting for the EHR Incentive Program. We will continue to work toward complete alignment 

of measure specifications across programs whenever possible. 

Through NQF’s measure maintenance process, NQF endorsed measures are sometimes 

updated to incorporate changes that we believe do not substantially change the nature of the 

measure. Examples of such changes could be updated diagnosis or procedure codes or changes 

to exclusions to the patient population or definitions. We believe these types of maintenance 

changes are distinct from more substantive changes to measures that result in what are 

considered new or different measures, and that they do not trigger the same agency obligations 

under the Administrative Procedure Act. We proposed that if the NQF updates an 

endorsed measure that we have adopted for the PQRS in a manner that we consider to not 

substantially change the nature of the measure, we would use a subregulatory process to 

incorporate those updates to the measure specifications that apply to the program (77 FR 44822).

Specifically, we would revise the Specifications Manual so that it clearly identifies the updates 

and provide links to where additional information on the updates can be found. We would 

also post the updates on the CMS QualityNet Website at https://www.QualityNet.org. We would 

provide sufficient lead time for implementing the changes where changes to the data collection 

systems would be necessary. 

We would continue to use the rulemaking process to adopt changes to measures that we 

consider to substantially change the nature of the measure. We believe that this proposal 
965 

adequately balances our need to incorporate NQF updates to NQF – endorsed measures in the 

most expeditious manner possible, while preserving the public's ability to comment on updates 

that so fundamentally change an endorsed measure that it is no longer the same measure that we 

originally adopted. 

We invite public comment on this proposal. The following is a summary of comments 

we received on this proposal to allow for altering of a measure that has been finalized in 

rulemaking, provided that the updates do not substantially change the nature of the measure. 

Comment: Some commenters opposed our proposal to handle changes to a measure 

through a subregulatory process. 

Response: We understand the need for transparency when effectuating changes to a 

measure. However, we note that the measure changes we envision making outside of rulemaking 

are relatively minor, such as minor changes to the measure specifications. Other examples of 

minor changes include: adding the NQF endorsement number to a measure, correcting faulty 

logic, adding or deleting codes as well as providing additional implementation guidance for a 

measure. These changes do not substantively change the measures we finalize in rulemaking. 

We believe it is necessary to be able to make non-substantive changes to PQRS measures, so that 

we may quickly address issues that arise with the reporting of measures. Therefore, we are 

finalizing our proposal to make non-substantive measure changes outside of rulemaking. 

We note that CMS does not usually make unilateral changes to measures. These minor 

changes are usually addressed in collaboration with stakeholder feedback – measure developers, 

measure owners, eligible professionals reporting the respective measures, etc. Therefore, to the 

extent that we received comments related to minor changes to the proposed PQRS measures, we 

did not address these comments in this final rule. Commenters are encouraged to contact the 

respective measures owners regarding these issues. 
966 

To receive more information on the proposed measures contained in this section, 

including the measure specifications for these proposed measures, please contact the respective 

measure owners. Contact information for the measure owners of these proposed PQRS measures 

is available at the PQRS Website at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html. 

(1) HHS Million Hearts Individual Measures Available for Claims, Qualified Registry, and 

EHR-based Reporting for 2013 and Beyond 

In 2011, the Department of Health and Human Services (HHS) started the Million Hearts 

Initiative, which is an initiative to prevent 1 million heart attacks and strokes in 5 years. We are 

dedicated to this initiative and seek to encourage eligible professionals to join in this endeavor. 

Therefore, based on our desire to support the Million Hearts initiative and maintain our focus on 

cardiovascular disease prevention, we proposed individual PQRS Core Measures that were 

specified in Table 94 of the CY 2013 MPFS proposed rule for 2013 and beyond (77 FR 44827). 

These measures were the same measures we finalized under the 2012 PQRS in the CY 2012 

Medicare PFS final rule (76 FR 73345). Please note that, although we proposed that certain 

measures serve as core PQRS quality measures, we did not propose to require that eligible 

professionals report on these proposed PQRS core measures. We invited public comment on the 

proposed PQRS core measures for 2013 and beyond. We did not receive public comment on the 

majority of measures we proposed to classify as PQRS core measures. 

The following is a summary of the comments we received on the proposed PQRS core 

measures for 2013 and beyond and our proposal regarding the “core” designation. 

Comment: One commenter recommended that we avoid classifying the proposed PQRS 

core measures as "core measures," because the EHR Incentive Program uses the term "core 

measures" differently. Therefore, the commenter stated that classifying these PQRS measures as 
967 

"core measures" may cause confusion. 

Response: We agree with the commenter that the term "core measures" is used differently 

under PQRS and the EHR Incentive Program. Therefore, we will refer to these measures as 

HHS Million Hearts Measures. 

 Comment: One commenter supports CMS' dedication to view the treatment of 

cardiovascular conditions as a top priority. 

 Response: We appreciate the commenter's feedback. Indeed, aside from finalizing our 

measures related to cardiovascular conditions, we are finalizing this proposed measure set. 

However, rather than referring to this measure set as PQRS core measures, we will refer to this 

measure set as the measure set containing the HHS Million Hearts Measures. 

 Comment: One commenter opposed classifying the following measure as a PQRS core 

measure: 

• Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL) Test 

Performed AND Risk- Stratified Fasting LDL 

 The commenter does not believe that this measure should be a core measure because it is 

only available for reporting using the EHR-based reporting mechanism. 

 Response: While this measure is only available for reporting using the EHR-based 

reporting mechanism, the measure addresses important quality actions related to the Million 

Hearts Initiative. Therefore, we are finalizing these proposed measures as part of the HHS 

Million Hearts measure set available for reporting under PQRS for 2013 and beyond. 

 Table 94 provides a summary of the HHS Million Hearts measures we are finalizing for 

2013 and beyond. Please note that, although we strongly encourage that eligible professionals 

report these measures, eligible professionals are not required to report these specific measures for 

the purposes of meeting the criteria for satisfactory reporting for the PQRS incentives or 
968 

payment adjustments. 

Table 94: HHS Million Hearts Measures for 2013 and Beyond* 
969 

Reporting 

Mechanism 

NQF/ PQRS New Measure National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

0064/

2 

 Clinical 

Process/ 

Effectiven

ess 

Diabetes Mellitus: Low Density 

Lipoprotein (LDL-C) Control: 

Percentage of patients aged 18 

through 75 years with diabetes 

mellitus who had most recent LDLC level in control (less than 100 

mg/dL) 

NCQA X X X X HITECH 

Million 

Hearts 

0068/

204 

 Clinical 

Process/ 

Effectiven

ess 

Ischemic Vascular Disease (IVD): 

Use of Aspirin or Another 

Antithrombotic: Percentage of 

patients aged 18 years and older 

with Ischemic Vascular Disease 

(IVD) with documented use of 

aspirin or another antithrombotic 

NCQA X X X X X HITECH 

ACO 

Million 

Hearts 

0028/

226 

 Population

/Public 

Health 

Preventive Care and Screening: 

Tobacco Use: Screening and 

Cessation Intervention: 

Percentage of patients 18 years and 

older who were screened for 

tobacco use one or more times 

within 24 months AND who 

received cessation counseling 

intervention if identified as a 

tobacco user 

AMAPCPI X X X X X HITECH 

ACO 

Million 

Hearts 

0018/

236 

 Clinical 

Process/ 

Effectiven

ess 

Hypertension (HTN): Controlling 

High Blood Pressure: Percentage 

of patients aged 18 through 85 

years of age who had a diagnosis of 

hypertension (HTN) and whose BP 

was adequately controlled (< 

140/90 mmHg) 

NCQA X X X X X HITECH 

ACO 

Million 

Hearts 

0075/

241 

 Clinical 

Process/ 

Effectiven

ess 

Ischemic Vascular Disease (IVD): 

Complete Lipid Panel and Low 

Density Lipoprotein (LDL-C) 

Control: Percentage of patients 

NCQA X X X X X HITECH 

ACO 

Million 

Hearts 
970 

(2) PQRS quality measures Available for Reporting via the Claims, Qualified Registry, EHR, 

and GPRO Web interface Reporting Mechanisms for 2013 and Beyond 

This section contains individual PQRS quality measures we proposed for 2013 and 

beyond (77 FR 44830) and the final measure set we are adopting in this final rule with comment 

period. Please note that, in large part, we proposed to retain most of the quality measures we 

finalized for reporting for the 2012 PQRS (76 FR 42865 through 42872). However, in 2013 and 

aged 18 years and older with 

Ischemic Vascular Disease (IVD) 

who received at least one lipid 

profile within 12 months and whose 

most recent LDL-C level was in 

control (less than 100 mg/dL) 

N/A/ 

316 

 Clinical 

Process/ 

Effectiven

ess 

Preventive Care and Screening: 

Cholesterol – Fasting Low 

Density Lipoprotein (LDL) Test 

Performed AND Risk-Stratified 

Fasting LDL: Percentage of 

patients aged 20 through 79 years 

whose risk factors* have been 

assessed and a fasting LDL test has 

been performed 

*There are three criteria for this 

measure based on the patient’s risk 

category. 

1. Highest Level of Risk: Coronary 

Heart Disease (CHD) or CHD Risk 

Equivalent 

2. Moderate Level of Risk: 

Multiple (2+) Risk Factors 

3. Lowest Level of Risk: 0 or 1 

Risk Factor 

CMS/

QIP 

 X HITECH 

Million 

Hearts 

N/A/ 

317 

 Population

/Public 

Health 

Preventive Care and Screening: 

Screening for High Blood 

Pressure and Follow-Up 

Documented: Percentage of 

patients aged 18 years and older 

seen during the reporting period 

who were screened for high blood 

pressure (BP) AND a 

recommended follow-up plan is 

documented based on the current 

blood pressure reading as indicated 

CMS/

QIP 

X X X X X HITECH 

ACO 

Million 

Hearts 
971 

2014, we proposed to include new measures, as well as remove measures that were available for 

reporting under the 2012 PQRS (not re-propose certain measures for 2013 and beyond). Table 

97 of the CY 2013 PFS proposed rule contains the list of measures we proposed to be available 

for reporting under the PQRS for 2013 and beyond that were available under the 2012 PQRS (77 

FR 44841). Tables 30 and 33 of the CY 2013 PFS proposed rule contains the list of new 

measures we proposed to be available for reporting under the PQRS beginning in 2013 and 2014 

respective that were not available under the 2012 PQRS (77 FR 44831 and 77 FR 44942). 

Tables 31 and 34 of the CY 2013 PFS proposed rule contains the list of measures we did not 

propose for reporting under PQRS beginning in 2013 and 2014 respectively that are available for 

reporting under the 2012 PQRS (77 FR 44837 and 77 FR 44953). 

General Comments on Proposed Individual Measures for Reporting for 2013/2014 

and Beyond. We received the following general comments related to the individual measures 

we proposed for reporting under PQRS beginning in 2013 or 2014: 

Comment: Several commenters appreciate CMS' efforts to align the PQRS measures 

available for reporting under the EHR-based reporting mechanisms with the measures available 

for reporting under the EHR Incentive Program. The commenters believe this alignment will 

reduce the administrative burden on eligible professionals while harmonizing the two programs. 

Response: We appreciate the commenter's feedback and note that we are working to 

completely align the measures available for reporting via EHR under PQRS and the EHR 

Incentive Program. For the 2012 PQRS, we have attempted to align the PQRS measures 

available for EHR-based reporting with the EHR measures available for reporting under the EHR 

Incentive Program (76 FR 73364) and we are retaining those measures for 2013 and beyond. In 

fact, we are adding or removing measures available for EHR-based reporting that align with 

what has been finalized for reporting under the EHR Incentive Program for beginning in CY 
972 

2014 (77 FR 54060). 

Comment: Some commenters were pleased that the proposed PQRS measure set provided 

a variety of measures for which certain specialties may report, such as vascular surgeons. 

Response: We appreciate the commenters’ feedback. It is our goal to ensure that 

specialties are able to report under PQRS. Therefore, as our final set of measures specified in 

Table 95 indicates, we allow for a broad variety of measures in the PQRS measure set. 

We note that we received several comments related to the addition of measures we did 

not propose for inclusion in PQRS. We note the need to be transparent and provide the public 

with an opportunity to provide comment on the measures we include in PQRS prior to finalizing 

these measures in the PQRS measure set. Since we did not propose including these measures for 

reporting under PQRS, we are not addressing these comments in this final rule. However, we 

will use the comments we have received when selecting measures to be included in PQRS for 

future program years. 

Prior Measures Not Proposed for Reporting under PQRS. We did not propose to 

retain 14 measures in 2013 that were previously established for reporting under the 2012 PQRS 

(see Table 96 of the CY 2013 PFS proposed rule, 77 FR 44837). We did not propose to retain 9 

measures in 2014 that were previously established for reporting under the 2012 PQRS (see Table 

34 of the CY 2013 proposed rule, 77 FR 44953). The public comments we received did not 

address the majority of the measures identified from prior PQRS program years that we did not 

propose to include from reporting under PQRS in 2013 and 2014. 

The following is a summary of the comments we did receive regarding prior program 

measures we did not propose to include under PQRS in 2013 or 2014: 

Comment: Some commenters opposed our decision not to propose for the 2013 PQRS 

and beyond: 
973 

• Chronic Wound Care: Use of Compression System in Patients with Venous Ulcers. 

One commenter states that the MAP recommended that the measure be submitted for NQF 

endorsement. 

Response: We are not retaining this measure for reporting under PQRS beginning in 

2013. Indeed, as the commenter stated, the MAP recommended that this measure be submitted 

for NQF endorsement. Currently, this measure is not-NQF endorsed. We interpret the MAPs 

recommendation that this measure be submitted for NQF endorsement as the MAP not 

recommending this measure until the measure is NQF endorsed. As such, according to the MAP 

recommendation, we are not retaining this measure for reporting under PQRS. However, we 

may consider including this measure for reporting under PQRS in future years should this 

measure later receive NQF endorsement. We note that it is the responsibility of the respective 

measure owners and developers to submit measures for NQF endorsement. 

Comment: Some commenters opposed our proposal not to retain the following measure 

for reporting under PQRS: 

• Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) 

One commenter suggested that this measure be retained until a majority of eligible 

professionals have adopted EHR systems. Another commenter disagreed with CMS’ contention 

that this measure is redundant to have an eligible professional report on whether or not s/he has 

adopted an EHR. The commenter believed that the measure is only redundant in the instances 

where the eligible professional is using direct EHR reporting. The commenter suggested that 

CMS follow the same protocol as other PQRS measures by designating measure #124 available 

only to those eligible professional who report using claims or registry reporting. 

Response: We appreciate the commenter's feedback, but we are not retaining this 

measure for reporting under PQRS. It is our intention to align the measures available for EHR-
974 

based reporting under PQRS with the measures available for reporting under the Medicare EHR 

Incentive Program. Since this measure is not available for reporting under the EHR Incentive 

Program, we do not believe it is appropriate to include in the final PQRS measure set. 

With respect to the commenter’s request that this measure be retained until a majority of 

eligible professionals have adopted EHR systems, we do not believe we need to retain this 

measure for reporting for this purpose as we are encouraging eligible professionals to adopt EHR 

systems in other ways. For example, we are aligning our EHR reporting criteria with the criteria 

for meeting the CQM component of meaningful use such that eligible professionals reporting 

quality measures data via an EHR may satisfy the requirements for satisfactory reporting under 

PQRS and achieving meaningful use under the EHR Incentive Program by submitting one set of 

data. 

With respect to the commenter who disagreed that the measure is redundant, we 

respectfully disagree with the commenter. Measures in PQRS generally provide that the eligible 

professional perform some sort of clinical quality action. For example, with respect to the HHS 

Million Hearts measure set that we are finalizing, the measure set indicates that an eligible 

professional asks certain questions of beneficiaries and perform certain procedures that we 

believe would help prevent heart disease. This measure does not do this; rather, the measure 

merely asks the eligible professional in indicate to CMS whether or not the eligible professional 

has adopted an EHR system. We do not believe this measure provides meaningful information 

to CMS anymore, as there are other PQRS requirements and CMS programs that more 

appropriately address the adoption and use of EHR systems. For these reasons, we will not 

extend the reporting of this measure for claims or registry-based reporting as the commenter 

requested. 

Comment: One commenter opposed our decision not to include the following measure for 
975 

reporting under PQRS: 

• Stroke and Stroke Rehabilitation: Computed Tomography (CT) and Magnetic Resonance 

Imaging (MRI) 

 Response: We respectfully disagree with the commenter. This measure was reviewed by 

the MAP and not recommended for inclusion in the PQRS measure set beginning 2013. 

Therefore, we are following the MAP’s recommendation and excluding this measure from 

reporting in PQRS beginning in 2013. 

Comment: One commenter opposed our decision not to retain the following measure 

from reporting under PQRS: 

• Coronary Artery Disease (CAD): Symptom and Activity Assessment 

The commenter is concerned that this measure is paired with PQRS Measure #242 (CAD: 

Symptom Management), and therefore should be remain in PQRS for reporting to coincide with 

the reporting of measure #242. 

Response: This measure was part of a two-part measure paired with Measure #242 for the 

2012 PQRS. The two measures were intended to reflect the quality of services provided for the 

primary management of patients with CAD who are seen in the ambulatory setting. For 2012, 

the PQRS measure specifications (available on the PQRS website at 

http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2012_PhysQualRptg_Individ

ualClaimsRegistry_Specs_SupportingDocs_01162012.zip) note that, should an eligible 

professional assess angina symptoms and patient activity under this measure, then Measure #242 

should also be reported. As such, this measure triggered the reporting of Measure #242. 

We prioritize the recommendation the MAP provides for the inclusion of measures in the 

PQRS measure set over our desire to retain the manner we have suggested that eligible 

professionals reporting these CAD measures in 2012. Since this measure was reviewed by the 
976 

MAP and not recommended for inclusion in the PQRS measure set beginning 2013, we are not 

retaining this measure for reporting in PQRS. Measure #242 will therefore be reportable as a 

standalone measure. The description on how to report Measure #242 will be found in the 

Measures Specifications Manual that will be published for 2013 that will be available on the 

PQRS website at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. 

Comment: One commenter opposed our proposal to remove the following measure from 

reporting under PQRS: 

• Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of 

Oxygen Saturation 

Response: The MAP recommended that this measure be “removed” from the PQRS 

measure set. Although we are not bound by the recommendations of the MAP, we find no 

reason to oppose the MAP’s recommendation and retain this measure for reporting in PQRS. 

Therefore, we are not retaining this measure for reporting in PQRS beginning in 2013. 

Comment: One commenter opposed our proposal to remove the following measure from 

the PQRS measure set: 

● Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness. 

The commenter urged CMS to consider retiring Measure 188: Referral for Otologic 

Evaluation for Patients with Congenital or Traumatic Deformity of the Ear in lieu of retiring 

Measure 190: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness, 

because Measure 100 relates to a relatively uncommon condition seen in audiology practices. 

Response: Although we are not bound by the MAP’s recommendation, we note that the 

MAP recommended that this measure be “removed” from reporting under PQRS. We agree with 

the MAP’s recommendation. We believe that this measure is too low bar as it is not a high 
977 

impact measure that provides analysis on the patient or provider level. Rather, the measure 

simply asks whether a beneficiary has been referred for an evaluation. Therefore, we are not 

retaining this measure for reporting in PQRS. However, we encourage the development of a 

similar, more robust measure related to Otologic services. 

Comment: Commenters supported our decision not to retain the following measure from 

reporting under PQRS: 

• Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of Mental 

Status 

• Heart Failure: Patient Education 

• Hypertension (HTN): Plan of Care 

• Hypertension (HTN): Blood Pressure Measurement 

• Prostate Cancer: Three Dimensional (3D) Radiotherapy 

• Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation 

• Preventive Care and Screening: Unhealthy Alcohol Use – Screening 

Response: We appreciate the commenter’s feedback. These measures will not be 

included in the PQRS measure set for 2013 or 2014 and beyond. 

Individual Measures Available for Reporting under PQRS. Table 97 of the CY 2013 

PFS proposed rule contains the list of measures we proposed to be available for reporting under 

the PQRS for 2013 and beyond that were available under the 2012 PQRS (77 FR 44841). Tables 

30 and 33 of the CY 2013 PFS proposed rule contains the list of new measures we proposed to 

be available for reporting under the PQRS beginning in 2013 and 2014 respective that were not 

available under the 2012 PQRS (77 FR 44831 and 77 FR 44942). We proposed a total of 212 

measures for available for reporting beginning in 2013. Beginning 2014, we proposed that 210 

measures be available for reporting under PQRS. As indicated previously, these proposed 
978 

measures are classified under 6 domains: (1) patient safety, (2) patient and family engagement, 

(3) care coordination, (4) clinical process/effectiveness, (5) population/public health, and (6) 

efficiency. 

With respect to the individual measures we proposed to include for reporting in PQRS 

beginning in 2013 or 2014, we did not receive public comments on a majority of the measures 

we proposed for inclusion in PQRS (specific measures we did receive comments on are 

addressed below). Therefore, based on the reasons previously stated in the CY 2013 PFS 

proposed rule, we are finalizing these measures, as proposed. These measures either meet the 

requirement that the measures available in the PQRS measure set be NQF endorsed or address an 

exception to NQF endorsement, such as filling a gap in the PQRS measure set. The following is 

a summary of the comments we did receive on certain proposed individual measures: 

Comment: Commenters provided general support for the following measures that are 

available for reporting in PQRS in 2012: 

• Melanoma: Coordination of Care -- The inclusion of this measure would expand the number 

of measures relevant to dermatologists 

• Melanoma: Continuity of Care – Recall System -- The inclusion of this measure would 

expand the number of measures relevant to dermatologists 

• Melanoma: Overutilization of Imaging Studies in Melanoma -- The inclusion of this measure 

would expand the number of measures relevant to dermatologists 

 For the following measures, one commenter supported the following proposed measures 

for inclusion in PQRS as they are relevant to ophthalmologists: 

• Age-Related Macular Degeneration (AMD): Dilated Macular Examination. 

• Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level 

of Severity of Retinopathy 
979 

• Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes 

Care. 

 One commenter applauds the decision to incorporate the following measures for 

reporting in PQRS: 

• Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluative in 

Low-Risk Surgery Patients. 

• Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After 

Percutaneous Coronary Intervention (PCI). 

• Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, 

Low-Risk Patients. 

 The commenter believes these measures collect data on three most common areas on 

inappropriate imaging, allowing CMS to more accurately capture information on the overall 

value of cardiac diagnostic imaging for beneficiaries. Another commenter specifically supported 

the measure titled “Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in 

Asymptomatic, Low-Risk Patients.” 

 Response: We agree with the commenters’ feedback and are therefore finalizing these 

individual measures for reporting in PQRS beginning in 2013 or 2014. Since these measures 

were available for reporting in 2012, we are retaining these measures so that eligible 

professionals may continue to report on these measures. 

 Comment: Commenters provided support for the following measures that we proposed to 

add to the PQRS measure set beginning in 2013: 

• Participation by a Hospital, Physician or Other Clinician in a Systematic Clinical Database 

Registry that Includes Consensus Endorsed Quality 
980 

• Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy -- The commenter 

also requested that the measure owner information on this measure should be updated to 

indicate that AMA-PCPI/ACCF/AHA is the current measure owner. 

• Pediatric Kidney Disease: Adequacy of Volume Management -- The commenter also 

requested that the measure owner information on this measure should be updated to indicate 

that AMA-PCPI is the current measure owner. 

 Response: We appreciate the commenters’ support for adding these measure and, for the 

reasons stated in the CY 2012 PFS proposed rule (76 FR 44956), are finalizing these measures 

for reporting under PQRS for 2013 and beyond. For the measure “Atrial Fibrillation and Atrial 

Flutter: Chronic Anticoagulation Therapy,” we will reflect that the measure owner for this 

measure is currently AMA-PCPI/ACCF/AHA. For the measure “Pediatric Kidney Disease: 

Adequacy of Volume Management,” we will reflect that the measure owner for this measure is 

currently AMA-PCPI. 

 Comment: One commenter supported our proposal to include the following measure: 

• Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Co-morbid 

Conditions

However, the commenter opposed our proposal that this measure be paired, since the measure 

owner did not support the following second part of the measure: “who have a follow-up attempt 

within 60 days of original communication by the physician treating MDD to elicit a response 

from the other physician.” 

Response: We appreciate the commenter’s feedback. However, this measure was 

submitted for consideration for inclusion in the PQRS measure set as a paired measure. Since 

we usually defer to the respective measures owners and developers on how a particular measure 

should be reported, we are finalizing this measure, as proposed. 
981 

Comment: One commenter urged CMS to consider retiring the following measure: 

• Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the 

Ear. 

The commenter requests retiring this measure in lieu of retiring Measure 190: Referral 

for Otologic Evaluation for Patients with Acute or Chronic Dizziness, because Measure 100 

relates to a relatively uncommon condition seen in audiology practices. 

Response: We appreciate the commenter’s feedback. According to the 2012 PQRS and 

eRx Experience Report, we note that no eligible professionals satisfactorily reported this 

measure. Since eligible professionals attempting to report this measure have had difficulty 

historically with reporting this measure, we are finalizing our decision not to retain this measure 

for reporting under PQRS. 

 Comment: Some commenters requested that the following measure be reclassified from 

the NCQA domain "Clinical Process/Effectiveness" to the "Care Coordination" domain: 

• Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care 

Since the activity addressed in the measure relates to communication and coordination with 

diabetes patients, the measure is more appropriately classified in the Care Coordination domain. 

 Response: We appreciate the commenters' feedback. We agree with the commenters that 

the actions indicated in this measure involve coordination between patients and physicians. We 

understand that measures may pertain to multiple domains. However, as the EHR Incentive 

Program has also classified this as a clinical process/effectiveness measure (77 FR 54071), we 

are retaining the classifying this measure as a clinical process/effectiveness measure. We will, 

however, consider changing the classification of this measure in the future. 

 Comment: One commenter supported our proposal to include an Osteoporosis composite 

measure but suggested that a sub-measure ("Osteoporosis: Management Following Fracture of 
982 

Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older") be added to the 

Osteoporosis composite measure owned by ABIM. 

 Response: We appreciate the commenter's feedback and are finalizing the Osteoporosis 

composite measure for inclusion in the PQRS measures set. However, we are not finalizing this 

measure under the individual measures set. Rather, this composite measure is being finalized as 

a measures group as specified in Table 119 because we believe that composite measures are 

reported more similarly to measures groups under which an eligible professional must report on a 

group of interrelated measures. Please note that the addition of sub-measures is determined by 

the measure owner, ABIM. The sub-measure suggested for inclusion under the Osteoporosis 

measure ("Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for 

Men and Women Aged 50 Years and Older") is owned by AMA. While we agree that postfracture care is an important component of quality related to Osteoporosis care, we are unable to 

add components to composite measures owned by outside entities. 

 Comment: One commenter opposed our proposal to include the following measures for 

reporting in PQRS, as the measure owners will no longer support these measures: 

• Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered (Paired 

Measure) 

• Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Administered 

Initiated (Paired Measure) 

• Coordination of Care of Patients with Co-Morbid Conditions – Timely Follow-Up (Paired 

Measure) 

 Response: We agree with the commenter and are therefore not finalizing these measures 

for reporting under PQRS. 

Please note that we are making the following changes to certain proposed measures for 
983 

the following reasons: 

• Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy – The measure 

owner updated the threshold of an FEV1/FVC less than 70 percent to 60 percent based on 

scientific evidence/clinical trials 

• Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients – The measure 

owner updated the age criteria for this measure to 18 to 80 

• Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis 

and Severity – The measure owner has added an assessment of depression severity to this 

measure 

• Oncology: Cancer Stage Documented – The measure owner has broadened the denominator 

for this measure 

• Melanoma: Overutilization of Imaging Studies in Melanoma – The measure owner has 

incorporated cancer staging into this measure 

• Radiation Dose Optimization – The measure owner has updated this measure title to 

“Optimizing Patient Exposure to Ionizing Radiation” 

A list of the measures we are finalizing for PQRS beginning in 2013 or 2014 is contained 

in Table 95. Please note that the titles of the measures may change slightly from CMS program 

and/or CMS program year based on specifications updates. We intend to continue to work 

toward complete alignment of measure specifications across programs whenever possible. 

Table 95: Individual Quality Measures for the Physician Quality Reporting System 

Proposed to be Available for Reporting via Claims, Registry, EHR, or GRPO Web 

Interface Beginning in 2013 or 2014* 

NQF/ PQRS be 

National 

Quality Measure Title and Description¥

asure Stewar

Reporting 

Mechanism 

ality Reporting
984 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups 

0059/ 

1 

 Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: Hemoglobin A1c 

Poor Control: Percentage of patients 

aged 18 through 75 years with diabetes 

mellitus who had most recent 

hemoglobin A1c greater than 9.0% 

NCQ

A 

X X X X X MU1/ 

MU2 

ACO 

0064/ 

2 

 Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: Low Density 

Lipoprotein (LDL-C) Control: 

Percentage of patients aged 18 through 

75 years with diabetes mellitus who had 

most recent LDL-C level in control (less 

than 100 mg/dL) 

NCQ

A 

X X X X MU1/ 

MU2 

Million 

Hearts 

0061/ 

3 

 Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: High Blood 

Pressure Control: Percentage of 

patients aged 18 through 75 years with 

diabetes mellitus who had most recent 

blood pressure in control (less than 

140/90 mmHg) 

NCQ

A 

X X X X MU1 

0081/ 

5 

 Clinical 

Process/ 

Effective

ness 

Heart Failure: AngiotensinConverting Enzyme (ACE) Inhibitor 

or Angiotensin Receptor Blocker 

(ARB) Therapy for Left Ventricular 

Systolic Dysfunction (LVSD): 

Percentage of patients aged 18 years and 

older with a diagnosis of heart failure 

(HF) with a current or prior left 

ventricular ejection fraction (LVEF) < 

40% who were prescribed ACE inhibitor 

or ARB therapy either within a 12 month 

period when seen in the outpatient 

setting OR at each hospital discharge 

AMA

- 

PCPI/

ACC

F/AH

A 

 X X X MU1/ 

MU2 

0067/ 

6 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Disease (CAD): 

Antiplatelet Therapy: Percentage of 

patients aged 18 years and older with a 

diagnosis of coronary artery disease seen 

within a 12 month period who were 

prescribed aspirin or clopidogrel 

AMA

- 

PCPI/

ACC

F/AH

A 

X X X X MU1 

0070/ 

7 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Disease (CAD): 

Beta-Blocker Therapy – Prior 

Myocardial Infarction (MI) or Left 

Ventricular Systolic Dysfunction 

(LVEF < 40%) : Percentage of patients 

AMA

- 

PCPI/

ACC

F/AH

 X X MU1/ 

MU2 
985 

aged 18 years and older with a diagnosis 

of coronary artery disease seen within a 

12 month period who also have prior MI 

OR a current or prior left ventricular 

ejection fraction (LVEF) < 40% who 

were prescribed beta-blocker therapy 

A 

0083/ 

8 

 Clinical 

Process/ 

Effective

ness 

Heart Failure: Beta-Blocker Therapy 

for Left Ventricular Systolic 

Dysfunction (LVSD): Percentage of 

patients aged 18 years and older with a 

diagnosis of heart failure (HF) with a 

current or prior left ventricular ejection 

fraction (LVEF) < 40% who were 

prescribed beta-blocker therapy either 

within a 12 month period when seen in 

the outpatient setting OR at each

hospital discharge 

AMA

- 

PCPI/

ACC

F/AH

A 

 X X X X MU1/ 

MU2 

ACO 

0105/ 

9 

 Clinical 

Process/ 

Effective

ness 

Major Depressive Disorder (MDD): 

Antidepressant Medication During 

Acute Phase for Patients with MDD: 

Percentage of patients aged 18 years and 

older diagnosed with a new episode of 

MDD and documented as treated with 

antidepressant medication during the 

entire 84-day (12-week) acute treatment 

phase 

NCQ

A 

X X X MU1/ 

MU2 

0086/ 

12 

 Clinical 

Process/ 

Effective

ness 

Primary Open Angle Glaucoma 

(POAG): Optic Nerve Evaluation: 

Percentage of patients aged 18 years and 

older with a diagnosis of primary openangle glaucoma who have an optic nerve 

head evaluation during one or more 

office visits within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X X MU1/ 

MU2 

0087/ 

14 

 Clinical 

Process/ 

Effective

ness 

Age-Related Macular Degeneration 

(AMD): Dilated Macular 

Examination: Percentage of patients 

aged 50 years and older with a diagnosis 

of AMD who had a dilated macular 

examination performed which included 

documentation of the presence or 

absence of macular thickening or 

hemorrhage AND the level of macular 

degeneration severity during one or 

more office visits within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X 

0088/ 

18 

 Clinical 

Process/ 

Effective

ness 

Diabetic Retinopathy: Documentation 

of Presence or Absence of Macular 

Edema and Level of Severity of 

Retinopathy: Percentage of patients 

aged 18 years and older with a diagnosis 

of diabetic retinopathy who had a dilated 

macular or fundus exam performed 

which included documentation of the 

AMA

- 

PCPI/

NCQ

A 

X X X MU1/ 

MU2 
986 

level of severity of retinopathy and the 

presence or absence of macular edema 

during one or more office visits within 

12 months 

0089/ 

19 

 Care 

Coordinat

ion 

Diabetic Retinopathy: 

Communication with the Physician 

Managing Ongoing Diabetes Care: 

Percentage of patients aged 18 years and 

older with a diagnosis of diabetic 

retinopathy who had a dilated macular or 

fundus exam performed with 

documented communication to the 

physician who manages the ongoing care 

of the patient with diabetes mellitus 

regarding the findings of the macular or 

fundus exam at least once within 12 

months 

AMA

- 

PCPI/

NCQ

A 

X X X MU1/ 

MU2 

0270/ 

20 

 Patient 

Safety 

Perioperative Care: Timing of 

Prophylactic Parenteral Antibiotic – 

Ordering Physician: Percentage of 

surgical patients aged 18 years and older 

undergoing procedures with the 

indications for prophylactic parenteral 

antibiotics, who have an order for 

prophylactic parenteral antibiotic to be 

given within one hour (if 

fluoroquinolone or vancomycin, 2 

hours), prior to the surgical incision (or 

start of procedure when no incision is 

required) 

AMA

- 

PCPI/

NCQ

A 

X X X 

0268/ 

21 

 Patient 

Safety 

Perioperative Care: Selection of 

Prophylactic Antibiotic – First OR 

Second Generation Cephalosporin: 

Percentage of surgical patients aged 18 

years and older undergoing procedures 

with the indications for a first OR 

second generation cephalosporin 

prophylactic antibiotic, who had an 

order for cefazolin OR cefuroxime for 

antimicrobial prophylaxis 

AMA

- 

PCPI/

NCQ

A 

X X X 

0271/ 

22 

 Patient 

Safety 

Perioperative Care: Discontinuation 

of Prophylactic Parenteral Antibiotics 

(Non-Cardiac Procedures): Percentage 

of non-cardiac surgical patients aged 18 

years and older undergoing procedures 

with the indications for prophylactic 

parenteral antibiotics AND who received 

a prophylactic parenteral antibiotic, who 

have an order for discontinuation of 

prophylactic parenteral antibiotics within 

24 hours of surgical end time 

AMA

- 

PCPI/

NCQ

A 

X X X 

0239/ Patient Perioperative Care: Venous AMA X X X 
987 

23 Safety Thromboembolism (VTE) 

Prophylaxis (When Indicated in ALL 

Patients): Percentage of surgical 

patients aged 18 years and older 

undergoing procedures for which VTE 

prophylaxis is indicated in all patients, 

who had an order for Low Molecular 

Weight Heparin (LMWH), Low-Dose 

Unfractionated Heparin (LDUH), 

adjusted-dose warfarin, fondaparinux or 

mechanical prophylaxis to be given 

within 24 hours prior to incision time or 

within 24 hours after surgery end time 

- 

PCPI/

NCQ

A 

0045/ 

24 

 Care 

Coordinat

ion 

Osteoporosis: Communication with 

the Physician Managing On-going 

Care Post-Fracture of Hip, Spine or 

Distal Radius for Men and Women 

Aged 50 Years and Older: Percentage 

of patients aged 50 years and older 

treated for a hip, spine or distal radial 

fracture with documentation of 

communication with the physician 

managing the patient’s on-going care 

that a fracture occurred and that the 

patient was or should be tested or treated 

for osteoporosis 

AMA

- 

PCPI/

NCQ

A 

X X 

0092/ 

28 

 Clinical 

Process/ 

Effective

ness 

Aspirin at Arrival for Acute 

Myocardial Infarction (AMI): 

Percentage of patients, regardless of age, 

with an emergency department discharge 

diagnosis of AMI who had 

documentation of receiving aspirin 

within 24 hours before emergency 

department arrival or during emergency 

department stay 

AMA

- 

PCPI/

NCQ

A 

X X 

0269/ 

30 

 Patient 

Safety 

Perioperative Care: Timely 

Administration of Prophylactic 

Parenteral Antibiotics: Percentage of 

surgical patients aged 18 years and older 

who receive an anesthetic when 

undergoing procedures with the 

indications for prophylactic parenteral 

antibiotics for whom administration of 

the prophylactic parenteral antibiotic 

ordered has been initiated within one 

hour (if fluoroquinolone or vancomycin, 

2 hours) prior to the surgical incision (or 

start of procedure when no incision is 

required) 

AMA

- 

PCPI/

NCQ

A 

X X 

0240/ 

31 

 Clinical 

Process/ 

Effective

Stroke and Stroke Rehabilitation: 

Deep Vein Thrombosis (DVT) 

Prophylaxis for Ischemic Stroke or 

AMA

- 

PCPI/

X X 
988 

ness Intracranial Hemorrhage: Percentage 

of patients aged 18 years and older with 

a diagnosis of ischemic stroke or 

intracranial hemorrhage who were 

administered DVT prophylaxis by end of 

hospital day 2 

NCQ

A 

0325/ 

32 

 Clinical 

Process/ 

Effective

ness 

Stroke and Stroke Rehabilitation: 

Discharged on Antithrombotic 

Therapy: Percentage of patients aged 18 

years and older with a diagnosis of 

ischemic stroke or transient ischemic 

attack (TIA) who were prescribed 

antithrombotic therapy at discharge 

AMA

- 

PCPI/

NCQ

A 

X X 

0241/ 

33 

 Clinical 

Process/ 

Effective

ness 

Stroke and Stroke Rehabilitation: 

Anticoagulant Therapy Prescribed for 

Atrial Fibrillation (AF) at Discharge: 

Percentage of patients aged 18 years and 

older with a diagnosis of ischemic stroke 

or transient ischemic attack (TIA) with 

documented permanent, persistent, or 

paroxysmal atrial fibrillation who were 

prescribed an anticoagulant at discharge 

AMA

- 

PCPI/

NCQ

A 

 X 

0243/ 

35 

 Clinical 

Process/ 

Effective

ness 

Stroke and Stroke Rehabilitation: 

Screening for Dysphagia: Percentage 

of patients aged 18 years and older with 

a diagnosis of ischemic stroke or 

intracranial hemorrhage who receive any 

food, fluids or medication by mouth 

(PO) for whom a dysphagia screening 

was performed prior to PO intake in 

accordance with a dysphagia screening 

tool approved by the institution in which 

the patient is receiving care 

AMA

- 

PCPI/

NCQ

A 

X X 

0244/ 

36 

 Clinical 

Process/ 

Effective

ness 

Stroke and Stroke Rehabilitation: 

Rehabilitation Services Ordered: 

Percentage of patients aged 18 years and 

older with a diagnosis of ischemic stroke 

or intracranial hemorrhage for whom 

occupational, physical, or speech 

rehabilitation services were ordered at or 

prior to inpatient discharge OR 

documentation that no rehabilitation 

services are indicated at or prior to 

inpatient discharge 

AMA

- 

PCPI/

NCQ

A 

X X 

0046/ 

39 

 Clinical 

Process/ 

Effective

ness 

Screening or Therapy for 

Osteoporosis for Women Aged 65 

Years and Older: Percentage of female 

patients aged 65 years and older who 

have a central dual-energy X- ray 

absorptiometry (DXA) measurement 

ordered or performed at least once since 

age 60 or pharmacologic therapy 

AMA

- 

PCPI/

NCQ

A 

X X X X 
989 

prescribed within 12 months 

0048/ 

40 

 Clinical 

Process/ 

Effective

ness 

Osteoporosis: Management Following 

Fracture of Hip, Spine or Distal 

Radius for Men and Women Aged 50 

Years and Older: Percentage of 

patients aged 50 years and older with 

fracture of the hip, spine, or distal radius 

who had a central dual-energy X-ray 

absorptiometry (DXA) measurement 

ordered or performed or pharmacologic 

therapy prescribed 

AMA

- 

PCPI/

NCQ

A 

X X 

0049/ 

41 

 Clinical 

Process/ 

Effective

ness 

Osteoporosis: Pharmacologic Therapy 

for Men and Women Aged 50 Years 

and Older: Percentage of patients aged 

50 years and older with a diagnosis of 

osteoporosis who were prescribed 

pharmacologic therapy within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X 

0134/ 

43 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Use of Internal Mammary 

Artery (IMA) in Patients with Isolated 

CABG Surgery: Percentage of patients 

aged 18 years and older undergoing 

isolated CABG surgery who received an 

IMA graft 

STS X X X 

0236/ 

44 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Preoperative Beta-Blocker 

in Patients with Isolated CABG 

Surgery: Percentage of isolated 

Coronary Artery Bypass Graft (CABG) 

surgeries for patients aged 18 years and 

older who received a beta-blocker within 

24 hours prior to surgical incision 

CMS/

QIP 

X X X 

0637/ 

45 

 Patient 

Safety 

Perioperative Care: Discontinuation 

of Prophylactic Parenteral Antibiotics 

(Cardiac Procedures): Percentage of 

cardiac surgical patients aged 18 years 

and older undergoing procedures with 

the indications for prophylactic 

parenteral antibiotics AND who received 

a prophylactic parenteral antibiotic, who 

have an order for discontinuation of 

prophylactic parenteral antibiotics within 

48 hours of surgical end time 

AMA

- 

PCPI/

NCQ

A 

X X 

0097/ 

46 

 Patient 

Safety 

Medication Reconciliation: Percentage 

of patients aged 65 years and older 

discharged from any inpatient facility

(e.g., hospital, skilled nursing facility, or 

rehabilitation facility) and 

seen within 30 days following 

discharge in the office by the physician 

providing on-going care who had a 

reconciliation of the discharge 

AMA

- 

PCPI/

NCQ

A 

X X X ACO 
990 

medications with the current medication 

list in the outpatient medical record 

documented 

0326/ 

47 

 Care 

Coordinat

ion 

Advance Care Plan: Percentage of 

patients aged 65 years and older who 

have an advance care plan or surrogate 

decision maker documented in the 

medical record or documentation in the 

medical record that an advance care plan 

was discussed but the patient did not 

wish or was not able to name a surrogate 

decision maker or provide an advance 

care plan 

AMA

- 

PCPI/

NCQ

A 

X X X 

0098/ 

48 

 Clinical 

Process/ 

Effective

ness 

Urinary Incontinence: Assessment of 

Presence or Absence of Urinary 

Incontinence in Women Aged 65 

Years and Older: Percentage of female 

patients aged 65 years and older who 

were assessed for the presence or 

absence of urinary incontinence within 

12 months 

AMA

- 

PCPI/

NCQ

A 

X X X X 

0099/ 

49 

 Clinical 

Process/ 

Effective

ness 

Urinary Incontinence: 

Characterization of Urinary 

Incontinence in Women Aged 65 

Years and Older: Percentage of female 

patients aged 65 years and older with a 

diagnosis of urinary incontinence whose 

urinary incontinence was characterized 

at least once within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X 

0100/ 

50 

 Patient 

and 

Family 

Engagem

ent 

Urinary Incontinence: Plan of Care 

for Urinary Incontinence in Women 

Aged 65 Years and Older: Percentage 

of female patients aged 65 years and 

older with a diagnosis of urinary 

incontinence with a documented plan of 

care for urinary incontinence at least 

once within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X 

0091/ 

51 

 Clinical 

Process/ 

Effective

ness 

Chronic Obstructive Pulmonary 

Disease (COPD): Spirometry 

Evaluation: Percentage of patients aged 

18 years and older with a diagnosis of 

COPD who had spirometry evaluation 

results documented 

AMA

-PCPI 

X X X 

0102/ 

52 

 Clinical 

Process/ 

Effective

ness 

Chronic Obstructive Pulmonary 

Disease (COPD): Bronchodilator 

Therapy: 

Percentage of patients aged 18 years and 

older with a diagnosis of COPD and who 

have an FEV1/FVC less than 60% and 

have symptoms who were prescribed an 

inhaled bronchodilator 

AMA

-PCPI 

X X X 

0047/ Clinical Asthma: Pharmacologic Therapy for AMA X X X X MU1 
991 

53 Process/ 

Effective

ness 

Persistent Asthma - Ambulatory Care 

Setting: Percentage of patients aged 5 

through 50 years with a diagnosis of 

persistent asthma and at least one 

medical encounter for asthma during the 

measurement year who were prescribed 

long-term control medication 

- 

PCPI/

NCQ

A 

0090/ 

54 

 Clinical 

Process/ 

Effective

ness 

Emergency Medicine: 12-Lead 

Electrocardiogram (ECG) Performed 

for Non- Traumatic Chest Pain: 

Percentage of patients aged 40 years and 

older with an emergency department 

discharge diagnosis of non-traumatic 

chest pain who had a 12-lead ECG 

performed 

AMA

- 

PCPI/

NCQ

A 

X X 

0093/ 

55 

 Clinical 

Process/ 

Effective

ness 

Emergency Medicine: 12-Lead 

Electrocardiogram (ECG) Performed 

for Syncope: Percentage of patients 

aged 60 years and older with an 

emergency department discharge 

diagnosis of syncope who had a 12-lead 

ECG performed 

AMA

- 

PCPI/

NCQ

A 

X X 

0232/ 

56 

 Clinical 

Process/ 

Effective

ness 

Emergency Medicine: CommunityAcquired Pneumonia (CAP): Vital 

Signs: Percentage of patients aged 18 

years and older with a diagnosis of 

community-acquired bacterial 

pneumonia with vital signs documented 

and reviewed 

AMA

- 

PCPI/

NCQ

A 

X X 

0096/ 

59 

 Clinical 

Process/ 

Effective

ness 

Emergency Medicine: CommunityAcquired Pneumonia (CAP): Empiric 

Antibiotic: Percentage of patients aged 

18 years and older with a diagnosis of 

community-acquired bacterial 

pneumonia with an appropriate empiric 

antibiotic prescribed 

AMA

- 

PCPI/

NCQ

A 

X X 

0001/ 

64 

 Clinical 

Process/ 

Effective

ness 

Asthma: Assessment of Asthma 

Control – Ambulatory Care Setting: 

Percentage of patients aged 5 through 50 

years with a diagnosis of asthma who 

were evaluated at least once for asthma 

control (comprising asthma impairment 

and asthma risk) 

AMA

- 

PCPI/

NCQ

A 

X X X X MU1 

0069/ 

65 

 Efficient 

Use of 

Healthcar

e 

Resource

s 

Appropriate Treatment for Children 

with Upper Respiratory Infection 

(URI): Percentage of children aged 3 

months through 18 years with a 

diagnosis of URI who were 

not prescribed or dispensed an 

antibiotic prescription on or within 3 

days of the initial date of service 

NCQ

A 

X X MU2 

0002/ Efficient Appropriate Testing for Children NCQ X X X MU1/ 
992 

66 Use of 

Healthcar

e 

Resource

s 

with Pharyngitis: Percentage of 

children aged 2 through 18 years with a 

diagnosis of pharyngitis, who were 

prescribed an antibiotic and who 

received a group A streptococcus (strep) 

test for the episode. A higher rate 

represents better performance (i.e. 

appropriate testing). 

A MU2 

0377/ 

67 

 Clinical 

Process/ 

Effective

ness 

Hematology: Myelodysplastic 

Syndrome (MDS) and Acute 

Leukemias: Baseline 

Cytogenetic Testing Performed on 

Bone Marrow: Percentage of patients 

aged 18 years and older with a diagnosis 

of MDS or an acute leukemia who had 

baseline cytogenetic testing performed 

on bone marrow 

AMA

- 

PCPI/

ASH 

X X 

0378/ 

68 

 Clinical 

Process/ 

Effective

ness 

Hematology: Myelodysplastic 

Syndrome (MDS): Documentation of 

Iron Stores in Patients Receiving 

Erythropoietin Therapy: Percentage of 

patients aged 18 years and older with a 

diagnosis of MDS who are receiving 

erythropoietin therapy with 

documentation of iron stores within 60 

days prior to initiating erythropoietin 

therapy 

AMA

- 

PCPI/

ASH 

X X 

0380/ 

69 

 Clinical 

Process/ 

Effective

ness 

Hematology: Multiple Myeloma: 

Treatment with Bisphosphonates: 

Percentage of patients aged 18 years and 

older with a diagnosis of multiple 

myeloma, not in remission, who were 

prescribed or received intravenous 

bisphosphonate therapy within the 12-

month reporting period 

AMA

- 

PCPI/

ASH 

X X 

0379/ 

70 

 Clinical 

Process/ 

Effective

ness 

Hematology: Chronic Lymphocytic 

Leukemia (CLL): Baseline Flow 

Cytometry: Percentage of patients aged 

18 years and older seen within a 12 

month reporting period with a diagnosis 

of chronic lymphocytic leukemia (CLL) 

made at any time during or prior to the 

reporting period who had baseline flow 

cytometry studies performed and 

documented in the chart 

AMA

- 

PCPI/

ASH 

X X 

0387/ 

71 

 Clinical 

Process/ 

Effective

ness 

Breast Cancer: Hormonal Therapy 

for Stage IC - IIIC Estrogen 

Receptor/Progesterone Receptor 

(ER/PR) Positive Breast Cancer: 

Percentage of female patients aged 18 

years and older with Stage IC through 

IIIC, ER or PR positive breast cancer 

AMA

-

PCPI/

ASC

O/NC

CN 

X X X X MU1/ 

MU2 
993 

who were prescribed tamoxifen or 

aromatase inhibitor (AI) during the 12-

month reporting period 

0385/ 

72 

 Clinical 

Process/ 

Effective

ness 

Colon Cancer: Chemotherapy for 

AJCC Stage III Colon Cancer 

Patients: Percentage of patients aged 18 

through 80 years with AJCC Stage III 

colon cancer who are referred for 

adjuvant chemotherapy, prescribed 

adjuvant chemotherapy, or have 

previously received adjuvant 

chemotherapy within the 12-month 

reporting period 

AMA

-

PCPI/ 

ASC

O/NC

CN 

X X X X MU1/ 

MU2 

0464/ 

76 

 Patient 

Safety 

Prevention of Catheter-Related 

Bloodstream Infections (CRBSI): 

Central Venous Catheter (CVC) 

Insertion Protocol: Percentage of 

patients, regardless of age, who undergo 

CVC insertion for whom CVC was 

inserted with all elements of maximal 

sterile barrier technique [cap AND mask 

AND sterile gown AND sterile gloves 

AND a large sterile sheet AND hand 

hygiene AND 2% chlorhexidine for 

cutaneous antisepsis (or acceptable 

alternative antiseptics per current 

guideline)] followed 

AMA

-PCPI 

X X 

0323/ 

81 

 Care 

Coordinat

ion 

Adult Kidney Disease: Hemodialysis 

Adequacy: Solute: Percentage of 

calendar months within a 12-month 

period during which patients aged 18 

years and older with a diagnosis of 

ESRD receiving hemodialysis three 

times a week for ≥ 90 days who have a 

spKt/V ≥ 1.2 

AMA

-PCPI 

 X 

0321/ 

82 

 Care 

Coordinat

ion 

Adult Kidney Disease: Peritoneal 

Dialysis Adequacy: Solute: Percentage 

of patients aged 18 years and older with 

a diagnosis of ESRD receiving 

peritoneal dialysis who have a total Kt/V 

≥ 1.7 per week measured once every 4 

months 

AMA

-PCPI 

 X 

0393/ 

83 

 Clinical 

Process/ 

Effective

ness 

Hepatitis C: Testing for Chronic 

Hepatitis C – Confirmation of 

Hepatitis C Viremia: Percentage of 

patients aged 18 years and older with a 

diagnosis of hepatitis C seen for an 

initial evaluation who had HCV RNA 

testing ordered or previously performed 

AMA

-PCPI 

 X 

0395/ 

84 

 Clinical 

Process/ 

Effective

Hepatitis C: Ribonucleic Acid (RNA) 

Testing Before Initiating Treatment: 

Percentage of patients aged 18 years and 

AMA

-PCPI 

X X X 
994 

ness older with a diagnosis of chronic 

hepatitis C who are receiving antiviral 

treatment for whom quantitative HCV 

RNA testing was performed within 6 

months prior to initiation of antiviral 

treatment 

0396/ 

85 

 Clinical 

Process/ 

Effective

ness 

Hepatitis C: HCV Genotype Testing 

Prior to Treatment: Percentage of 

patients aged 18 years and older with a 

diagnosis of chronic hepatitis C who are 

receiving antiviral treatment for whom 

HCV genotype testing was performed 

prior to initiation of antiviral treatment 

AMA

-PCPI 

X X X 

0397/ 

86 

 Clinical 

Process/ 

Effective

ness 

Hepatitis C: Antiviral Treatment 

Prescribed: Percentage of patients aged 

18 years and older with a diagnosis of 

chronic hepatitis C who were prescribed 

at a minimum peginterferon and 

ribavirin therapy within the 12-month 

reporting period 

AMA

-PCPI 

X X X 

0398/ 

87 

 Clinical 

Process/ 

Effective

ness 

Hepatitis C: HCV Ribonucleic Acid 

(RNA) Testing at Week 12 of 

Treatment: Percentage of patients aged 

18 years and older with a diagnosis of 

chronic hepatitis C who are receiving 

antiviral treatment for whom 

quantitative HCV RNA testing was 

performed at no greater than 12 weeks 

from the initiation of antiviral treatment 

AMA

-PCPI 

X X X 

0401/ 

89 

 Clinical 

Process/ 

Effective

ness 

Hepatitis C: Counseling Regarding 

Risk of Alcohol Consumption: 

Percentage of patients aged 18 years and 

older with a diagnosis of hepatitis C who 

were counseled about the risks of 

alcohol use at least once within 12-

months 

AMA

-PCPI 

X X X 

0394/ 

90 

 Clinical 

Process/ 

Effective

ness 

Hepatitis C: Counseling Regarding 

Use of Contraception Prior to 

Antiviral Therapy: Percentage of 

female patients aged 18 through 44 years 

and all men aged 18 years and older with 

a diagnosis of chronic hepatitis C who 

are receiving antiviral treatment who 

were counseled regarding contraception 

prior to the initiation of treatment 

AMA

-PCPI 

X X X 

0653/ 

91 

 Clinical 

Process/ 

Effective

ness 

Acute Otitis Externa (AOE): Topical 

Therapy: Percentage of patients aged 2 

years and older with a diagnosis of AOE 

who were prescribed topical 

preparations 

AMA

-PCPI 

X X 

0654/ 

93 

 Care 

Coordinat

Acute Otitis Externa (AOE): Systemic 

Antimicrobial Therapy – Avoidance 

AMA

-PCPI 

X X 
995 

ion of 

Inappropriate Use: Percentage of 

patients aged 2 years and older with a 

diagnosis of AOE who were not 

prescribed systemic antimicrobial 

therapy 

0391/ 

99 

 Clinical 

Process/ 

Effective

ness 

Breast Cancer Resection Pathology 

Reporting: pT Category (Primary 

Tumor) and pN Category (Regional 

Lymph Nodes) with Histologic Grade: 

Percentage of breast cancer resection 

pathology reports that include the pT 

category (primary tumor), the pN 

category (regional lymph nodes), and the 

histologic grade 

AMA

- 

PCPI/

CAP 

X X 

0392/ 

100 

 Clinical 

Process/ 

Effective

ness 

Colorectal Cancer Resection 

Pathology Reporting: pT Category 

(Primary Tumor) and pN Category 

(Regional Lymph Nodes) with 

Histologic Grade: Percentage of colon 

and rectum cancer resection pathology 

reports that include the pT category 

(primary tumor), the pN category 

(regional lymph nodes) and the 

histologic grade 

AMA

- 

PCPI/

CAP 

X X 

0389/ 

102 

 Efficient 

Use of 

Healthcar

e 

Resource

s 

Prostate Cancer: Avoidance of 

Overuse of Bone Scan for Staging 

Low-Risk Prostate Cancer Patients: 

Percentage of patients, regardless of age, 

with a diagnosis of prostate cancer at 

low risk of recurrence receiving 

interstitial prostate brachytherapy, OR 

external beam radiotherapy to the 

prostate, OR radical prostatectomy, OR 

cryotherapy who did not have a bone 

scan performed at any time since 

diagnosis of prostate cancer 

AMA

-PCPI 

X X X MU1/ 

MU2 

0390/ 

104 

 Clinical 

Process/ 

Effective

ness 

Prostate Cancer: Adjuvant Hormonal 

Therapy for High Risk Prostate 

Cancer Patients: Percentage of patients, 

regardless of age, with a diagnosis of 

prostate cancer at high risk of recurrence 

receiving external beam radiotherapy to 

the prostate who were prescribed 

adjuvant hormonal therapy (GnRH 

agonist or antagonist) 

AMA

-PCPI 

X X 

0103/ 

106 

 Clinical 

Process/ 

Effective

ness 

Adult Major Depressive Disorder 

(MDD): Comprehensive Depression 

Evaluation: Diagnosis and Severity: 

Percentage of patients aged 18 years and 

older with a diagnosis of major 

depressive disorder (MDD) with 

AMA

-PCPI 

X X 
996 

evidence that they met the DSM-IV-TR 

criteria for MDD AND for whom there 

is an assessment of depression severity 

during the visit in which a new diagnosis 

or recurrent episode was identified 

0104/ 

107 

 Clinical 

Process/ 

Effective

ness 

Adult Major Depressive Disorder 

(MDD): Suicide Risk Assessment: 

Percentage of patients aged 18 years and 

older with a diagnosis of major 

depressive disorder (MDD) with a 

suicide risk assessment completed during 

the visit in which a new diagnosis or 

recurrent episode was identified 

AMA

-PCPI 

X X MU2 

0054/ 

108 

 Clinical 

Process/ 

Effective

ness 

Rheumatoid Arthritis (RA): Disease 

Modifying Anti-Rheumatic Drug 

(DMARD) Therapy: Percentage of 

patients aged 18 years and older who 

were diagnosed with RA and were 

prescribed, dispensed, or administered at 

least one ambulatory prescription for a 

DMARD 

NCQ

A 

X X X 

0050/ 

109 

 Patient 

and 

Family 

Engagem

ent 

Osteoarthritis (OA): Function and 

Pain Assessment: Percentage of patient 

visits for patients aged 21 years and 

older with a diagnosis of OA with 

assessment for function and pain 

AMA

-PCPI 

X X 

0041/ 

110 

 Populatio

n/Public 

Health 

Preventive Care and Screening: 

Influenza Immunization: Percentage of 

patients aged 6 months and older seen 

for a visit between October 1 and March 

31 who received an influenza 

immunization OR who reported previous 

receipt of an influenza immunization 

AMA

-PCPI 

X X X X X MU1/ 

MU2 

ACO 

0043/ 

111 

 Clinical 

Process/ 

Effective

ness 

Preventive Care and Screening: 

Pneumococcal Vaccination for 

Patients 65 Years and Older: 

Percentage of patients aged 65 years and 

older who have ever received a 

pneumococcal vaccine 

NCQ

A 

X X X X X MU1/ 

MU2 

 ACO 

0031/ 

112 

 Clinical 

Process/ 

Effective

ness 

Preventive Care and Screening: 

Breast Cancer Screening: Percentage 

of women aged 40 through 69 years who 

had a mammogram to screen for breast 

cancer within 24 months 

NCQ

A 

X X X X X MU1/ 

MU2 

ACO 

0034/ 

113 

 Clinical 

Process/ 

Effective

ness 

Preventive Care and Screening: 

Colorectal Cancer Screening: 

Percentage of patients aged 50 through 

75 years who received the appropriate 

colorectal cancer screening 

NCQ

A 

X X X X X MU1/ 

MU2 

ACO 

0058/ 

116 

 Efficient 

Use of 

Antibiotic Treatment for Adults with 

Acute Bronchitis: Avoidance of 

NCQ

A 

X X 
997 

 Healthcar

e 

Resource

s 

Inappropriate Use: Percentage of 

adults aged 18 through 64 years with a 

diagnosis of acute bronchitis who were 

not prescribed or dispensed an 

antibiotic prescription on or within 3 

days of the initial date of service 

0055/ 

117 

 Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: Dilated Eye Exam: 

Percentage of patients aged 18 through 

75 years with a diagnosis of diabetes 

mellitus who had a dilated eye exam 

NCQ

A 

X X X X MU1/ 

MU2 

0066/ 

118 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Disease (CAD): 

Angiotensin-Converting Enzyme 

(ACE) Inhibitor or Angiotensin 

Receptor Blocker (ARB) Therapy - 

Diabetes or Left Ventricular Systolic 

Dysfunction (LVEF < 40%): 

Percentage of patients aged 18 years and 

older with a diagnosis of coronary artery 

disease seen within a 12 month period 

who also have diabetes OR a current or 

prior Left Ventricular Ejection Fraction 

(LVEF) < 40% who were prescribed 

ACE inhibitor or ARB therapy 

AMA

- 

PCPI/

ACC

F/AH

A 

 X X ACO 

0062/ 

119 

 Clinical 

Process/ 

Effective

ness 

Diabetes: Medical Attention for 

Nephropathy: Percentage of patients 

aged 18 through 75 years with diabetes 

mellitus who received urine protein 

screening or medical attention for 

nephropathy during at least one office 

visit within 12 months 

NCQ

A 

X X X X MU1/ 

MU2 

AQA 

adopt

ed/ 

121 

 Clinical 

Process/ 

Effective

ness 

Adult Kidney: Disease Laboratory 

Testing (Lipid Profile): Percentage of 

patients aged 18 years and older with a 

diagnosis of CKD (stage 3, 4, or 5, not 

receiving Renal Replacement Therapy 

[RRT]) who had a fasting lipid profile 

performed at least once within a 12-

month period 

AMA

-PCPI 

X X X 

AQA 

adopt

ed/ 

122 

 Clinical 

Process/ 

Effective

ness 

Adult Kidney Disease: Blood Pressure 

Management: Percentage of patient 

visits for those patients aged 18 years 

and older with a diagnosis of CKD 

(stage 3, 4, or 5, not receiving Renal 

Replacement Therapy [RRT]) and 

documented proteinuria with a blood 

pressure < 130/80 mmHg OR ≥ 130/80 

mmHg with a documented plan of care 

AMA

-PCPI 

X X X 

AQA 

adopt

ed/ 

123 

 Clinical 

Process/ 

Effective

ness 

Adult Kidney Disease: Patients On 

Erythropoiesis-Stimulating Agent 

(ESA) - Hemoglobin Level > 12.0 

g/dL: Percentage of calendar months 

within a 12-month period during which a 

AMA

-PCPI 

X X X 
998 

Hemoglobin level is measured for 

patients aged 18 years and older with a 

diagnosis of advanced Chronic Kidney 

Disease (CKD) (stage 4 or 5, not 

receiving RRT [Renal Replacement 

Therapy]) or End Stage Renal Disease 

(ESRD) (who are on hemodialysis or 

peritoneal dialysis) who are also 

receiving ESA therapy AND have a 

Hemoglobin level > 12.0 g/dL 

0417/ 

126 

 Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: Diabetic Foot and 

Ankle Care, Peripheral Neuropathy – 

Neurological Evaluation: Percentage of 

patients aged 18 years and older with a 

diagnosis of diabetes mellitus who had a 

neurological examination of their lower 

extremities within 12 months 

APM

A 

X X 

0416/ 

127 

 Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: Diabetic Foot and 

Ankle Care, Ulcer Prevention – 

Evaluation of Footwear: Percentage of 

patients aged 18 years and older with a 

diagnosis of diabetes mellitus who were 

evaluated for proper footwear and sizing 

APM

A 

X X 

0421/ 

128 

 Populatio

n/Public 

Health 

Preventive Care and Screening: Body 

Mass Index (BMI) Screening and 

Follow-Up: Percentage of patients aged 

18 years and older with a calculated 

BMI in the past 6 months or during the 

current visit documented in the medical 

record AND if the most recent BMI is 

outside of normal parameters, a 

follow-up plan is documented within the 

past 6 months or during the current visit 

Normal Parameters: Age 65 years and 

older BMI ≥ 23 and < 30; Age 18 – 64 

years BMI ≥ 18.5 and < 25 

CMS/

QIP 

X X X X X MU1/ 

MU2 

ACO 

0419/ 

130 

 Patient 

Safety 

Documentation of Current 

Medications in the Medical Record: 

Percentage of specified visits for patients 

aged 18 years and older for which the 

eligible professional attests to 

documenting a list of current 

medications to the best of his/her 

knowledge and ability. This list must

include ALL prescriptions, over-thecounters, herbals, and 

vitamin/mineral/dietary (nutritional) 

supplements AND must contain the 

medications’ name, dosage, frequency 

and route of administration 

CMS/

QIP 

X X X MU2 

 

0420/ 

131 

 Populatio

n/Public 

Pain Assessment and Follow-Up: 

Percentage of visits for patients aged 18 

CMS/

QIP 

X X 
999 

Health years and older with documentation of a 

pain assessment through discussion with 

the patient including the use of a 

standardized tool(s) on each visit AND 

documentation of a follow-up plan when 

pain is present 

0418/ 

134 

 Populatio

n/Public 

Health 

Preventive Care and Screening: 

Screening for Clinical Depression and 

Follow-Up Plan: Percentage of patients 

aged 12 years and older screened for 

clinical depression on the date of 

encounter using an age appropriate 

standardized depression screening tool 

AND, if positive, a follow-up plan is 

documented on the date of the positive 

screen 

CMS/

QIP 

X X X MU2 

ACO 

0650/ 

137 

 Clinical 

Process/ 

Effective

ness 

Melanoma: Continuity of Care – 

Recall System: Percentage of patients, 

regardless of age, with a current 

diagnosis of melanoma or a history of 

melanoma whose information was 

entered, at least once within a 12 month 

period, into a recall system that includes:

• A target date for the next complete 

physical skin exam, AND 

• A process to follow up with patients 

who either did not make an appointment 

within the specified timeframe or who 

missed a scheduled appointment 

AMA

- 

PCPI/

NCQ

A 

 X 

0561/ 

138 

 Care 

Coordinat

ion 

Melanoma: Coordination of Care: 

Percentage of patient visits, regardless of 

age, with a new occurrence of melanoma 

who have a treatment plan documented 

in the chart that was communicated to 

the physician(s) providing continuing 

care within one month of diagnosis 

AMA

- 

PCPI/

NCQ

A 

 X 

0566/ 

140 

 Clinical 

Process/ 

Effective

ness 

Age-Related Macular Degeneration 

(AMD): Counseling on Antioxidant 

Supplement: Percentage of patients 

aged 50 years and older with a diagnosis 

of age-related macular degeneration or 

their caregiver(s) who were counseled 

within 12 months on the benefits and/or 

risks of the Age-Related Eye Disease 

Study (AREDS) formulation for 

preventing progression of AMD 

AMA

- 

PCPI/

NCQ

A 

X X 

0563/ 

141 

 Care 

Coordinat

ion 

Primary Open-Angle Glaucoma 

(POAG): Reduction of Intraocular 

Pressure (IOP) by 15% OR 

Documentation of a Plan of Care: 

Percentage of patients aged 18 years and 

older with a diagnosis of primary openAMA

- 

PCPI/

NCQ

A 

X X 
1000 

angle glaucoma whose glaucoma 

treatment has not failed (the most recent 

IOP was reduced by at least 15% from 

the pre- intervention level) OR if the 

most recent IOP was not reduced by at 

least 15% from the pre- intervention 

level, a plan of care was documented 

within 12 months 

0051/ 

142 

 Clinical 

Process/ 

Effective

ness 

Osteoarthritis (OA): Assessment for 

Use of Anti-Inflammatory or 

Analgesic Over-the-Counter (OTC) 

Medications: Percentage of patient 

visits for patients aged 21 years and 

older with a diagnosis of OA with an 

assessment for use of anti-inflammatory 

or analgesic OTC medications 

AMA

-PCPI 

X X 

0384/ 

143 

 Patient 

and 

Family 

Engagem

ent 

Oncology: Medical and Radiation – 

Pain Intensity Quantified: Percentage 

of patient visits, regardless of patient 

age, with a diagnosis of cancer currently 

receiving chemotherapy or radiation 

therapy in which pain intensity is 

quantified 

AMA

-PCPI 

 X X MU2 

0383/ 

144 

 Patient 

and 

Family 

Engagem

ent 

Oncology: Medical and Radiation – 

Plan of Care for Pain: Percentage of 

visits for patients, regardless of age, with 

a diagnosis of cancer currently receiving 

chemotherapy or radiation therapy who 

report having pain with a documented 

plan of care to address pain 

AMA

-PCPI 

 X X 

0510/ 

145 

 Patient 

Safety 

Radiology: Exposure Time Reported 

for Procedures Using Fluoroscopy: 

Percentage of final reports for 

procedures using fluoroscopy that 

include documentation of radiation 

exposure or exposure time 

AMA

- 

PCPI/

NCQ

A 

X X 

0508/ 

146 

 Efficient 

Use of 

Healthcar

e 

Resource

s 

Radiology: Inappropriate Use of 

“Probably Benign” Assessment 

Category in Mammography 

Screening: Percentage of final reports 

for screening mammograms that are 

classified as “probably benign” 

AMA

- 

PCPI/

NCQ

A 

X X 

0511/ 

147 

 Care 

Coordinat

ion 

Nuclear Medicine: Correlation with 

Existing Imaging Studies for All 

Patients Undergoing Bone 

Scintigraphy: Percentage of final 

reports for all patients, regardless of age, 

undergoing bone scintigraphy that 

include physician documentation of 

correlation with existing relevant 

imaging studies (e.g., x-ray, MRI, CT, 

etc.) that were performed 

AMA

-PCPI 

X X 
1001 

0322/ 

148 

 Efficient 

Use of 

Healthcar

e 

Resource

s 

Back Pain: Initial Visit: The 

percentage of patients aged 18 through 

79 years with a diagnosis of back pain or 

undergoing back surgery who had back 

pain and function assessed during the 

initial visit to the clinician for the 

episode of back pain 

NCQ

A 

 X 

0319/ 

149 

 Clinical 

Process/ 

Effective

ness 

Back Pain: Physical Exam: Percentage 

of patients aged 18 through 79 years 

with a diagnosis of back pain or 

undergoing back surgery who received a 

physical examination at the initial visit 

to the clinician for the episode of back 

pain 

NCQ

A 

 X 

0314/ 

150 

 Clinical 

Process/ 

Effective

ness 

Back Pain: Advice for Normal 

Activities: The percentage of patients 

aged 18 through 79 years with a 

diagnosis of back pain or undergoing 

back surgery who received advice for 

normal activities at the initial visit to the 

clinician for the episode of back pain 

NCQ

A 

 X 

0313/ 

151 

 Clinical 

Process/ 

Effective

ness 

Back Pain: Advice Against Bed Rest: 

The percentage of patients aged 18 

through 79 years with a diagnosis of 

back pain or undergoing back surgery 

who received advice against bed rest 

lasting 4 days or longer at the initial visit 

to the clinician for the episode of back 

pain 

NCQ

A 

 X 

0101/ 

154 

 Patient 

Safety 

Falls: Risk Assessment: Percentage of 

patients aged 65 years and older with a 

history of falls who had a risk 

assessment for falls completed within 12 

months 

AMA

- 

PCPI/

NCQ

A 

X X 

0101/ 

155 

 Care 

Coordinat

ion 

Falls: Plan of Care: Percentage of 

patients aged 65 years and older with a 

history of falls who had a plan of care 

for falls documented within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X 

0382/ 

156 

 Patient 

Safety 

Oncology: Radiation Dose Limits to 

Normal Tissues: Percentage of patients, 

regardless of age, with a diagnosis of 

pancreatic or lung cancer receiving 3D 

conformal radiation therapy with 

documentation in medical record that 

radiation dose limits to normal tissues 

were established prior to the initiation of 

a course of 3D conformal radiation for a 

minimum of two tissues 

AMA

-PCPI 

X X 

0455/ 

157 

 Patient 

Safety 

Thoracic Surgery: Recording of 

Clinical Stage Prior to Lung Cancer 

or Esophageal Cancer Resection: 

STS X X 
1002 

Percentage of surgical patients aged 18 

years and older undergoing resection for 

lung or esophageal cancer who had 

clinical staging provided prior to surgery 

0404/ 

159 

 Clinical 

Process/ 

Effective

ness 

HIV/AIDS: CD4+ Cell Count or 

CD4+ Percentage: Percentage of 

patients aged 6 months and older with a 

diagnosis of HIV/AIDS for whom a 

CD4+ cell count or CD4+ cell 

percentage was performed at least once 

every 6 months 

AMA

- 

PCPI/

NCQ

A 

 X X 

0405/ 

160 

 Clinical 

Process/ 

Effective

ness 

HIV/AIDS: Pneumocystis Jiroveci 

Pneumonia (PCP) Prophylaxis: 

Percentage of patients aged 6 years and 

older with a diagnosis of HIV/AIDS and 

CD4+ cell count < 200 cells/mm3

 who 

were prescribed PCP prophylaxis within 

3 months of low CD4+ cell count 

AMA

- 

PCPI/

NCQ

A 

 X X MU2 

0406/ 

161 

 Clinical 

Process/ 

Effective

ness 

HIV/AIDS: Adolescent and Adult 

Patients with HIV/AIDS Who Are 

Prescribed Potent Antiretroviral 

Therapy: Percentage of patients with a 

diagnosis of HIV/AIDS aged 13 years 

and older: who have a history of a nadir 

CD4+ cell count below 350/mm3

 or who 

have a history of an AIDS-defining 

condition, regardless of CD4+ cell 

count; or who are pregnant, regardless of 

CD4+ cell count or age, who were 

prescribed potent antiretroviral therapy 

AMA

- 

PCPI/

NCQ

A 

 X X 

N/A/ 

162 

 Clinical 

Process/ 

Effective

ness 

HIV/AIDS: HIV RNA Control After 

Six Months of Potent Antiretroviral 

Therapy: Percentage of patients aged 13 

years and older with a diagnosis of 

HIV/AIDS who are receiving potent 

antiretroviral therapy, who have a viral 

load below limits of quantification after 

at least 6 months of potent antiretroviral 

therapy or patients whose viral load is 

not below limits of quantification after at 

least 6 months of potent antiretroviral 

therapy and have documentation of a 

plan of care 

AMA

- 

PCPI/

NCQ

A 

 X X MU2 

0056/ 

163 

 Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: Foot Exam: The 

percentage of patients aged 18 through 

75 years with diabetes who had a foot 

examination 

NCQ

A 

X X X X MU1/ 

MU2 

0129/ 

164 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Prolonged Intubation: 

Percentage of patients aged 18 years and 

older undergoing isolated CABG 

surgery who require intubation > 24 

STS X X 
1003 

hours 

0130/ 

165 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Deep Sternal Wound 

Infection Rate: Percentage of patients 

aged 18 years and older undergoing 

isolated CABG surgery who, within 30 

days postoperatively, develop deep 

sternal wound infection involving 

muscle, bone, and/or mediastinum 

requiring operative intervention 

STS X X 

0131/ 

166 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Stroke: Percentage of patients 

aged 18 years and older undergoing 

isolated CABG surgery who have a 

postoperative stroke (i.e., any 

confirmed neurological deficit of abrupt 

onset caused by a disturbance in blood 

supply to the brain) that did not resolve 

within 24 hours 

STS X X 

0114/ 

167 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Postoperative Renal Failure: 

Percentage of patients aged 18 years and 

older undergoing isolated CABG 

surgery (without pre-existing renal 

failure) who develop postoperative renal 

failure or require dialysis 

STS X X 

0115/ 

168 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Surgical Re-Exploration: 

Percentage of patients aged 18 years and 

older undergoing isolated CABG 

surgery who require a return to the 

operating room (OR) during the current 

hospitalization for mediastinal bleeding 

with or without tamponade, graft 

occlusion, valve dysfunction, or other 

cardiac reason 

STS X X 

0116/ 

169 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Antiplatelet Medications at 

Discharge: 

Percentage of patients aged 18 years and 

older undergoing isolated CABG 

surgery who were discharged on 

antiplatelet medication 

STS X X 

0117/ 

170 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Bypass Graft 

(CABG): Beta-Blockers Administered 

at Discharge: Percentage of patients 

aged 18 years and older undergoing 

isolated CABG surgery who were 

discharged on beta-blockers 

STS X X 

0118/ 

171 

 Clinical 

Process/ 

Effective

Coronary Artery Bypass Graft 

(CABG): Anti-Lipid Treatment at 

Discharge: Percentage of patients aged 

STS X X 
1004 

ness 18 years and older undergoing isolated 

CABG surgery who were discharged on 

a statin or other lipid-lowering regimen 

0259/ 

172 

 Clinical 

Process/ 

Effective

ness 

Hemodialysis Vascular Access 

Decision-Making by Surgeon to 

Maximize Placement of Autogenous 

Arterial Venous (AV) Fistula: 

Percentage of patients aged 18 years and 

older with a diagnosis of advanced 

Chronic Kidney Disease (CKD) (stage 4 

or 5) or End Stage Renal Disease 

(ESRD) requiring hemodialysis vascular 

access documented by surgeon to have 

received autogenous AV fistula 

SVS X X 

AQA 

adopt

ed/ 

173 

◊ Populatio

n/Public 

Health 

Preventive Care and Screening: 

Unhealthy Alcohol Use – Screening: 

Percentage of patients aged 18 years and 

older who were screened for unhealthy 

alcohol use using a systematic screening 

method within 24 months 

AMA

-PCPI 

X X X X 

AQA 

adopt

ed/ 

176 

 Clinical 

Process/ 

Effective

ness 

Rheumatoid Arthritis (RA): 

Tuberculosis Screening: Percentage of 

patients aged 18 years and older with a 

diagnosis of RA who have 

documentation of a tuberculosis (TB) 

screening performed and results 

interpreted within 6 months prior to 

receiving a first course of therapy using 

a biologic disease-modifying antirheumatic drug (DMARD) 

AMA

- 

PCPI/

NCQ

A 

X X X 

AQA 

adopt

ed/ 

177 

 Clinical 

Process/ 

Effective

ness 

Rheumatoid Arthritis (RA): Periodic 

Assessment of Disease Activity: 

Percentage of patients aged 18 years and 

older with a diagnosis of RA who have 

an assessment and classification of 

disease activity within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X X 

AQA 

adopt

ed/ 

178 

 Clinical 

Process/ 

Effective

ness 

Rheumatoid Arthritis (RA): 

Functional Status Assessment: 

Percentage of patients aged 18 years and 

older with a diagnosis of RA for whom a 

functional status assessment was 

performed at least once within 12 

months 

AMA

- 

PCPI/

NCQ

A 

X X X 

AQA 

adopt

ed/ 

179 

 Clinical 

Process/ 

Effective

ness 

Rheumatoid Arthritis (RA): 

Assessment and Classification of 

Disease Prognosis: Percentage of 

patients aged 18 years and older with a 

diagnosis of RA who have an 

assessment and classification of disease 

prognosis at least once within 12 months 

AMA

- 

PCPI/

NCQ

A 

X X X 

AQA 

adopt

 Care 

Coordinat

Rheumatoid Arthritis (RA): 

Glucocorticoid Management: 

AMA

- 

X X X 
1005 

ed/ 

180 

ion Percentage of patients aged 18 years and 

older with a diagnosis of RA who have 

been assessed for glucocorticoid use 

and, for those on prolonged doses of 

prednisone ≥ 10 mg daily (or equivalent) 

with improvement or no change in 

disease activity, documentation of 

glucocorticoid management plan within 

12 months 

PCPI/

NCQ

A 

AQA 

adopt

ed/ 

181 

 Patient 

Safety 

Elder Maltreatment Screen and 

Follow-Up Plan: Percentage of patients 

aged 65 years and older with a 

documented elder maltreatment screen 

on the date of encounter AND a 

documented follow-up plan on the date 

of the positive screen 

CMS/

QIP 

X X 

AQA 

adopt

ed/ 

182 

 Care 

Coordinat

ion 

Functional Outcome Assessment: 

Percentage of visits for patients aged 18 

years and older with documentation of a 

current functional outcome assessment 

using a standardized functional outcome 

assessment tool on the date of encounter 

AND documentation of a care plan 

based on identified functional outcome 

deficiencies on the date of the identified 

deficiencies 

CMS/

QIP 

X X 

0399/ 

183 

 Populatio

n/Public 

Health 

Hepatitis C: Hepatitis A Vaccination 

in Patients with HCV: Percentage of 

patients aged 18 years and older with a 

diagnosis of hepatitis C who received at 

least one injection of hepatitis A 

vaccine, or who have documented 

immunity to hepatitis A 

AMA

-PCPI 

X X X 

0400/ 

184 

 Populatio

n/Public 

Health 

Hepatitis C: Hepatitis B Vaccination 

in Patients with HCV: Percentage of 

patients aged 18 years and older with a 

diagnosis of hepatitis C who received at 

least one injection of hepatitis B vaccine, 

or who have documented immunity to 

hepatitis B 

AMA

-PCPI 

X X X 

0659/ 

185 

 Care 

Coordinat

ion 

Endoscopy & Polyp Surveillance: 

Colonoscopy Interval for Patients 

with a History of Adenomatous Polyps 

– Avoidance of Inappropriate Use: 

Percentage of patients aged 18 years and 

older receiving a surveillance 

colonoscopy, with a history of a prior 

colonic polyp(s) in previous 

colonoscopy findings, who had an 

interval of 3 or more years since their 

last colonoscopy 

AMA

- 

PCPI/

NCQ

A 

X X 

0437/ Clinical Stroke and Stroke Rehabilitation: AHA/ X 
1006 

187 Process/ 

Effective

ness 

Thrombolytic Therapy: Percentage of 

patients aged 18 years and older with a 

diagnosis of acute ischemic stroke who 

arrive at the hospital within 2 hours of 

time last known well and for whom IV tPA was initiated within 3 hours of time 

last known well 

ASA/ 

TJC 

N/A/ 

188 

 Care 

Coordinat

ion 

Referral for Otologic Evaluation for 

Patients with Congenital or 

Traumatic Deformity of the Ear: 

Percentage of patients aged birth and 

older referred to a physician (preferably 

a physician with training in disorders of 

the ear) for an otologic evaluation 

subsequent to an audiologic evaluation 

after presenting with a congenital or 

traumatic deformity of the ear (internal 

or external) 

AQC X X 

N/A/ 

189 

 Care 

Coordinat

ion 

Referral for Otologic Evaluation for 

Patients with History of Active 

Drainage from the Ear Within the 

Previous 90 Days: Percentage of 

patients aged birth and older who have 

disease of the ear and mastoid processes 

referred to a physician (preferably a 

physician with training in disorders of 

the ear) for an otologic evaluation 

subsequent to an audiologic evaluation 

after presenting with a history of active 

drainage from the ear within the 

previous 90 days

AQC X X 

N/A/ 

190 

 Care 

Coordinat

ion 

Referral for Otologic Evaluation for 

Patients with a History of Sudden or 

Rapidly Progressive Hearing Loss: 

Percentage of patients aged birth and 

older referred to a physician (preferably 

a physician with training in disorders of 

the ear) for an otologic evaluation 

immediately following an audiologic 

evaluation that verifies and documents 

sudden or rapidly progressive hearing 

loss

AQC X

 

X

 

 

0565/ 

191 

 Clinical 

Process/ 

Effective

ness 

Cataracts: 20/40 or Better Visual 

Acuity within 90 Days Following 

Cataract Surgery: Percentage of 

patients aged 18 years and older with a 

diagnosis of uncomplicated cataract who 

had cataract surgery and no significant 

ocular conditions impacting the visual 

outcome of surgery and had bestcorrected visual acuity of 20/40 or better 

(distance or near) achieved within 90 

AMA

- 

PCPI/

NCQ

A 

 X X MU2 
1007 

days following the cataract surgery 

0564/ 

192 

 Patient 

Safety 

Cataracts: Complications within 30 

Days Following Cataract Surgery 

Requiring Additional Surgical 

Procedures: Percentage of patients aged 

18 years and older with a diagnosis of 

uncomplicated cataract who had cataract 

surgery and had any of a specified list of 

surgical procedures in the 30 days 

following cataract surgery which would 

indicate the occurrence of any of the 

following major complications: retained 

nuclear fragments, endophthalmitis, 

dislocated or wrong power IOL, retinal 

detachment, or wound dehiscence 

AMA

- 

PCPI/

NCQ

A 

 X X MU2 

0454/ 

193 

 Patient 

Safety 

Perioperative Temperature 

Management: Percentage of patients, 

regardless of age, undergoing surgical or 

therapeutic procedures under general or 

neuraxial anesthesia of 60 minutes 

duration or longer, except patients 

undergoing cardiopulmonary bypass, for 

whom either active warming was used 

intraoperatively for the purpose of 

maintaining normothermia, OR at least 

one body temperature equal to or greater 

than 36 degrees Centigrade (or 96.8 

degrees Fahrenheit) was recorded within 

the 30 minutes immediately before or 

the 15 minutes immediately after 

anesthesia end time 

AMA

-PCPI 

X X 

0386/ 

194 

 Clinical 

Process/ 

Effective

ness 

Oncology: Cancer Stage Documented: 

Percentage of patients, regardless of age, 

with a diagnosis of cancer who are seen 

in the ambulatory setting who have a 

baseline AJCC cancer stage or 

documentation that the cancer is 

metastatic in the medical record at least 

once within 12 months 

AMA

- 

PCPI/

ASC

O 

X X X 

0507/ 

195 

 Clinical 

Process/ 

Effective

ness 

Radiology: Stenosis Measurement in 

Carotid Imaging Reports: Percentage 

of final reports for carotid imaging 

studies (neck magnetic resonance 

angiography [MRA], neck computed 

tomography angiography [CTA], neck 

duplex ultrasound, carotid angiogram) 

performed that include direct or indirect 

reference to measurements of distal 

internal carotid diameter as the 

denominator for stenosis measurement 

AMA

- 

PCPI/

NCQ

A 

X X 

0074/ 

197 

 Clinical 

Process/ 

Coronary Artery Disease (CAD): 

Lipid Control: Percentage of patients 

AMA

- 

 X X X X MU1 

ACO 
1008 

Effective

ness 

aged 18 years and older with a diagnosis 

of coronary artery disease seen within a 

12 month period who have a LDL-C 

result < 100 mg/dL OR patients who 

have a LDL-C result ≥ 100 mg/dL and 

have a documented plan of care to 

achieve LDL-C < 100 mg/dL, including 

at a minimum the prescription of a statin 

PCPI/

ACC

F/AH

A 

0079/ 

198 

 Clinical 

Process/ 

Effective

ness 

Heart Failure: Left Ventricular 

Ejection Fraction (LVEF) 

Assessment: Percentage of patients aged 

18 years and older with a diagnosis of 

heart failure for whom the quantitative 

or qualitative results of a recent or prior 

[any time in the past] LVEF assessment 

is documented within a 12 month period 

AMA

- 

PCPI/

ACC

F/AH

A 

 X X 

0084/ 

200 

◊ Clinical 

Process/ 

Effective

ness 

Heart Failure: Warfarin Therapy for 

Patients with Atrial Fibrillation: 

Percentage of all patients aged 18 and 

older with a diagnosis of heart failure 

and paroxysmal or chronic atrial 

fibrillation who were prescribed 

warfarin therapy 

AMA

- 

PCPI/

ACC

F/A 

HA 

 X MU1 

0073/ 

201 

 Clinical 

Process/ 

Effective

ness 

Ischemic Vascular Disease (IVD): 

Blood Pressure Management: 

Percentage of patients aged 18 to 75 

years with Ischemic Vascular Disease 

(IVD) who had most recent blood 

pressure in control (less than 140/90 

mmHg) 

NCQ

A 

X X X X MU1 

0068/ 

204 

 Clinical 

Process/ 

Effective

ness 

Ischemic Vascular Disease (IVD): Use 

of Aspirin or Another 

Antithrombotic: Percentage of patients 

aged 18 years and older with Ischemic 

Vascular Disease (IVD) with 

documented use of aspirin or another 

antithrombotic 

NCQ

A 

X X X X X MU1/ 

MU2 

ACO 

Million 

Hearts 

0409/ 

205 

 Clinical 

Process/ 

Effective

ness 

HIV/AIDS: Sexually Transmitted 

Disease Screening for Chlamydia and 

Gonorrhea: Percentage of patients aged 

13 years and older with a diagnosis of 

HIV/AIDS for whom chlamydia and 

gonorrhea screenings were performed at 

least once since the diagnosis of HIV 

infection 

AMA

- 

PCPI/

NCQ

A 

 X X 

0410/ 

208 

 Clinical 

Process/ 

Effective

ness 

HIV/AIDS: Sexually Transmitted 

Disease Screening for Syphilis: 

Percentage of patients aged 13 years and 

older with a diagnosis of HIV/AIDS 

who were screened for syphilis at least 

once within 12 months 

AMA

- 

PCPI/

NCQ

A 

 X X 

0445/ Clinical Functional Communication Measure - ASH X 
1009 

209 Process/ 

Effective

ness 

Spoken Language Comprehension: 

Percentage of patients aged 16 years and 

older with a diagnosis of late effects of 

cerebrovascular disease (CVD) that 

make progress on the Spoken Language 

Comprehension Functional 

Communication Measure 

A 

0449/ 

210 

 Clinical 

Process/ 

Effective

ness 

Functional Communication Measure – 

Attention: Percentage of patients aged 

16 years and older with a diagnosis of 

late effects of cerebrovascular disease 

(CVD) that make progress on the 

Attention Functional Communication 

Measure 

ASH

A 

 X 

0448/ 

211 

 Clinical 

Process/ 

Effective

ness 

Functional Communication Measure – 

Memory: Percentage of patients aged 16 

years and older with a diagnosis of late 

effects of cerebrovascular disease 

(CVD) that make progress on the 

Memory Functional Communication 

Measure 

ASH

A 

 X 

0447/ 

212 

 Clinical 

Process/ 

Effective

ness 

Functional Communication Measure - 

Motor Speech: Percentage of patients 

aged 16 years and older with a diagnosis 

of late effects of cerebrovascular disease 

(CVD) that make progress on the Motor 

Speech Functional Communication 

Measure

ASH

A 

 X 

0446/ 

213 

 Clinical 

Process/ 

Effective

ness 

Functional Communication Measure – 

Reading: Percentage of patients aged 16 

years and older with a diagnosis of late 

effects of cerebrovascular disease 

(CVD) that make progress on the 

Reading Functional Communication 

Measure 

ASH

A 

 X 

0444/ 

214 

 Clinical 

Process/ 

Effective

ness 

Functional Communication Measure - 

Spoken Language Expression: 

Percentage of patients aged 16 years and 

older with a diagnosis of late effects of 

cerebrovascular disease (CVD) that 

make progress on the Spoken Language 

Expression Functional Communication 

Measure 

ASH

A 

 X 

0442/ 

215 

 Clinical 

Process/ 

Effective

ness 

Functional Communication Measure – 

Writing: Percentage of patients aged 16 

years and older with a diagnosis of late 

effects of cerebrovascular disease 

(CVD) that make progress on the 

Writing Functional Communication 

Measure 

ASH

A 

 X 

0443/ 

216 

 Clinical 

Process/ 

Functional Communication Measure – 

Swallowing: Percentage of patients aged 

ASH

A 

 X 
1010 

Effective

ness 

16 years and older with a diagnosis of 

late effects of cerebrovascular disease 

(CVD) that make progress on the 

Swallowing Functional Communication 

Measure 

0422/ 

217 

 Care 

Coordinat

ion 

Functional Deficit: Change in RiskAdjusted Functional Status for 

Patients with Knee Impairments: 

Percentage of patients aged 18 or older 

that receive treatment for a functional 

deficit secondary to a diagnosis that 

affects the knee in which the change in 

their Risk-Adjusted Functional Status is 

measured 

FOT

O 

 X 

0423/ 

218 

 Care 

Coordinat

ion 

Functional Deficit: Change in RiskAdjusted Functional Status for 

Patients with Hip Impairments: 

Percentage of patients aged 18 or older 

that receive treatment for a functional 

deficit secondary to a diagnosis that 

affects the hip in which the change in 

their Risk-Adjusted Functional Status is 

measured 

FOT

O 

 X 

0424/ 

219 

 Care 

Coordinat

ion 

Functional Deficit: Change in RiskAdjusted Functional Status for 

Patients with Lower Leg, Foot or 

Ankle Impairments: Percentage of 

patients aged 18 or older that receive 

treatment for a functional deficit 

secondary to a diagnosis that affects the 

lower leg, foot or ankle in which the 

change in their Risk-Adjusted 

Functional Status is measured 

FOT

O 

 X 

0425/ 

220 

 Care 

Coordinat

ion 

Functional Deficit: Change in RiskAdjusted Functional Status for 

Patients with Lumbar Spine 

Impairments: Percentage of patients 

aged 18 or older that receive treatment 

for a functional deficit secondary to a 

diagnosis that affects the lumbar spine in 

which the change in their Risk-Adjusted 

Functional Status is measured 

FOT

O 

 X 

0426/ 

221 

 Care 

Coordinat

ion 

Functional Deficit: Change in RiskAdjusted Functional Status for 

Patients with Shoulder Impairments: 

Percentage of patients aged 18 or older 

that receive treatment for a functional 

deficit secondary to a diagnosis that 

affects the shoulder in which the change 

in their Risk-Adjusted Functional Status 

is measured 

FOT

O 

 X 

0427/ Care Functional Deficit: Change in Risk- FOT X 
1011 

222 Coordinat

ion 

Adjusted Functional Status for 

Patients with Elbow, Wrist or Hand 

Impairments: Percentage of patients 

aged 18 or older that receive treatment 

for a functional deficit secondary to a 

diagnosis that affects the elbow, wrist or 

hand in which the change in their RiskAdjusted Functional Status is measured 

O 

0428/ 

223 

 Care 

Coordinat

ion 

Functional Deficit: Change in RiskAdjusted Functional Status for 

Patients with Neck, Cranium, 

Mandible, Thoracic Spine, Ribs, or 

Other General Orthopedic 

Impairments: Percentage of patients 

aged 18 or older that receive treatment 

for a functional deficit secondary to a 

diagnosis that affects the neck, cranium, 

mandible, thoracic spine, ribs, or other 

general orthopedic impairment in which 

the change in their Risk-Adjusted 

Functional Status is measured 

FOT

O 

 X 

0562/ 

224 

 Efficient 

Use of 

Healthcar

e 

Resource

s 

Melanoma: Overutilization of 

Imaging Studies in Melanoma: 

Percentage of patients, regardless of age, 

with a current diagnosis of stage 0 

through IIC melanoma or a history of 

melanoma of any stage, without signs or 

symptoms suggesting systemic spread, 

seen for an office visit during the oneyear measurement period, for whom no 

diagnostic imaging studies were ordered 

AMA

- 

PCPI/

NCQ

A 

 X 

0509/ 

225 

 Care 

Coordinat

ion 

Radiology: Reminder System for 

Mammograms: Percentage of patients 

aged 40 years and older undergoing a 

screening mammogram whose 

information is entered into a reminder 

system with a target due date for the 

next mammogram 

AMA

- 

PCPI/

NCQ

A 

X X 

0028/ 

226 

 Populatio

n/Public 

Health 

Preventive Care and Screening: 

Tobacco Use: Screening and Cessation 

Intervention: Percentage of patients 18 

years and older who were screened for 

tobacco use one or more times within 24 

months AND who received cessation 

counseling intervention if identified as a 

tobacco user 

AMA

-PCPI 

X X X X X MU1/ 

MU2 

ACO 

Million 

Hearts 

N/A/ 

228 

 Clinical 

Process/ 

Effective

ness 

Heart Failure (HF): Left Ventricular 

Function (LVF) Testing: Percentage of 

patients 18 years and older with Left 

Ventricular Function (LVF) testing 

performed within the previous 12 

months for patients who are hospitalized 

CMS/

QIP 

 X 
1012 

with a principal diagnosis of Heart 

Failure (HF) during the reporting period 

N/A/ 

231 

 Clinical 

Process/ 

Effective

ness 

Asthma: Tobacco Use: Screening - 

Ambulatory Care Setting: Percentage 

of patients (or their primary caregiver) 

aged 5 through 50 years with a diagnosis 

of asthma who were queried about 

tobacco use and exposure to second 

hand smoke within their home 

environment at least once during the 

one-year measurement period 

AMA

- 

PCPI/

NCQ

A 

X X X 

N/A/ 

232 

 Clinical 

Process/ 

Effective

ness 

Asthma: Tobacco Use: Intervention - 

Ambulatory Care Setting: Percentage 

of patients (or their primary caregiver) 

aged 5 through 50 years with a diagnosis 

of asthma who were identified as 

tobacco users (patients who currently 

use tobacco AND patients who do not 

currently use tobacco, but are exposed to 

second hand smoke in their home 

environment) who received tobacco 

cessation intervention at least once 

during the one-year measurement period 

AMA

- 

PCPI/

NCQ

A 

X X X 

0457/ 

233 

 Clinical 

Process/ 

Effective

ness 

Thoracic Surgery: Recording of 

Performance Status Prior to Lung or 

Esophageal Cancer Resection: 

Percentage of patients aged 18 years and 

older undergoing resection for lung or 

esophageal cancer who had performance 

status documented and reviewed within 

2 weeks prior to surgery 

STS X 

0458/ 

234 

 Patient 

Safety 

Thoracic Surgery: Pulmonary 

Function Tests Before Major 

Anatomic Lung Resection 

(Pneumonectomy, Lobectomy, or 

Formal Segmentectomy): Percentage 

of thoracic surgical patients aged 18 

years and older undergoing at least one 

pulmonary function test within 12 

months prior to a major lung resection 

(pneumonectomy, lobectomy, or formal 

segmentectomy) 

STS X 

0018/ 

236 

 Clinical 

Process/ 

Effective

ness 

Hypertension (HTN): Controlling 

High Blood Pressure: Percentage of 

patients aged 18 through 85 years of age 

who had a diagnosis of hypertension 

(HTN) and whose BP was adequately 

controlled (< 140/90 mmHg) 

NCQ

A 

X X X X X MU1/ 

MU2 

ACO 

Million 

Hearts 

0013/ 

237 

◊ Clinical 

Process/ 

Effective

ness 

Hypertension (HTN): Blood Pressure 

Measurement: Percentage of patient 

visits for patients aged 18 years and 

older with a diagnosis of hypertension 

AMA

-PCPI 

 X MU1 
1013 

with blood pressure (BP) recorded 

0022/ 

238 

 Patient 

Safety 

Drugs to be Avoided in the Elderly: 

Percentage of patients ages 65 years and 

older who received at least one drug to 

be avoided in the elderly and/or two 

different drugs to be avoided in the 

elderly in the measurement period 

NCQ

A 

 X MU2 

0024/ 

239 

 Populatio

n/Public 

Health 

Weight Assessment and Counseling 

for Children and Adolescents: 

Percentage of children 2 through 17 

years of age who had an outpatient visit 

with a PCP or OB/GYN and who had 

evidence of BMI percentile 

documentation, counseling for nutrition 

and counseling for physical activity 

during the measurement period 

NCQ

A 

 X MU1/ 

MU2 

0038/ 

240 

 Populatio

n/Public 

Health 

Childhood Immunization Status: The 

percentage of children 2 years of age 

who had four diphtheria, tetanus and 

acellular pertussis (DTaP); three polio 

(IPV); one measles, mumps, rubella 

(MMR); three H influenza type B (HiB); 

three hepatitis B (Hep B); one chicken 

pox (VZV); four pneumococcal 

conjugate (PCV); two hepatitis A (Hep 

A); two or three rotavirus (RV); and two 

influenza (flu) vaccines by their second 

birthday 

NCQ

A 

 X MU1/ 

MU2 

0075/ 

241 

 Clinical 

Process/ 

Effective

ness 

Ischemic Vascular Disease (IVD): 

Complete Lipid Panel and Low 

Density Lipoprotein (LDL-C) 

Control: Percentage of patients aged 18 

years and older with Ischemic Vascular 

Disease (IVD) who received at least one 

lipid profile within 12 months and 

whose most recent LDL-C level was in 

control (less than 100 mg/dL) 

NCQ

A 

X X X X X MU1/ 

MU2 

ACO 

Million 

Hearts 

N/A/ 

242 

 Clinical 

Process/ 

Effective

ness 

Coronary Artery Disease (CAD): 

Symptom Management: Percentage of 

patients aged 18 years and older with a 

diagnosis of coronary artery disease seen 

within a 12 month period with an 

evaluation of level of activity and an 

assessment of whether anginal 

symptoms are present or absent with 

appropriate management of anginal 

symptoms within a 12 month period 

AMA

- 

PCPI/

ACC

F/AH

A 

 X X 

0643/ 

243 

 Clinical 

Process/ 

Effective

ness 

Cardiac Rehabilitation Patient 

Referral from an Outpatient Setting: 

Percentage of patients evaluated in an 

outpatient setting who within the 

previous 12 months have experienced an 

ACC

FAHA 

 X 
1014 

acute myocardial infarction (MI), 

coronary artery bypass graft (CABG) 

surgery, a percutaneous coronary 

intervention (PCI), cardiac valve 

surgery, or cardiac transplantation, or 

who have chronic stable angina (CSA) 

and have not already participated in an 

early outpatient cardiac 

rehabilitation/secondary prevention (CR) 

program for the qualifying 

event/diagnosis who were referred to a 

CR program 

N/A/ 

244 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Blood Pressure 

Management: Percentage of patients 

aged 18 years and older with a diagnosis 

of hypertension seen within a 12 month 

period with a blood pressure < 140/90 

mmHg OR patients with a blood 

pressure ≥ 140/90 mmHg and prescribed 

two or more anti-hypertensive 

medications during the most recent 

office visit 

AMA

- 

PCPI/

ACC

F/AH

A 

 X 

AQA 

adopt

ed/ 

245 

 Clinical 

Process/ 

Effective

ness 

Chronic Wound Care: Use of Wound 

Surface Culture Technique in Patients 

with Chronic Skin Ulcers (Overuse 

Measure): Percentage of patient visits 

for those patients aged 18 years and 

older with a diagnosis of chronic skin 

ulcer without the use of a wound surface 

culture technique 

AMA

- 

PCPI/

NCQ

A 

X X 

AQA 

adopt

ed/ 

246 

 Clinical 

Process/ 

Effective

ness 

Chronic Wound Care: Use of Wet to 

Dry Dressings in Patients with 

Chronic Skin Ulcers (Overuse 

Measure): Percentage of patient visits 

for those patients aged 18 years and 

older with a diagnosis of chronic skin 

ulcer without a prescription or 

recommendation to use wet to dry 

dressings 

AMA

- 

PCPI/

NCQ

A 

X X 

AQA 

adopt

ed/ 

247 

 Clinical 

Process/ 

Effective

ness 

Substance Use Disorders: Counseling 

Regarding Psychosocial and 

Pharmacologic Treatment Options for 

Alcohol Dependence: Percentage of 

patients aged 18 years and older with a 

diagnosis of current alcohol dependence 

who were counseled regarding 

psychosocial AND pharmacologic 

treatment options for alcohol 

dependence within the 12-month 

reporting period 

AMA

- 

PCPI/

NCQ

A 

X X 

AQA 

adopt

 Clinical 

Process/ 

Substance Use Disorders: Screening 

for Depression Among Patients with 

AMA

- 

X X 
1015 

ed/ 

248 

Effective

ness 

Substance Abuse or Dependence: 

Percentage of patients aged 18 years and 

older with a diagnosis of current 

substance abuse or dependence who 

were screened for depression within the 

12-month reporting period 

PCPI/

NCQ

A 

N/A/ 

249 

 Clinical 

Process/ 

Effective

ness 

Barrett's Esophagus: Percentage of 

esophageal biopsy reports that document 

the presence of Barrett’s mucosa that 

also include a statement about dysplasia 

CAP X X 

N/A/ 

250 

 Clinical 

Process/ 

Effective

ness 

Radical Prostatectomy Pathology 

Reporting: Percentage of radical 

prostatectomy pathology reports that 

include the pT category, the pN 

category, the Gleason score and a 

statement about margin status 

CAP X X 

N/A/ 

251 

 Clinical 

Process/ 

Effective

ness 

Immunohistochemical (IHC) 

Evaluation of Human Epidermal 

Growth Factor Receptor 2 Testing 

(HER2) for Breast Cancer Patients: 

This is a measure based on whether 

quantitative evaluation of Human 

Epidermal Growth Factor Receptor 2 

Testing (HER2) by 

immunohistochemistry (IHC) uses the 

system recommended in the ASCO/CAP 

Guidelines for Human Epidermal 

Growth Factor Receptor 2 Testing in 

breast cancer 

CAP X X 

0503/ 

252 

 Clinical 

Process/ 

Effective

ness 

Anticoagulation for Acute Pulmonary 

Embolus Patients: Anticoagulation 

ordered for patients who have been 

discharged from the emergency 

department (ED) with a diagnosis of 

acute pulmonary embolus 

ACEP X X 

0651/ 

254 

 Clinical 

Process/ 

Effective

ness 

Ultrasound Determination of 

Pregnancy Location for Pregnant 

Patients with 

Abdominal Pain: Percentage of 

pregnant female patients aged 14 to 50 

who present to the emergency 

department (ED) with a chief complaint 

of abdominal pain or vaginal bleeding 

who receive a trans-abdominal or transvaginal ultrasound to determine 

pregnancy location 

ACEP X X 

0652/ 

255 

 Clinical 

Process/ 

Effective

ness 

Rh Immunoglobulin (Rhogam) for 

Rh-Negative Pregnant Women at Risk 

of Fetal Blood Exposure: Percentage of 

Rh-negative pregnant women aged 14-

50 years at risk of fetal blood exposure 

who receive Rh-Immunoglobulin 

ACEP X X 
1016 

(Rhogam) in the emergency department 

(ED) 

N/A/ 

256 

 Care 

Coordinat

ion 

Surveillance after Endovascular 

Abdominal Aortic Aneurysm Repair 

(EVAR): Percentage of patients 18 

years of age or older undergoing 

endovascular abdominal aortic aneurysm 

repair (EVAR) who have at least one 

follow-up imaging study after 3 months 

and within 15 months of EVAR 

placement that documents aneurysm sac 

diameter and endoleak status 

SVS X 

N/A/ 

257 

 Clinical 

Process/ 

Effective

ness 

Statin Therapy at Discharge after 

Lower Extremity Bypass (LEB): 

Percentage of patients aged 18 years and 

older undergoing infra-inguinal lower 

extremity bypass who are prescribed a 

statin medication at discharge 

SVS X 

N/A/ 

258 

 Care 

Coordinat

ion 

Rate of Open Repair of Small or 

Moderate Non-Ruptured Abdominal 

Aortic Aneurysms (AAA) without 

Major Complications (Discharged to 

Home by Post-Operative Day #7): 

Percent of patients undergoing open 

repair of small or moderate sized nonruptured abdominal aortic aneurysms 

who do not experience a major 

complication (discharge to home no later 

than post-operative day #7) 

SVS X 

N/A/ 

259 

 Care 

Coordinat

ion 

Rate of Endovascular Aneurysm 

Repair (EVAR) of Small or Moderate 

Non-Ruptured Abdominal Aortic 

Aneurysms (AAA) without Major 

Complications (Discharged to Home 

by Post-Operative Day #2): Percent of 

patients undergoing endovascular repair 

of small or moderate non-ruptured 

abdominal aortic aneurysms (AAA) that 

do not experience a major complication 

(discharged to home no later than postoperative day #2) 

SVS X 

N/A/ 

260 

 Care 

Coordinat

ion 

Rate of Carotid Endarterectomy 

(CEA) for Asymptomatic Patients, 

without Major Complications 

(Discharged to Home by PostOperative Day #2): Percent of 

asymptomatic patients undergoing CEA 

who are discharged to home no later 

than post-operative day #2 

SVS X 

N/A/ 

261 

 Care 

Coordinat

ion 

Referral for Otologic Evaluation for 

Patients with Acute or Chronic 

Dizziness: Percentage of patients aged 

AQC X X 
1017 

birth and older referred to a physician 

(preferably a physician specially trained 

in disorders of the ear) for an otologic 

evaluation subsequent to an audiologic 

evaluation after presenting with acute or 

chronic dizziness 

N/A/ 

262 

 Patient 

Safety 

Image Confirmation of Successful 

Excision of Image–Localized Breast 

Lesion: Image confirmation of lesion(s) 

targeted for image guided excisional 

biopsy or image guided partial 

mastectomy in patients with 

nonpalpable, image-detected breast 

lesion(s). Lesions may include: 

microcalcifications, mammographic or 

sonographic mass or architectural 

distortion, focal suspicious abnormalities 

on magnetic resonance imaging (MRI) 

or other breast imaging amenable to 

localization such as positron emission 

tomography (PET) mammography, or a 

biopsy marker demarcating site of 

confirmed pathology as established by 

previous core biopsy. 

ASBS X X 

N/A/ 

263 

 Clinical 

Process/ 

Effective

ness 

Preoperative Diagnosis of Breast 

Cancer: The percent of patients 

undergoing breast cancer operations who 

obtained the diagnosis of breast cancer 

preoperatively by a minimally invasive 

biopsy method 

ASBS X X 

N/A/ 

264 

 Clinical 

Process/ 

Effective

ness 

Sentinel Lymph Node Biopsy for 

Invasive Breast Cancer: The 

percentage of clinically node negative 

(clinical stage T1N0M0 or T2N0M0) 

breast cancer patients who undergo a 

sentinel lymph node (SLN) procedure 

ASBS X 

0645/ 

265 

 Care 

Coordinat

ion 

Biopsy Follow-Up: Percentage of new 

patients whose biopsy results have been 

reviewed and communicated to the 

primary care/referring physician and 

patient by the performing physician 

AAD X 

N/A/ 

266 

 Clinical 

Process/ 

Effective

ness 

Epilepsy: Seizure Type(s) and 

Current Seizure Frequency(ies): 

Percentage of patient visits with a 

diagnosis of epilepsy who had the 

type(s) of seizure(s) and current seizure 

frequency(ies) for each seizure type 

documented in the medical record 

AAN X X 

N/A/ 

267 

 Clinical 

Process/ 

Effective

ness 

Epilepsy: Documentation of Etiology 

of Epilepsy or Epilepsy Syndrome: All 

visits for patients with a diagnosis of 

epilepsy who had their etiology of 

AAN X X 
1018 

epilepsy or with epilepsy syndrome(s) 

reviewed and documented if known, or 

documented as unknown or cryptogenic 

N/A/ 

268 

 Clinical 

Process/ 

Effective

ness 

Epilepsy: Counseling for Women of 

Childbearing Potential with Epilepsy: 

All female patients of childbearing 

potential (12-44 years old) diagnosed 

with epilepsy who were counseled about 

epilepsy and how its treatment may 

affect contraception and pregnancy at 

least once a year 

AAN X X 

N/A/ 

269 

 Clinical 

Process/ 

Effective

ness 

Inflammatory Bowel Disease (IBD): 

Type, Anatomic Location and Activity 

All Documented: Percentage of patients 

aged 18 years and older with a diagnosis 

of inflammatory bowel disease who have 

documented the disease type, anatomic 

location and activity, at least once during 

the reporting period 

AGA X 

N/A/ 

270 

 Clinical 

Process/ 

Effective

ness 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Corticosteroid 

Sparing Therapy: Percentage of 

patients aged 18 years and older with a 

diagnosis of inflammatory bowel disease 

who have been managed by 

corticosteroids greater than or equal to 

10 mg/day for 60 or greater consecutive 

days that have been prescribed 

corticosteroid sparing therapy in the last 

reporting year 

 AGA X 

N/A/ 

271 

 Clinical 

Process/ 

Effective

ness 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Corticosteroid 

Related 

Iatrogenic Injury – Bone Loss 

Assessment: Percentage of patients aged 

18 years and older with a diagnosis of 

inflammatory bowel disease who have 

received dose of corticosteroids greater 

than or equal to 10 mg/day for 60 or 

greater consecutive days and were 

assessed for risk of bone loss once per 

the reporting year 

AGA X 

N/A/ 

272 

 Clinical 

Process/ 

Effective

ness 

Inflammatory Bowel Disease (IBD): 

Preventive Care: Influenza 

Immunization: Percentage of patients 

aged 18 years and older with a diagnosis 

of inflammatory bowel disease for 

whom influenza immunization was 

recommended, administered or 

previously received during the reporting 

year 

AGA X 

N/A/ Clinical Inflammatory Bowel Disease (IBD): AGA X 
1019 

273 Process/ 

Effective

ness 

Preventive Care: Pneumococcal 

Immunization: Percentage of patients 

aged 18 years and older with a diagnosis 

of inflammatory bowel disease that had 

pneumococcal vaccination administered 

or previously received 

N/A/ 

274 

 Clinical 

Process/ 

Effective

ness 

Inflammatory Bowel Disease (IBD): 

Testing for Latent Tuberculosis (TB) 

Before Initiating Anti-TNF (Tumor 

Necrosis Factor) Therapy: Percentage 

of patients aged 18 years and older with 

a diagnosis of inflammatory bowel 

disease for whom a tuberculosis (TB) 

screening was performed and results 

interpreted within 6 months prior to 

receiving a first course of anti-TNF 

(tumor necrosis factor) therapy 

AGA X 

N/A/ 

275 

 Clinical 

Process/ 

Effective

ness 

Inflammatory Bowel Disease (IBD): 

Assessment of Hepatitis B Virus 

(HBV) Status Before Initiating AntiTNF (Tumor Necrosis Factor) 

Therapy: Percentage of patients aged 18 

years and older with a diagnosis of 

inflammatory bowel disease who had 

Hepatitis B Virus (HBV) status assessed 

and results interpreted within one year 

prior to receiving a first course of antiTNF (tumor necrosis factor) therapy 

AGA X 

N/A/ 

276 

 Clinical 

Process/ 

Effective

ness 

Sleep Apnea: Assessment of Sleep 

Symptoms: Percentage of visits for 

patients aged 18 years and older with a 

diagnosis of obstructive sleep apnea that 

includes documentation of an 

assessment of symptoms, including 

presence or absence of snoring and 

daytime sleepiness 

AMA

- 

PCPI/

NCQ

A 

 X 

N/A/ 

277 

 Clinical 

Process/ 

Effective

ness 

Sleep Apnea: Severity Assessment at 

Initial Diagnosis: Percentage of patients 

aged 18 years and older with a diagnosis 

of obstructive sleep apnea who had an 

apnea hypopnea index (AHI) or a 

respiratory disturbance index (RDI) 

measured at the time of initial diagnosis 

AMA

- 

PCPI/

NCQ

A 

 X 

N/A/ 

278 

 Clinical 

Process/ 

Effective

ness 

Sleep Apnea: Positive Airway 

Pressure Therapy Prescribed: 

Percentage of patients aged 18 years and 

older with a diagnosis of moderate or 

severe obstructive sleep apnea who were 

prescribed positive airway pressure 

therapy 

AMA

- 

PCPI/

NCQ

A 

 X 

N/A/ 

279 

 Clinical 

Process/ 

Sleep Apnea: Assessment of 

Adherence to Positive Airway 

AMA

- 

 X 
1020 

Effective

ness 

Pressure Therapy: Percentage of visits 

for patients aged 18 years and older with 

a diagnosis of obstructive sleep apnea 

who were prescribed positive airway 

pressure therapy who had documentation 

that adherence to positive airway 

pressure therapy was objectively 

measured 

PCPI/

NCQ

A 

N/A/ 

280 

 Care 

Coordinat

ion 

Dementia: Staging of Dementia: 

Percentage of patients, regardless of age, 

with a diagnosis of dementia whose 

severity of dementia was classified as 

mild, moderate or severe at least once 

within a 12 month period 

AMA

-PCPI 

 X 

N/A/ 

281 

 Clinical 

Process/ 

Effective

ness 

Dementia: Cognitive Assessment: 

Percentage of patients, regardless of age, 

with a diagnosis of dementia for whom 

an assessment of cognition is performed 

and the results reviewed at least once 

within a 12 month period 

AMA

-PCPI 

 X MU2 

N/A/ 

282 

 Clinical 

Process/ 

Effective

ness 

Dementia: Functional Status 

Assessment: Percentage of patients, 

regardless of age, with a diagnosis of 

dementia for whom an assessment of 

patient’s functional status is performed 

and the results reviewed at least once 

within a 12 month period 

AMA

-PCPI 

 X 

N/A/ 

283 

 Clinical 

Process/ 

Effective

ness 

Dementia: Neuropsychiatric Symptom 

Assessment: Percentage of patients, 

regardless of age, with a diagnosis of 

dementia and for whom an assessment 

of patient’s neuropsychiatric symptoms 

is performed and results reviewed at 

least once in a 12 month period 

AMA

-PCPI 

 X 

N/A/ 

284 

 Clinical 

Process/ 

Effective

ness 

Dementia: Management of 

Neuropsychiatric Symptoms: 

Percentage of patients, regardless of age, 

with a diagnosis of dementia who have 

one or more neuropsychiatric symptoms 

who received or were recommended to 

receive an intervention for 

neuropsychiatric symptoms within a 12 

month period 

AMA

-PCPI 

 X 

N/A/ 

285 

 Clinical 

Process/ 

Effective

ness 

Dementia: Screening for Depressive 

Symptoms: Percentage of patients, 

regardless of age, with a diagnosis of 

dementia who were screened for 

depressive symptoms within a 12 month 

period 

AMA

-PCPI 

 X 

N/A/ 

286 

 Patient 

Safety 

Dementia: Counseling Regarding 

Safety Concerns: Percentage of 

patients, regardless of age, with a 

AMA

-PCPI 

 X 
1021 

diagnosis of dementia or their 

caregiver(s) who were counseled or 

referred for counseling regarding safety 

concerns within a 12 month period 

N/A/ 

287 

 Clinical 

Process/ 

Effective

ness 

Dementia: Counseling Regarding 

Risks of Driving: Percentage of 

patients, regardless of age, with a 

diagnosis of dementia or their 

caregiver(s) who were counseled 

regarding the risks of driving and the 

alternatives to driving at least once 

within a 12 month period 

AMA

-PCPI 

 X 

N/A/ 

288 

 Clinical 

Process/ 

Effective

ness 

Dementia: Caregiver Education and 

Support: Percentage of patients, 

regardless of age, with a diagnosis of 

dementia whose caregiver(s) were 

provided with education on dementia 

disease management and health behavior 

changes AND referred to additional 

sources for support within a 12 month 

period 

AMA

-PCPI 

 X 

N/A/ 

289 

 Clinical 

Process/ 

Effective

ness 

Parkinson’s Disease: Annual 

Parkinson’s Disease Diagnosis 

Review: All patients with a diagnosis of 

Parkinson’s disease who had an annual 

assessment including a review of current 

medications (e.g., medications than can 

produce Parkinson-like signs or 

symptoms) and a review for the presence 

of atypical features (e.g., falls at 

presentation and early in the disease 

course, poor response to levodopa, 

symmetry at onset, rapid progression [to 

Hoehn and Yahr stage 3 in 3 years], lack 

of tremor or dysautonomia) at least 

annually 

AAN X 

N/A/ 

290 

 Clinical 

Process/ 

Effective

ness 

Parkinson’s Disease: Psychiatric 

Disorders or Disturbances 

Assessment: All patients with a 

diagnosis of Parkinson’s disease who 

were assessed for psychiatric disorders 

or disturbances (e.g., psychosis, 

depression, anxiety disorder, apathy, or 

impulse control disorder) at least 

annually 

AAN X 

N/A/ 

291 

 Clinical 

Process/ 

Effective

ness 

Parkinson’s Disease: Cognitive 

Impairment or Dysfunction 

Assessment: All patients with a 

diagnosis of Parkinson’s disease who 

were assessed for cognitive impairment 

or dysfunction at least annually 

AAN X 

N/A/ Clinical Parkinson’s Disease: Querying about AAN X 
1022 

292 Process/ 

Effective

ness 

Sleep Disturbances: All patients with a 

diagnosis of Parkinson’s disease (or 

caregivers, as appropriate) who were 

queried about sleep disturbances at least 

annually 

N/A/ 

293 

 Clinical 

Process/ 

Effective

ness 

Parkinson’s Disease: Rehabilitative 

Therapy Options: All patients with a 

diagnosis of Parkinson’s disease (or 

caregiver(s), as appropriate) who had 

rehabilitative therapy options (e.g., 

physical, occupational, or speech 

therapy) discussed at least annually 

AAN X 

N/A/ 

294 

 Clinical 

Process/ 

Effective

ness 

Parkinson’s Disease: Parkinson’s 

Disease Medical and Surgical 

Treatment Options Reviewed: All 

patients with a diagnosis of Parkinson’s 

disease (or caregiver(s), as appropriate 

who had the Parkinson’s disease 

treatment options (e.g., nonpharmacological treatment, 

pharmacological treatment, or surgical 

treatment) reviewed at least once 

annually 

AAN X 

N/A/ 

295 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Appropriate Use of 

Aspirin or Other Antithrombotic 

Therapy: Percentage of patients aged 30 

through 90 years old with a diagnosis of 

hypertension and are eligible for asprin 

or other antithrombotic therapy who 

were prescribed aspirin or other 

antithrombotic therapy 

ABI

M 

 X 

N/A/ 

296 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Complete Lipid 

Profile: Percentage of patients aged 18 

through 90 years old with a diagnosis of 

hypertension who received a complete 

lipid profile within 60 months

ABI

M 

 X 

N/A/ 

297 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Urine Protein Test: 

Percentage of patients aged 18 through 

90 years old with a diagnosis of 

hypertension who either have chronic 

kidney disease diagnosis documented or 

had a urine protein test done within 36 

months

ABI

M 

 X 

N/A/ 

298 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Annual Serum 

Creatinine Test: Percentage of patients 

aged 18 through 90 years old with a 

diagnosis of hypertension who had a 

serum creatinine test done within 12 

months

ABI

M 

 X 

N/A/ 

299 

 Clinical 

Process/ 

Effective

Hypertension: Diabetes Mellitus 

Screening Test: Percentage of patients 

aged 18 through 90 years old with a 

ABI

M 

 X 
1023 

ness diagnosis of hypertension who had a 

diabetes screening test within 36 months

N/A/ 

300 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Blood Pressure 

Control: Percentage of patients aged 18 

through 90 years old with a diagnosis of 

hypertension who had most recent blood 

pressure level under control (at goal) 

ABI

M 

 X 

N/A/ 

301 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Low Density 

Lipoprotein (LDL-C) Control: 

Percentage of patients aged 18 through 

90 years old with a diagnosis of 

hypertension who had most recent LDL 

cholesterol level under control (at goal) 

ABI

M 

 X 

N/A/ 

302 

 Clinical 

Process/ 

Effective

ness 

Hypertension: Dietary and Physical 

Activity Modifications Appropriately 

Prescribed: Percentage of patients aged 

18 through 90 years old with a diagnosis 

of hypertension who received dietary 

and physical activity counseling at least 

once within 12 months

ABI

M 

 X 

N/A/ 

303 

 Clinical 

Process/ 

Effective

ness 

Cataracts: Improvement in Patient’s 

Visual Function within 90 Days 

Following Cataract Surgery: 

Percentage of patients aged 18 years and 

older in sample who had cataract surgery 

and had improvement in visual function 

achieved within 90 days following the 

cataract surgery, based on completing a 

pre-operative and post-operative visual 

function survey 

AAO X X 

N/A/ 

304 

 Patient 

and 

Family 

Engagem

ent 

Cataracts: Patient Satisfaction within 

90 Days Following Cataract Surgery: 

Percentage of patients aged 18 years and 

older in sample who had cataract surgery 

and were satisfied with their care within 

90 days following the cataract surgery, 

based on completion of the Consumer 

Assessment of Healthcare Providers and 

Systems Surgical Care Survey 

AAO X X 

0004/ 

305 

 Clinical 

Process/ 

Effective

ness 

Initiation and Engagement of Alcohol 

and Other Drug Dependence 

Treatment: (a) Initiation, (b) 

Engagement: Percentage of adolescent 

and adult patients with a new episode of 

alcohol or other drug (AOD) dependence 

who initiate treatment through an 

inpatient AOD admission, outpatient 

visit, intensive outpatient encounter or 

partial hospitalization within 14 days of 

the diagnosis and who initiated treatment 

AND who had two or more additional 

services with an AOD diagnosis within 

NCQ

A 

 X MU1/ 

MU2 
1024 

30 days of the initial visit 

0012/ 

306 

◊ Populatio

n/Public 

Health 

Prenatal Care: Screening for Human 

Immunodeficiency Virus (HIV): 

Percentage of patients, regardless of age, 

who gave birth during a 12-month 

period who were screened for HIV 

infection during the first or second 

prenatal visit 

AMA

-PCPI 

 X MU1 

0014/ 

307 

◊ Patient 

Safety 

Prenatal Care: Anti-D Immune 

Globulin: Percentage of D (Rh) 

negative, unsensitized patients, 

regardless of age, who gave birth during 

a 12-month period who received anti-D 

immune globulin at 26-30 weeks 

gestation 

AMA

-PCPI 

 X MU1 

0027/ 

308 

◊ Populatio

n/Public 

Health 

Smoking and Tobacco Use Cessation, 

Medical Assistance: a. Advising 

Smokers and Tobacco Users to Quit, 

b. Discussing Smoking and Tobacco 

Use Cessation Medications, c. 

Discussing Smoking and Tobacco Use 

Cessation Strategies: Percentage of 

patients aged 18 years and older who 

were current smokers or tobacco users, 

who were seen by a practitioner during 

the measurement year and who received 

advice to quit smoking or tobacco use or 

whose practitioner recommended or 

discussed smoking or tobacco use 

cessation medications, methods or 

strategies 

NCQ

A 

 X MU1 

0032/ 

309 

 Clinical 

Process/ 

Effective

ness 

Cervical Cancer Screening: Percentage 

of women aged 21 through 63 years who 

received one or more Pap tests to screen 

for cervical cancer 

NCQ

A 

 X MU1/ 

MU2 

0033/ 

310 

 Populatio

n/Public 

Health 

Chlamydia Screening for Women: 

Percentage of women aged 15 through 

24 years who were identified as sexually 

active and who had at least one test for 

chlamydia during the measurement year 

NCQ

A 

 X MU1/ 

MU2 

0036/ 

311 

 Clinical 

Process/ 

Effective

ness 

Use of Appropriate Medications for 

Asthma: Percentage of patients aged 5 

through 50 years of age who were 

identified as having persistent asthma 

and were appropriately prescribed 

medication during the measurement year 

NCQ

A 

 X MU1/ 

MU2 

0052/ 

312 

 Efficient 

Use of 

Healthcar

e 

Resource

s 

Low Back Pain: Use of Imaging 

Studies: Percentage of patients with a 

primary diagnosis of low back pain who 

did not have an imaging study (plain Xray, MRI, CT scan) within 28 days of 

diagnosis 

NCQ

A 

 X MU1/ 

MU2 
1025 

0575/ 

313 

◊ Clinical 

Process/ 

Effective

ness 

Diabetes Mellitus: Hemoglobin A1c 

Control (< 8%): The percentage of 

patients 18 through 75 years of age with 

a diagnosis of diabetes (type 1 or type 2) 

who had HbA1c < 8% 

NCQ

A 

 X MU1 

N/A/ 

316 

 Clinical 

Process/ 

Effective

ness 

Preventive Care and Screening: 

Cholesterol – Fasting Low Density 

Lipoprotein (LDL) Test Performed 

AND Risk-Stratified Fasting LDL: 

Percentage of patients aged 20 through 

79 years whose risk factors* have been 

assessed and a fasting LDL test has been 

performed 

*There are three criteria for this measure 

based on the patient’s risk category. 

1. Highest Level of Risk: Coronary 

Heart Disease (CHD) or CHD Risk 

Equivalent 

2. Moderate Level of Risk: Multiple 

(2+) Risk Factors 

3. Lowest Level of Risk: 0 or 1 Risk 

Factor 

CMS/

QIP 

 X MU2 

Million 

Hearts 

N/A/ 

317 

 Populatio

n/Public 

Health 

Preventive Care and Screening: 

Screening for High Blood Pressure 

and Follow-Up Documented: 

Percentage of patients aged 18 years and 

older seen during the reporting period 

who were screened for high blood 

pressure (BP) AND a recommended 

follow-up plan is documented based on 

the current blood pressure reading as 

indicated 

CMS/

QIP 

X X X X X MU2 

ACO 

Million 

Hearts 

0101/ 

318 

 Patient 

Safety 

Falls: Screening for Future Fall Risk: 

Percentage of patients aged 65 years and 

older who were screened for future fall 

risk at least once within the reporting 

period 

AMA

- 

PCPI/

NCQ

A 

 X MU2 

ACO 

0729/ 

TBD 

‡ Clinical 

Process/ 

Effective

ness 

Diabetes Composite: Optimal 

Diabetes Care: Patients ages 18 through 

75 with a diagnosis of diabetes, who 

meet all the numerator targets of this 

composite measure: 

• A1c < 8.0%, 

• LDL < 100 mg/dL, 

• blood pressure < 140/90 mmHg, 

• tobacco non-user and 

• for patients with a diagnosis of 

ischemic vascular disease daily 

aspirin use unless 

contraindicated

MNC

M 

 X ACO 

0658/ 

TBD 

‡ Care 

Coordinat

Endoscopy/Polyp Surveillance: 

Appropriate Follow-Up Interval for 

AMA

-PCPI 

X X 
1026 

ion Normal Colonoscopy in Average Risk 

Patients: Percentage of patients aged 50 

years and older receiving a screening 

colonoscopy without biopsy or 

polypectomy who had a recommended 

follow-up interval of at least 10 years for 

repeat colonoscopy documented in their 

colonoscopy report

0493/ 

TBD 

‡ Care 

Coordinat

ion 

Participation by a Hospital, Physician 

or Other Clinician in a Systematic 

Clinical Database Registry that 

Includes Consensus Endorsed 

Quality: Participation in a systematic 

qualified clinical database registry 

involves: 

a. Physician or other clinician submits 

standardized data elements to registry. 

b. Data elements are applicable to 

consensus endorsed quality measures. 

c. Registry measures shall include at 

least two (2) representative NQF 

consensus endorsed measures for 

registry's clinical topic(s) and report on 

all patients eligible for the selected 

measures. 

d. Registry provides calculated measures 

results, benchmarking, and quality 

improvement information to individual 

physicians and clinicians. 

e. Registry must receive data from more 

than 5 separate practices and may not be 

located (warehoused) at an individual 

group’s practice. Participation in a 

national or state-wide registry is 

encouraged for this measure. 

f. Registry may provide feedback 

directly to the provider’s local registry if 

one exists.

OFM

Q 

X X 

0005

& 

0006/ 

TBD 

‡ Care 

Coordinat

ion 

CG-CAHPS Clinician/Group Survey 

• Getting timely care, 

appointments and information 

• How well your doctors 

communicate 

• Patients rating of doctor 

• Access to specialists 

• Health promotion and education 

• Shared decision making 

• Health status/Functional status 

ASPE X ACO 

0670/ 

TBD 

‡ Efficient 

Use of 

Healthcar

e 

Cardiac Stress Imaging Not Meeting 

Appropriate Use Criteria: 

Preoperative Evaluation in Low-Risk 

Surgery Patients: Percentage of stress 

 ACC X 
1027 

Resource

s 

single-photon emission computed 

tomography (SPECT) myocardial 

perfusion imaging (MPI), stress 

echocardiogram (ECHO), cardiac 

computed tomography angiography 

(CCTA), or cardiac magnetic resonance 

(CMR) performed in low risk surgery 

patients 18 years or older for 

preoperative evaluation during the 12-

month reporting period

0671/ 

TBD 

‡ Efficient 

Use of 

Healthcar

e 

Resource

s 

Cardiac Stress Imaging Not Meeting 

Appropriate Use Criteria: Routine 

Testing After Percutaneous Coronary 

Intervention (PCI): Percentage of all 

stress single-photon emission computed 

tomography (SPECT) myocardial 

perfusion imaging (MPI), stress 

echocardiogram (ECHO), cardiac 

computed tomography angiography 

(CCTA), and cardiovascular magnetic 

resonance (CMR) performed in patients 

aged 18 years and older routinely after 

percutaneous coronary intervention 

(PCI), with reference to timing of test 

after PCI and symptom status 

ACC X 

0672/ 

TBD 

‡ Efficient 

Use of 

Healthcar

e 

Resource

s 

Cardiac Stress Imaging Not Meeting 

Appropriate Use Criteria: Testing in 

Asymptomatic, Low-Risk Patients: 

Percentage of all stress single-photon 

emission computed tomography 

(SPECT) myocardial perfusion imaging 

(MPI), stress echocardiogram (ECHO), 

cardiac computed tomography 

angiography (CCTA), and 

cardiovascular magnetic resonance 

(CMR) performed in asymptomatic, low 

coronary heart disease (CHD) risk 

patients 18 years and older for initial 

detection and risk assessment

ACC X 

TBD/ 

TBD 

‡ Clinical 

Process/ 

Effective

ness 

Adult Major Depressive Disorder 

(MDD): Coordination of Care of 

Patients with Specific Comorbid 

Conditions: Percentage of medical 

records of patients aged 18 years and 

older with a diagnosis of major 

depressive disorder (MDD) and a 

specific diagnosed comorbid condition 

(diabetes, coronary artery disease, 

ischemic stroke, intracranial 

hemorrhage, chronic kidney disease 

[stages 4 or 5], ESRD or congestive 

heart failure) being treated by another 

AMA

-PCPI 

 X 
1028 

clinician with communication to the 

other clinician treating the comorbid 

condition 

1525/ 

TBD 

‡ Patient 

Safety 

Atrial Fibrillation and Atrial Flutter: 

Chronic Anticoagulation Therapy: 

Patients aged 18 and older with a 

diagnosis of nonvalvular AF or atrial 

flutter whose assessment of specified 

thromboembolic risk factors indicate one 

or more high-risk factors or more than 

one moderate risk factor, as determined 

by CHADS2 risk stratification, who are 

prescribed warfarin OR another oral 

anticoagulant drug that is FDA approved 

for the prevention of thromboembolism

AMA

-

PCPI/

ACC

F/AH

A 

X X 

TBD/ 

TBD 

‡ Clinical 

Process/ 

Effective

ness 

Pediatric Kidney Disease: Adequacy 

of Volume Management: Percentage of 

calendar months within a 12-month 

period during which patients aged 17 

years and younger with a diagnosis of 

End Stage Renal Disease (ESRD) 

undergoing maintenance hemodialysis in 

an outpatient dialysis facility have an 

assessment of the adequacy of volume 

management from a nephrologist 

AMA X X 

1667/ 

TBD 

‡ Clinical 

Process/ 

Effective

ness 

Pediatric Kidney Disease: ESRD 

Patients Receiving Dialysis: 

Hemoglobin Level < 10 g/dL: 

Percentage of calendar months within a 

12-month period during which patients 

aged 17 years and younger with a 

diagnosis of End Stage Renal Disease 

(ESRD) receiving hemodialysis or 

peritoneal dialysis have a hemoglobin 

level < 10 g/dL

AMA

-PCPI 

X X 

N/A/ 

TBD 

○ Care 

Coordinat

ion 

Total Knee Replacement: 

Coordination of Post Discharge Care: 

Percentage of patients undergoing total 

knee replacement who received written 

instructions for post discharge care 

including all the following: post 

discharge physical therapy, home health 

care, post discharge deep vein 

thrombosis (DVT) prophylaxis and 

follow-up physician visits

AAH

KS/A

MAPCPI 

 X 

N/A/ 

TBD 

○ Patient 

Safety 

Total Knee Replacement: Venous 

Thromboembolic and Cardiovascular 

Risk Evaluation: Percentage of patients 

undergoing a total knee replacement 

who are evaluated for the presence or 

absence of venous thromboembolic and 

cardiovascular risk factors within 30 

AAH

KS/A

MAPCPI 

 X 
1029 

days prior to the procedure including 

history of deep vein thrombosis (DVT), 

pulmonary embolism (PE), myocardial 

infarction (MI), arrhythmia and stroke

N/A/ 

TBD 

○ Patient 

Safety 

Total Knee Replacement: 

Preoperative Antibiotic Infusion with 

Proximal Tourniquet: Percentage of 

patients undergoing a total knee 

replacement who had the prophylactic 

antibiotic completely infused prior to the 

inflation of the proximal tourniquet

AAH

KS/A

MAPCPI) 

 X 

N/A/ 

TBD 

○ Patient 

Safety 

Total Knee Replacement: 

Identification of Implanted Prosthesis 

in Operative Report: Percentage of 

patients undergoing total knee 

replacement whose operative report 

identifies the prosthetic implant 

specifications including the prosthetic 

implant manufacturer, the brand name of 

prosthetic implant and the size of 

prosthetic implant

AAH

KS/A

MAPCPI 

 X 

TBD/ 

TBD 

○ Care 

Coordinat

ion 

Optimizing Patient Exposure to 

Ionizing Radiation: Utilization of a 

Standardized Nomenclature for CT 

Imaging Description: Percentage of 

computed tomography (CT) imaging 

reports for all patients, regardless of age, 

with the imaging study named according 

to a standardized nomenclature (e.g., 

RadLex®) and the standardized 

nomenclature is used in institutions 

computer systems

AMA

-PCPI 

 X 

TBD/ 

TBD 

○ Patient 

Safety 

Optimizing Patient Exposure to 

Ionizing Radiation : Count of 

Potential High Dose Radiation 

Imaging Studies: Computed 

Tomography (CT) Scans and Cardiac 

Nuclear Medicine Scans: Percentage of 

CT and cardiac nuclear medicine

(myocardial perfusion studies) imaging 

reports for all patients, regardless of age,

that document a count of known 

previous CT studies (any type of CT) 

and cardiac nuclear medicine 

(myocardial perfusion studies) studies 

that the patient has received in the 12-

month period prior to the current study

AMA

-PCPI 

 X 

TBD/ 

TBD 

○ Patient 

Safety 

Optimizing Patient Exposure to 

Ionizing Radiation: Reporting to a 

Radiation Dose Index Registry:

Percentage of total computed 

tomography (CT) studies performed for 

AMA

-PCPI 

 X 
1030 

all patients, regardless of age, that are 

reported to a radiation dose index 

registry AND that include at a minimum 

selected data elements

TBD/ 

TBD 

○ Care 

Coordinat

ion 

Optimizing Patient Exposure to 

Ionizing Radiation: CT Images 

Available for Patient Follow-up and 

Comparison Purposes: Percentage of 

final reports for computed tomography 

(CT) studies performed for all patients, 

regardless of age, which document that 

Digital Imaging and Communications in 

Medicine (DICOM) format image data 

are available to non-affiliated external 

entities on a secure, media free, 

reciprocally searchable basis with 

patient authorization for at least a 12-

month period after the study

AMA

-PCPI 

 X 

TBD/ 

TBD 

○ Care 

Coordinat

ion 

Optimizing Patient Exposure to 

Ionizing Radiation: Search for Prior 

Imaging Studies Through a Secure, 

Authorized, Media-Free, Shared 

Archive: Percentage of final reports of 

computed tomography (CT) studies 

performed for all patients, regardless of 

age, which document that a search for 

Digital Imaging and Communications in 

Medicine (DICOM) format images was 

conducted for prior patient imaging 

studies completed at non-affiliated 

external entities within the past 12-

months and are available through a 

secure, authorized, media free, shared 

archive prior to an imaging study being 

performed

AMA

-PCPI 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Osteoporosis: Status of Participation 

in Weight-Bearing Exercise and 

Weight-bearing Exercise Advice: 

Percentage of patients aged 18 and older 

with a diagnosis of osteoporosis, 

osteopenia, or prior low impact fracture; 

women age 65 and older; or men age 70 

and older whose status regarding 

participation in weight-bearing exercise 

was documented and for those not 

participating regularly who received 

advice within 12 months to participate in 

weight-bearing exercise

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Osteoporosis: Current Level of 

Alcohol Use and Advice on Potentially 

Hazardous Drinking Prevention: 

Percentage of patients aged 18 and older 

ABI

M 

 X 
1031 

with a diagnosis of osteoporosis, 

osteopenia, or prior low impact fracture; 

women age 65 and older; or men age 70 

and older whose current level of alcohol 

use was documented and for those 

engaging in potentially hazardous 

drinking who received counseling within 

12 months

N/A/ 

TBD 

○ Patient 

Safety 

Osteoporosis: Screen for Falls Risk 

Evaluation and Complete Falls Risk 

Assessment and Plan of Care:

Percentage of patients aged 18 and older 

with a diagnosis of osteoporosis, 

osteopenia, or prior low impact fracture; 

women age 65 and older; or men age 70 

and older who had a screen for falls risk 

evaluation within the past 12 months and 

for those reported as having a history of 

two or more falls, or fall-related injury 

who had a complete risk assessment for 

falls and a falls plan of care within the 

past 12 months

ABI

M 

 X 

N/A/ 

TBD 

○ Care 

Coordinat

ion 

Osteoporosis: Dual-Emission X-ray 

Absorptiometry (DXA) Scan:

Percentage of patients aged 18 and older 

with a diagnosis of osteoporosis, 

osteopenia, or prior low impact fracture; 

women age 65 and older; or men age 70 

and older who had a DXA scan and 

result documented

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Osteoporosis: Calcium Intake 

Assessment and Counseling: 

Percentage of patients aged 18 and older 

with a diagnosis of osteoporosis, 

osteopenia, or prior low impact fracture; 

women age 65 and older; or men age 70 

and older who had calcium intake 

assessment and counseling at least once 

within 12 months

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Osteoporosis: Vitamin D Intake 

Assessment and Counseling: 

Percentage of patients aged 18 and older 

with a diagnosis of osteoporosis, 

osteopenia, or prior low impact fracture; 

women age 65 and older; or men age 70 

and older who had vitamin D intake 

assessment and counseling at least once

within 12 months

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Osteoporosis: Pharmacologic 

Therapy: Percentage of patients aged 18 

and older with a diagnosis of 

osteoporosis, osteopenia, or prior low 

ABI

M 

 X 
1032 

impact fracture; women age 65 and 

older; or men age 70 and older who were 

prescribed pharmacologic therapy 

approved by the Food and Drug 

Administration

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Blood Pressure at Goal: Percentage of 

patients in the sample whose most recent 

blood pressure reading was at goal

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Low Density Lipids (LDL) Cholesterol 

at Goal: Percentage of patients in the 

sample whose LDL cholesterol is 

considered to be at goal, based upon 

their coronary heart disease (CHD) risk 

factors

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Timing of Lipid Testing Complies 

with Guidelines: Percentage of patients 

in the sample whose timing of lipid 

testing complies with guidelines (lipid 

testing performed in the preceding 12-

month period (with a 3-month grace 

period) for patients with known 

coronary heart disease (CHD) or CHD 

risk equivalent (prior myocardial 

infarction (MI), other clinical CHD, 

symptomatic carotid artery disease, 

peripheral artery disease, abdominal 

aortic aneurysm, diabetes mellitus); or in 

the preceding 24-month period (with a 

3-month grace period) for patients with 

> 2 risk factors for CHD (smoking, 

hypertension, low high density lipid 

(HDL), men > 45 years, women > 55 

years, family history of premature CHD; 

HDL > 60 mg/dL acts as a negative risk 

factor); or in the preceding 60-month 

period (with a 3-month grace period) for 

patients with < 1 risk factor for CHD)

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Diabetes Documentation or Screen 

Test: Percentage of patients in the 

sample who had a screening test for type 

2 diabetes or had a diagnosis of diabetes

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Correct Determination of Ten-Year 

Risk for Coronary Death or 

Myocardial Infarction (MI): Number 

of patients in the sample whose ten-year 

risk of coronary death or MI is correctly 

assessed and documented

ABI

M 

 X 
1033 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Counseling for Diet and Physical 

Activity: Percentage of patients in the 

sample who received dietary and 

physical activity counseling

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Appropriate Use of Aspirin or Other 

Antiplatelet/Anticoagulant Therapy: 

Percentage of patients in the sample who 

are: 1) taking aspirin or other 

anticoagulant/antiplatelet therapy, or 2) 

under age 30, or 3) age 30 or older and 

who are documented to be at low risk. 

Low-risk patients include those who are 

documented with no prior coronary heart 

disease (CHD) or CHD risk equivalent 

(prior myocardial infarction (MI), other 

clinical CHD, symptomatic carotid 

artery disease, peripheral artery disease, 

abdominal aortic aneurysm, diabetes 

mellitus) and whose ten-year risk of 

developing CHD is < 10%

ABI

M 

 X 

N/A/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Preventive Cardiology Composite: 

Smoking Status and Cessation 

Support: Percentage of patients in the 

sample whose current smoking status is 

documented in the chart, and if they 

were smokers, were documented to have 

received smoking cessation counseling 

during the reporting period

ABI

M 

 X 

0060/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Hemoglobin A1c Test for Pediatric 

Patients: Percentage of pediatric 

patients 5-17 years of age with diabetes 

with a HbA1c test during the 

measurement period

NCQ

A 

 X MU2 

0108/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

ADHD: Follow-Up Care for Children 

Prescribed AttentionDeficit/Hyperactivity Disorder 

(ADHD) Medication: Percentage of 

children 6-12 years of age and newly 

dispensed a medication for attentiondeficit/hyperactivity disorder (ADHD) 

who had appropriate follow-up care. 

Two rates are reported. 

A. Percentage of children who had one 

follow-up visit with a practitioner with 

prescribing authority during the 30-Day 

Initiation Phase. 

B. Percentage of children who remained 

on ADHD medication for at least 210 

days and who, in addition to the visit in 

the Initiation Phase, had at least two 

NCQ

A 

 X MU2 
1034 

additional follow-up visits with a 

practitioner within 270 days (9 months) 

after the Initiation Phase ended.

0110/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Bipolar Disorder and Major 

Depression: Appraisal for alcohol or 

chemical substance use: Percentage of 

patients with depression or bipolar 

disorder with evidence of an initial 

assessment that includes an appraisal for 

alcohol or chemical substance use

Cente

r for 

Qualit

y 

Asses

sment 

and 

Impro

veme

nt in 

Menta

l 

Healt

h 

 X MU2 

0403/ 

TBD 

○ Efficient 

Use of 

Healthcar

e 

Resource

s 

HIV/AIDS: Medical Visit: Percentage 

of patients, regardless of age, with a 

diagnosis of HIV/AIDS with at least two 

medical visits during the measurement 

year with a minimum of 60 days 

between each visit

AMA

/NCQ

A 

 X MU2 

0608/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Pregnant women that had HBsAg 

testing: This measure identifies 

pregnant women who had a HBsAg 

(hepatitis B) test during their pregnancy

Ingeni

x 

 X MU2 

0710/

TBD 

○ Clinical 

Process/ 

Effective

ness 

Depression Remission at Twelve 

Months: Adult patients age 18 and older 

with major depression or dysthymia and 

an initial PHQ-9 score > 9 who 

demonstrate remission at 12 months 

defined as PHQ-9 score less than 5. 

This measure applies to both patients 

with newly diagnosed and existing 

depression whose current PHQ-9 score 

indicates a need for treatment

MNC

M 

 X MU2 

0712/ 

TBD 

○ Clinical 

Process/ 

Effective

ness 

Depression Utilization of the PHQ-9 

Tool: Adult patients age 18 and older 

with the diagnosis of major depression 

or dysthymia who have a PHQ-9 tool 

administered at least once during a 4 

month period in which there was a 

qualifying visit

MNC

M 

 X MU2 

1401/ 

TBD 

○ Populati

on/Public 

Health 

Maternal depression screening: The 

percentage of children who turned 6 

months of age during the measurement 

year, who had a face-to-face visit 

between the clinician and the child 

during child’s first 6 months, and who 

had a maternal depression screening for 

the mother at least once between 0 and 6 

NCQ

A 

 X MU2 
1035 

months of life

Not 

yet 

endor

sed/ 

TBD 

○ Clinical 

Process/E

ffectivene

ss 

Hypertension: Improvement in blood 

pressure: Percentage of patients aged 

18-85 years of age with a diagnosis of 

hypertension whose blood pressure 

improved during the measurement 

period

CMS X MU2 

Not 

yet 

endor

sed/ 

TBD 

○ Care 

Coordinat

ion 

Closing the referral loop: receipt of 

specialist report: Percentage of patients 

with referrals, regardless of age, for 

which the referring provider receives a 

report from the provider to whom the 

patient was referred

CMS X MU2 

Not 

yet 

endor

sed/ 

TBD 

○ Patient 

and 

Family 

Engagem

ent 

Functional status assessment for knee 

replacement: Percentage of patients 

aged 18 years and older with primary 

total knee arthroplasty (TKA) who 

completed baseline and follow-up 

(patient-reported) functional status 

assessments

CMS X MU2 

Not 

yet 

endor

sed/ 

TBD 

○ Patient 

and 

Family 

Engagem

ent 

Functional status assessment for hip 

replacement: Percentage of patients 

aged 18 years and older with primary 

total hip arthroplasty (THA) who 

completed baseline and follow-up 

(patient-reported) functional status 

assessments

CMS X MU2 

Not 

yet 

endor

sed/ 

TBD 

○ Patient 

and 

Family 

Engagem

ent 

Functional status assessment for 

complex chronic conditions: 

Percentage of patients aged 65 years and 

older with heart failure who completed 

initial and follow-up patient-reported 

functional status assessments

CMS X MU2 

TBD/

TBD 

○ Clinical 

Process/ 

Effective

ness 

Children who have dental decay or 

cavities: Percentage of children ages 0-

20, who have had tooth decay or cavities 

during the measurement period

Mater

nal 

and 

Child 

Healt

h 

Burea

u, 

Healt

h 

Resou

rces 

and 

Servic

es 

 X MU2 

TBD/

TBD 

○ Clinical 

Process/ 

Effective

ness 

Primary Caries Prevention 

Intervention as Offered by Primary 

Care Providers, including Dentists: 

Percentage of children, age 0-20 years, 

Unive

rsity 

of 

Minn

 X MU2 
1036 

who received a fluoride varnish 

application during the measurement 

period

esota 

TBD/

TBD 

○ Patient 

Safety 

ADE Prevention and Monitoring: 

Warfarin Time in Therapeutic Range: 

Average percentage of time in which 

individuals with atrial fibrillation who 

are on chronic anticoagulation have 

International Normalized Ratio (INR) 

test results within the therapeutic range 

during the measurement period

CMS X MU2 

* MU1 refers to CQMs included in the EHR Incentive Program – Stage 1 Final Rule for reporting in 2011-2013. 

MU2 refers to CQMs included in the EHR Incentive Program – Stage 2 Final Rule for reporting beginning in 2014 

 

(3) PQRS Quality Measures Available for Group Practices Using the GPRO Web interface 

 We have previously discussed our measure proposals for group practices using the GPRO 

web interface in the proposed rule (77 FR 44954). A summary of these proposed measures for 

group practices using the GPRO web interface can be found in Table 35 of the CY 2013 PFS 

proposed rule (77 FR 44960). We proposed (77 FR 44959) 18 measures – including 2 composite 

measures for diabetes (5 component measures) and CAD (2 component measures), for a total of 

22 measures – for reporting under the PQRS using the GPRO web interface for 2013 and 

beyond to align with the quality measures available for reporting under the Medicare Shared 

Savings Program (76 FR 67890). Because of our desire to align with measures available for 

reporting under the Medicare Shared Savings Program, we did not propose to retain the 13 

measures specified in Table 36 of the CY 2013 PFS proposed rule for purpose of reporting via 

the GPRO web interface beginning in 2013 (77 FR 44963). We invited public comment on the 

proposed PQRS quality measures available for reporting under the GPRO web interface for 2013 

and beyond. We did not receive public comment on a majority of the measures we proposed for 

reporting in the GPRO web interface. The following is a summary of the comments we did 

receive regarding the proposed measures for the GPRO web interface: 

 Comment: Several commenters supported our overall proposal to align the measures 
1037 

available for reporting in the GPRO web interface with the measures that are available for 

reporting under the Medicare Shared Savings Program. 

 Response: We appreciate the commenters’ support and are moving forward with our 

proposals to align the measures available for reporting in the GPRO web interface with the 

measures that are available for reporting under the Medicare Shared Savings Program. Therefore, 

mainly due to our desire to align measures available under PQRS and the Medicare Shared 

Savings Program, as indicated in Table 96 of this final rule, we are finalizing the 18 measures – 

which includes 2 composites, for a total of 22 measures --- we proposed to be available for 

reporting via the GPRO web interface and not retaining 13 measures that were previously 

available for reporting under the GPRO web interface in 2012. 

 We also proposed to have the following measure available for reporting occurring in 

2013 and beyond: CG-CAHPS Clinician/Group Survey: Getting timely care, appointments and 

information; How well your doctors communicate; Patients rating of doctor; Access to 

specialists; Health promotion and education; Shared decision making; Courteous and helpful 

office staff; Care coordination; Between visit communication; Educating patients about 

medication adherences; and Stewardship of patient resources (77 FR 44964). 

 Comment: One commenter noted that the proposed CAHPS measures do not apply to 

hospital-based physicians and encouraged PQRS to incorporate measures that reflect care 

provided by all types of physicians. 

 Response: We believe that PQRS measures should be broadly applicable to eligible 

professionals of varying practices. Therefore, we are not excluding hospital-based physicians 

from reporting the CAHPS measures, as we believe these CAHPS measures may be relevant to 

the practice of hospital-based physicians. 

 Comment: One commenter requested that our proposal to report the CG-CAHPS survey 
1038 

measure under the GPRO web interface be made voluntary as the survey is expensive to 

administer. 

 Response: We understand the commenter's concern regarding the expense of 

administering the CG-CAHPS survey. However, we require group practices using the GPRO 

web interface to report on all measures available under the GPRO web interface. As this CGCAHPS survey is part of the GPRO web interface, it will be mandatory for group practices using 

the GPRO web interface to also be held accountable for the survey results. We are developing a 

process, however, to standardize the administration of the survey, which should help lower the 

cost. We note that this survey measure requires a different form of data collection and analysis 

than the other proposed measures in the PQRS. Therefore, for these measures only, CMS 

intends to administer the survey on behalf of the group practices participating in the 2013 and 

2014 PQRS GPRO. In other words, CMS initially intends to fund data collection for this 

measure on group practices’ behalf for the CYs 2013 and 2014 reporting periods. 

 The final measures available for reporting using the GPRO web interface beginning in 

2013 and listed in Table 96: 

Table 96: PQRS Quality Measures Available for Reporting for Group Practices Using the 

GPRO Web Interface for 2013 and Beyond 

NQF/ PQRS 

GPRO 

Disease 

Module 

National 

Quality 

Strategy 

Domain Measure and Title Description¥

Measure Steward Other Quality Reporting Programs 

0059/ 

1 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectiven

ess 

Diabetes: Hemoglobin A1c Poor Control:

Percentage of patients aged 18 through75 years 

of age with diabetes mellitus who had most 

recent hemoglobin A1c greater than 9.0% 

NCQA HITECH 

ACO 

0083/ 

8 

Heart 

Failure 

Clinical 

Process/ 

Effectiven

Heart Failure (HF): Beta-Blocker Therapy 

for Left Ventricular Systolic Dysfunction 

(LVSD): Percentage of patients aged 18 years 

AMAPCPI/

ACCF

HITECH 

ACO 
1039 

ess and older with a diagnosis of heart failure (HF) 

with a current or prior left ventricular ejection 

fraction (LVEF) < 40% who were prescribed 

beta-blocker therapy either within a 12 month 

period when seen in the outpatient setting OR 

at each hospital discharge 

/AHA 

0097/ 

46 

Care 

Coordin

ation/ 

Patient 

Safety 

Patient 

Safety 

Medication Reconciliation: Percentage of 

patients aged 65 years and older discharged 

from any inpatient facility (e.g. hospital, 

skilled nursing facility, or rehabilitation 

facility) and seen within 60 days following 

discharge in the office by the physician 

providing on-going care who had a 

reconciliation of the discharge medications 

with the current medication list in the 

outpatient medical record documented 

AMAPCPI/

NCQA

ACO 

0041/ 

110 

Preventi

ve Care 

Population

/Public 

Health 

Preventive Care and Screening: Influenza 

Immunization: Percentage of patients aged 6 

months and older seen for a visit between 

October 1 and March 31 who received an 

influenza immunization OR who reported 

previous receipt of an influenza immunization 

AMAPCPI HITECH 

ACO 

0043/ 

111 

Preventi

ve Care 

Clinical 

Process/ 

Effectiven

ess 

Pneumococcal Vaccination Status for Older 

Adults: Percentage of patients aged 65 years 

and older who have ever received a 

pneumococcal vaccine 

NCQA HITECH 

ACO 

0031/ 

112 

Preventi

ve Care 

Clinical 

Process/ 

Effectiven

ess 

Preventive Care and Screening: Breast 

Cancer Screening: Percentage of women aged 

40 through69 years who had a mammogram to 

screen for breast cancer within 24 months 

NCQA HITECH 

ACO 

0034/ 

113 

Preventi

ve Care 

Clinical 

Process/ 

Effectiven

ess 

Colorectal Cancer Screening: Percentage of 

patients aged 50 through75 years who received 

the appropriate colorectal cancer screening 

NCQA HITECH 

ACO 

0066/ 

118 

Coronar

y Artery 

Disease 

Clinical 

Process/ 

Effectiven

ess 

Coronary Artery Disease (CAD): 

Angiotensin-converting Enzyme (ACE) 

Inhibitor or Angiotensin Receptor Blocker 

(ARB) Therapy -- Diabetes or Left 

Ventricular Systolic Dysfunction (LVEF < 

40%): Percentage of patients aged 18 years 

and older with a diagnosis of coronary artery 

disease seen within a 12 month period who 

also have diabetes OR a current or prior Left 

Ventricular Ejection Fraction (LVEF) < 40% 

who were prescribed ACE inhibitor or ARB 

therapy 

AMAPCPI/

ACCF

/AHA 

ACO 

0421/ 

128 

Preventi

ve Care 

Population

/Public 

Adult Weight Screening and Follow-Up: 

Percentage of patients aged 18 years and older 

CMS/

QIP 

HITECH 

ACO 
1040 

Health with a calculated body mass index (BMI) in 

the past 6 months or during the current visit 

documented in the medical record AND if the 

most recent BMI is outside of normal 

parameters, a follow-up plan is documented 

within the past 6 months or during the current 

visit 

Normal Parameters: Age 65 years and older 

BMI ≥ 23 and < 30; Age 18-64 years BMI ≥

18.5 and < 25

0418/ 

134 

Preventi

ve Care 

Population

/Public 

Health 

Preventive Care and Screening: Screening 

for Clinical Depression: Percentage of 

patients aged 12 years and older screened for 

clinical depression on the date of encounter 

using an age appropriate standardized 

depression screening tool AND, if positive, a 

follow-up plan documented on the date of the 

positive screen 

CMS/

QIP 

HITECH 

ACO 

0074/ 

197 

Coronar

y Artery 

Disease 

Clinical 

Process/ 

Effectiven

ess 

Coronary Artery Disease (CAD): Lipid 

Control: Percentage of patients aged 18 years 

and older with a diagnosis of coronary artery 

disease seen within a 12 month period who 

have a LDL-C result < 100 mg/dL OR patients 

who have a LDL-C result ≥ 100 mg/dL and 

have a documented plan of care to achieve 

LDL-C < 100mg/dL, including at a minimum 

the prescription of a statin 

AMAPCPI/

ACCF

/AHA 

ACO 

0068/ 

204 

Ischemi

c 

Vascular 

Disease 

Clinical 

Process/ 

Effectiven

ess 

Ischemic Vascular Disease (IVD): Use of 

Aspirin or Another Antithrombotic: 

Percentage of patients 18 years of age and 

older with Ischemic Vascular Disease (IVD) 

with documented use of aspirin or another 

antithrombotic 

NCQA HITECH 

ACO 

Million 

Hearts 

0028/ 

226 

Preventi

ve Care 

Population

/Public 

Health 

Preventive Care and Screening: Tobacco 

Use: Screening and Cessation Intervention: 

Percentage of patients 18 years and older who 

were screened for tobacco use one or more 

times within 24 months AND who received 

cessation counseling intervention if identified 

as a tobacco user 

AMAPCPI HITECH 

ACO 

Million 

Hearts 

0018/ 

236 

Hyperte

nsion 

Clinical 

Process/ 

Effectiven

ess 

Hypertension (HTN): Controlling High 

Blood Pressure: Percentage of patients 

aged18 through85 years of age who had a 

diagnosis of hypertension (HTN) and whose 

blood pressure was adequately controlled (< 

140/90 mmHg)

NCQA HITECH 

ACO 

Million 

Hearts 

0075/ 

241 

Ischemi

c 

Clinical 

Process/ 

Ischemic Vascular Disease (IVD): Complete 

Lipid Panel and LDL Control: Percentage of 

NCQA HITECH 

ACO 
1041 

Vascular 

Disease 

Effectiven

ess 

patients aged 18 years and older with Ischemic 

Vascular Disease (IVD) who received at least 

one lipid profile within 12 months and whose 

most recent LDL-C level was in control (less 

than 100 mg/dL) 

Million 

Hearts 

N/A/ 

317 

Preventi

ve Care 

Population

/Public 

Health 

Preventive Care and Screening: Screening 

for High Blood Pressure and Follow-Up 

Documented: Percentage of patients aged 18 

years and older seen during the measurement 

period who were screened for high blood 

pressure (BP) AND a recommended follow-up 

plan is documented based on the current blood 

pressure reading as indicated 

CMS/

QIP 

HITECH 

ACO 

Million 

Hearts 

0101/ 

318 

Care 

Coordin

ation/ 

Patient 

Safety 

Patient 

Safety 

Falls: Screening for Fall Risk: Percentage of 

patients aged 65 years and older who were 

screened for future fall risk at least once within 

the reporting period 

AMAPCPI/

NCQA

HITECH 

ACO 

0729/ 

TBD 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectiven

ess 

Diabetes Composite: Optimal Diabetes 

Care: Patients ages 18 through 75 with a 

diagnosis of diabetes, who meet all the 

numerator targets of this composite measure: 

• A1c < 8.0%

• LDL < 100 mg/dL

• blood pressure < 140/90 mmHg

• tobacco non-user 

• (for patients with a diagnosis of 

ischemic vascular disease) daily aspirin 

use unless contraindicated

MN 

Comm

unity 

Measu

rement 

ACO 

 (4) PQRS Measures Groups Available for Reporting for 2013 and Beyond 

We proposed the following 20 measures groups for reporting in the PQRS beginning with 

reporting periods occurring in 2013: Diabetes Mellitus; Chronic Kidney Disease (CKD); 

Preventive Care; Coronary Artery Bypass Graft (CABG); Rheumatoid Arthritis (RA); 

Perioperative Care; Back Pain; Hepatitis C; Heart Failure (HF); Coronary Artery Disease (CAD); 

Ischemic Vascular Disease (IVD); HIV/AIDS; Asthma; Chronic Obstructive Pulmonary Disease 

(COPD); Inflammatory Bowel Disease (IBD); Sleep Apnea; Dementia; Parkinson’s Disease; 

Hypertension; Cardiovascular Prevention; and Cataracts (77 FR 44964). These 20 proposed 

measures groups are also available for reporting under the PQRS in 2012. 
1042 

Beginning in 2013, we proposed the oncology measures group for reporting under the 

PQRS that provides measures available for reporting related to breast cancer and colon cancer. 

We believe it is important to measure cancer care (77 FR 44964). 

We proposed the following 4 measures groups for inclusion in the PQRS beginning with 

reporting periods occurring in 2014: Osteoporosis; Total Knee Replacement; Radiation Dose; 

and Preventive Cardiology. These measures groups address conditions that the measures groups 

established in 2012 do not address. 

Therefore, we proposed to finalize a total of 26 measures groups for inclusion in PQRS. 

We invited public comment on these proposed PQRS measures groups. The following is 

a summary of the comments we received regarding these proposed measures groups: 

Comment: One commenter supported inclusion of the Cataracts measures group for 2013 

and beyond, as the measures included in the measures group are relevant to an ophthalmologist’s 

practice. 

Response: Based on the comment we received and for the reasons stated previously, we 

are finalizing the Cataracts measures group for 2013 and beyond. 

Comment: One commenter generally supported the proposed osteoporosis measures 

group. However, the commenter suggests a change in the composition of the measures group. 

Specifically, the commenter suggested that CMS remove the proposed ABIM-sourced 

osteoporosis measures from the proposed osteoporosis measures group and, instead, include all 

six individual osteoporosis measures (PQRS measure numbers 24, 39, 40, 41, 154, and 155) 

currently available for reporting under PQRS. The commenter believes these six measures more 

closely reflect the desired outcomes to improve osteoporosis disease prevention and 

management. 

Response: We appreciate the commenters’ feedback. However, we note that the 
1043 

measures within the osteoporosis measures group have been examined to determine the ability to 

report and analyze the measures contained within the measures group as a whole, whereas the 

suggested PQRS measures have not been analyzed to determine the feasibility of reporting these 

measures together within a measures group. Therefore, we are finalizing the osteoporosis 

measures group as proposed. 

Comment: One commenter supported the addition of a new Oncology measures group for 

2013 and beyond. 

Response: Based on the comments received, we are finalizing the Oncology measures 

group for 2013 and beyond as proposed. 

Comment: One commenter opposed the measures contained within the proposed Diabetes 

Mellitus measures group because the measures are not reflective of the highly-skilled, labor 

intensive cognitive care provided by an endocrinologist over a long period of time to treat 

patients with uncontrolled diabetes. The commenter also believed that use of the measures 

contained in the Diabetes Mellitus measures group provides an incentive for primary care 

physicians to cherry pick diabetes patients who have well-controlled diabetes and to request 

endocrinologic care for difficult and complicated patients. 

Response: We appreciate the commenter's feedback regarding the measures contained 

within the Diabetes Mellitus measures group. While we understand that the measures contained 

within the Diabetes Mellitus measures group do not address every aspect of care to those patients 

with diabetes, we believe that the measures collect appropriate data and address an important 

issue. Therefore, we are finalizing the Diabetes Mellitus measures group with all of the 

proposed component measures for 2013 and beyond. However, we welcome other suggested 

measures addressing care of diabetes patients in the future. 

In addition, in 2012, the PQRS included a community-acquired pneumonia (CAP) 
1044 

measures group among others. We did not propose to include this measures group again in the 

PQRS measure set for the 2013 PQRS or subsequent years because measures contained within 

this measures group were not recommended for retention by the Measure Applications 

Partnership. We received no comments regarding our decision not to continue inclusion this 

measures group for reporting in PQRS beginning in 2013. 

We also proposed, as identified in Table 47 of the CY 2013 PFS proposed rule, to change 

the composition of the Coronary Artery Disease (CAD) measures group from what was finalized 

for 2012 (77 FR 44970). Specifically, we proposed to remove PQRS measure #196: Coronary 

Artery Disease (CAD): Symptom and Activity Assessment and replace this measure with PQRS 

measure #242: Coronary Artery Disease (CAD): Symptom Management in the CAD measures 

group, because the measure #196 was not recommended for retention by the Measure 

Applications Partnership (77 FR 44964). On the other hand, measure #242 was recommended 

for retention by the Measure Applications Partnership. We received no comments regarding our 

proposal to change the composition of the CAD measures group. Therefore, we are finalizing 

the CAD measures group, as proposed. 

Based on the comments received and for the reasons previously stated, we are finalizing 

the following 26 measures groups indicated in Tables 97 through 122. Descriptions of the 

measures within each measures group are provided in Tables 97 through 122. Please note that 

some of the proposed measures included within a final PQRS quality measures group may also 

be available for reporting as an individual measure. In addition, please note that the 

Osteoporosis and Preventive Cardiology measures groups contain composite measures. Since 

composite measures must be reported as a group, similar to reporting measures within a 

measures group, we felt it was appropriate to classify these two composite measures as measures 

groups. 
1045 

TABLE 97: Diabetes Mellitus Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0059/ 

1 

Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus: Percentage of 

patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin 

A1c greater than 9.0 percent 

NCQA 

0064/ 

2 

Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus: 

Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent 

LDL-C level in control (less than 100 mg/dL) 

NCQA 

0061/ 

3 

Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus: Percentage of 

patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure 

in control (less than 140/90 mmHg) 

NCQA 

0055/ 

117 

Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient: Percentage of patients aged 18 

through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam 

NCQA 

0062/ 

119 

Diabetes Mellitus: Urine Screening: Percentage of patients aged 18 through 75 years with 

diabetes (type 1 or type 2) who had a nephropathy screening test or evidence of nephropathy 

NCQA 

0056/ 

163 

Diabetes Mellitus: Foot Exam: The percentage of patients aged 18 through 75 years with 

diabetes who had a foot examination 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting.. 

 This measures group is available for reporting beginning in 2013. 

TABLE 98: Chronic Kidney Disease (CKD) Measures Group* 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 

6 months and older who received an influenza immunization during the flu season 

(October 1 through March 31) 

AMAPCPI 

AQA 

adopted/1

21 

Adult Kidney Disease: Laboratory Testing (Lipid Profile): Percentage of patients aged 

18 years and older with a diagnosis of CKD (stage 3, 4, or 5, not receiving Renal 

Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once 

within a 12-month period 

AMAPCPI 

AQA 

adopted/1

22 

Adult Kidney Disease: Blood Pressure Management: Percentage of patient visits for 

those patients aged 18 years and older with a diagnosis of CKD (stage 3, 4, or 5, not 

receiving Renal Replacement Therapy [RRT]) and documented proteinuria with a blood 

pressure < 130/80 mmHg OR ≥ 130/80 mmHg with a documented plan of care 

AMAPCPI 

AQA 

adopted/1

23 

Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) - 

Hemoglobin Level > 12.0 g/dL: Percentage of calendar months within a 12-month period 

during which a Hemoglobin level is measured for patients aged 18 years and older with a 

diagnosis of advanced Chronic Kidney Disease (CKD) (stage 4 or 5, not receiving Renal 

Replacement Therapy [RRT]) or End Stage Renal Disease (ESRD) (who are on 

hemodialysis or peritoneal dialysis) who are also receiving ESA therapy AND have a 

Hemoglobin level > 12.0 g/dL 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 99: Preventive Care Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0046/ 

39 

Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older: 

Percentage of female patients aged 65 years and older who have a central dual-energy Xray absorptiometry (DXA) measurement ordered or performed at least once since age 60 

or pharmacologic therapy prescribed within 12 months 

AMAPCPI/ 

NCQA 

0098/ 

48 

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence 

in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and 

older who were assessed for the presence or absence of urinary incontinence within 12 

AMAPCPI/ 

NCQA 
1046 

NQF/ 

PQRS Measure Title and Description Measure Developer 

months 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 

6 months and older who received an influenza immunization during the flu season 

(October 1 through March 31) 

AMAPCPI 

0043/ 

111 

Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and 

Older: Percentage of patients aged 65 years and older who have ever received a 

pneumococcal vaccine 

NCQA 

0031/ 

112 

Preventive Care and Screening: Screening Mammography: Percentage of women 

aged 40 through 69 years who had a mammogram to screen for breast cancer 

NCQA 

0034/ 

113 

Preventive Care and Screening: Colorectal Cancer Screening: Percentage of patients 

aged 50 through 75 years who received the appropriate colorectal cancer screening 

NCQA 

0421/ 

128 

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: 

Percentage of patients aged 18 years and older with a calculated BMI in the past 6 months 

or during the current visit documented in the medical record AND if the most recent BMI 

is outside of normal parameters, a follow-up plan is documented. Normal Parameters: Age 

65 years and older BMI > 23and < 30; Age 18 – 64 years BMI > 18.5 and < 25. 

CMS/ 

QIP 

AQA 

adopted/1

73 

Preventive Care and Screening: Unhealthy Alcohol Use – Screening: Percentage of 

patients aged 18 years and older who were screened for unhealthy alcohol use using a 

systematic screening method within 24 months 

AMAPCPI 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 100: Coronary Artery Bypass Graft (CABG) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0134/ 

43 

Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in 

Patients with Isolated CABG: Surgery Percentage of patients aged 18 years and older 

undergoing isolated CABG surgery using an IMA graft 

STS 

0236/ 

44 

Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with 

Isolated CABG Surgery: Percentage of patients aged 18 years and older undergoing 

isolated CABG surgery who received a beta-blocker within 24 hours prior to surgical 

incision 

CMS/ 

QIP 

0129/ 

164 

Coronary Artery Bypass Graft (CABG): Prolonged Intubation: Percentage of patients 

aged 18 years and older undergoing isolated CABG surgery who require intubation > 24 

hours 

STS 

0130/ 

165 

Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate: 

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, 

within 30 days postoperatively, develop deep sternal wound infection (involving muscle, 

bone, and/or mediastinum requiring operative intervention) 

STS 

0131/ 

166 

Coronary Artery Bypass Graft (CABG): Stroke: Percentage of patients aged 18 years 

and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any 

confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the 

brain) that did not resolve within 24 hours 

STS 

0114/ 

167 

Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure: Percentage of 

patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing 

renal failure) who develop postoperative renal failure or require dialysis 

STS 

0115/ 

168 

Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration: Percentage of 

patients aged 18 years and older undergoing isolated CABG surgery who require a return to 

the operating room (OR) during the current hospitalization for mediastinal bleeding with or 

without tamponade, graft occlusion, valve dysfunction, or other cardiac reason 

STS 
1047 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0116/ 

169 

Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge: 

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who 

were discharged on antiplatelet medication 

STS 

0117/ 

170 

Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge: 

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who 

were discharged on beta-blockers 

STS 

0118/ 

171 

Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge: 

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who 

were discharged on a statin or other lipid-lowering regimen 

STS 

*This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 101: Rheumatoid Arthritis (RA) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0054/ 

108 

Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) 

Therapy: Percentage of patients aged 18 years and older who were diagnosed with RA 

and were prescribed, dispensed, or administered at least one ambulatory prescription for a 

DMARD 

NCQA 

AQA 

adopted/1

76 

Rheumatoid Arthritis (RA): Tuberculosis Screening: Percentage of patients aged 18 

years and older with a diagnosis of RA who have documentation of a tuberculosis (TB) 

screening performed and results interpreted within 6 months prior to receiving a first 

course of therapy using a biologic disease-modifying anti- rheumatic drug (DMARD) 

AMAPCPI/ 

NCQA 

AQA 

adopted/1

77 

Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity: Percentage of 

patients aged 18 years and older with a diagnosis of RA who have an assessment and 

classification of disease activity within 12 months 

AMAPCPI/ 

NCQA 

AQA 

adopted 

/178 

Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients 

aged 18 years and older with a diagnosis of RA for whom a functional status assessment 

was performed at least once within 12 months 

AMAPCPI/ 

NCQA 

AQA 

adopted/1

79 

Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis: 

Percentage of patients aged 18 years and older with a diagnosis of RA who have an 

assessment and classification of disease prognosis at least once within 12 months 

AMAPCPI/ 

NCQA 

AQA 

adopted/1

80 

Rheumatoid Arthritis (RA): Glucocorticoid Management: Percentage of patients aged 

18 years and older with a diagnosis of RA who have been assessed for glucocorticoid use 

and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with 

improvement or no change in disease activity, documentation of glucocorticoid 

management plan within 12 months 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 102: Perioperative Care Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0270/ 

20 

Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician: Percentage 

of surgical patients aged 18 years and older undergoing procedures with the indications for 

prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic 

to be given within one hour (if fluoroquinolone or vancomycin, 2 hours), prior to the 

surgical incision (or start of procedure when no incision is required) 

AMAPCPI/ 

NCQA 

0268/ 

21 

Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation 

Cephalosporin: Percentage of surgical patients aged 18 years and older undergoing 

procedures with the indications for a first OR second generation cephalosporin prophylactic 

antibiotic, who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis 

AMAPCPI/ 

NCQA 

0271/ 

22 

Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac 

Procedures): Percentage of non-cardiac surgical patients aged 18 years and older 

AMAPCPI/ 
1048 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

 undergoing procedures with the indications for prophylactic parenteral antibiotics AND who 

received a prophylactic parenteral antibiotic, who have an order for discontinuation of 

prophylactic parenteral antibiotics within 24 hours of surgical end time 

NCQA 

0239/ 

23 

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in 

ALL Patients): Percentage of patients aged 18 years and older undergoing procedures for 

which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular 

Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose 

warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to 

incision time or within 24 hours after surgery end time 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 103: Back Pain Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0322/ 

148 

Back Pain: Initial Visit: The percentage of patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back surgery who had back pain and function assessed 

during the initial visit to the clinician for the episode of back pain 

NCQA 

0319/ 

149/ 

Back Pain: Physical Exam: Percentage of patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back surgery who received a physical examination at 

the initial visit to the clinician for the episode of back pain 

NCQA 

0314/ 

150 

Back Pain: Advice for Normal Activities: The percentage of patients aged 18 through 79 

years with a diagnosis of back pain or undergoing back surgery who received advice for 

normal activities at the initial visit to the clinician for the episode of back pain 

NCQA 

0313/ 

151 

Back Pain: Advice Against Bed Rest: The percentage of patients aged 18 through 79 years 

with a diagnosis of back pain or undergoing back surgery who received advice against bed 

rest lasting 4 days or longer at the initial visit to the clinician for the episode of back pain 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 104: Hepatitis C Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0395/ 

84 

Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment: Percentage 

of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving 

antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months 

prior to initiation of antiviral treatment 

AMAPCPI 

0396/ 

85 

Hepatitis C: HCV Genotype Testing Prior to Treatment: Percentage of patients aged 18 

years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment 

for whom HCV genotype testing was performed prior to initiation of antiviral treatment 

AMAPCPI 

0397/ 

86 

Hepatitis C: Antiviral Treatment Prescribed: Percentage of patients aged 18 years and 

older with a diagnosis of chronic hepatitis C who were prescribed at a minimum 

peginterferon and ribavirin therapy within the 12-month reporting period 

AMAPCPI 

0398/ 

87 

Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment: 

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who 

are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 

no greater than 12 weeks from the initiation of antiviral treatment 

AMAPCPI 

0401/ 

89 

Hepatitis C: Counseling Regarding Risk of Alcohol Consumption: Percentage of 

patients aged 18 years and older with a diagnosis of hepatitis C who were counseled about 

the risks of alcohol use at least once within 12-months 

AMAPCPI 

0394/ 

90 

Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy: 

Percentage of female patients aged 18 through 44 years and all men aged 18 years and older 

with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were 

AMAPCPI 
1049 

NQF/ 

PQRS Measure Title and Description Measure Developer 

counseled regarding contraception prior to the initiation of treatment 

0399/ 

183 

Hepatitis C: Hepatitis A Vaccination in Patients with HCV: Percentage of patients aged 

18 years and older with a diagnosis of hepatitis C who received at least one injection of 

hepatitis A vaccine, or who have documented immunity to hepatitis A 

AMAPCPI 

0400/ 

184 

Hepatitis C: Hepatitis B Vaccination in Patients with HCV: Percentage of patients aged 

18 years and older with a diagnosis of hepatitis C who received at least one injection of 

hepatitis B vaccine, or who have documented immunity to hepatitis B 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 105: Heart Failure (HF) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0081/ 

5 

Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin 

Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD): 

Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD 

(LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy 

AMAPCPI/ 

ACCF/AH

A 

0083/ 

8 

Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction 

(LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure 

who also have LVSD (LVEF < 40%) and who were prescribed beta-blocker therapy 

AMAPCPI/ 

ACCF/AH

A 

0079/ 

198 

Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment: Percentage of 

patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative 

or qualitative result (of a recent or prior [any time in the past] LVEF assessment) is 

documented within a 12 month period 

AMAPCPI/ 

ACCF/AH

A 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 106: Coronary Artery Disease (CAD) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0067/ 

6 

Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage of patients aged 18 

years and older with a diagnosis of coronary artery disease seen within a 12 month period 

who were prescribed aspirin or clopidogrel 

AMAPCPI/ 

ACCF/AH

A 

0074/ 

197 

Coronary Artery Disease (CAD): Lipid Control: Percentage of patients aged 18 years and 

older with a diagnosis of coronary artery disease seen within a 12 month period who have a 

LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a 

documented plan of care to achieve LDL-C <100 mg/dL, including at a minimum the 

prescription of a statin 

AMAPCPI/ 

ACCF/AH

A 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI 

N/A/ 

242 

Coronary Artery Disease (CAD): Symptom Management: Percentage of patients aged 18 

years and older with a diagnosis of coronary artery disease seen within a 12-month period 

and with results of an evaluation of level of activity AND an assessment for the presence or

absence of anginal symptoms, with a plan of care to manage anginal symptoms, if present 

AMAPCPI/ 

ACCF/ 

AHA 

 *This measures group is reportable through registry-based reporting only 
1050 

 This measures group is available for reporting beginning in 2013. 

TABLE 107: Ischemic Vascular Disease (IVD) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0073/ 

201 

Ischemic Vascular Disease (IVD): Blood Pressure Management Control: Percentage of 

patients aged 18 years and older with ischemic vascular disease (IVD) who had most recent 

blood pressure in control (less than 140/90 mmHg) 

NCQA 

0068/ 

204 

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic: 

Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) with 

documented use of aspirin or other antithrombotic 

NCQA 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI 

0075/ 

241 

Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein 

(LDL-C) Control: Percentage of patients aged 18 years and older with Ischemic Vascular 

Disease (IVD) who received at least one lipid profile within 12 months and whose most 

recent LDL-C level was in control (less than 100 mg/dL) 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 108: HIV/AIDS Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0404/ 

159 

HIV/AIDS: CD4+ Cell Count or CD4+ Percentage: Percentage of patients aged 6 months 

and older with a diagnosis of HIV/AIDS for whom a CD4+ cell count or CD4+ cell 

percentage was performed at least once every 6 months 

AMAPCPI/ 

NCQA 

0405/ 

160 

HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of 

patients aged 6 years and older with a diagnosis of HIV/AIDS and CD4+ cell count < 200 

cells/mm3 who were prescribed PCP prophylaxis within 3 months of low CD4+ cell count 

AMAPCPI/ 

NCQA 

0406/ 

161 

HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent 

Antiretroviral Therapy: Percentage of patients with a diagnosis of HIV/AIDS aged 13 

years and older: who have a history of a nadir CD4+ cell count below 350/mm3 or who have 

a history of an AIDS- defining condition, regardless of CD4+ cell count; or who are 

pregnant, regardless of CD4+ cell count or age, who were prescribed potent antiretroviral 

therapy 

AMAPCPI/ 

NCQA 

0407/ 

162 

HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy: 

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who are 

receiving potent antiretroviral therapy, who have a viral load below limits of quantification 

after at least 6 months of potent antiretroviral therapy or patients whose viral load is not 

below limits of quantification after at least 6 months of potent antiretroviral therapy and 

have documentation of a plan of care 

AMAPCPI/ 

NCQA 

0409/ 

205 

HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea: 

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom 

chlamydia and gonorrhea screenings were performed at least once since the diagnosis of 

HIV infection 

AMAPCPI/ 

NCQA 

0413/ 

206 

HIV/AIDS: Screening for High Risk Sexual Behaviors: Percentage of patients aged 13 

years and older with a diagnosis of HIV/AIDS who were screened for high risk sexual 

behaviors at least once within 12 months 

AMAPCPI/ 

NCQA 

0415/ 

207 

HIV/AIDS: Screening for Injection Drug Use: Percentage of patients aged 13 years and 

older with a diagnosis of HIV/AIDS who were screened for injection drug use at least once 

within 12 months 

AMAPCPI/ 

NCQA 

0410/ 

208 

HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis: Percentage of patients 

aged 13 years and older with a diagnosis of HIV/AIDS who were screened for syphilis at 

AMAPCPI/ 
1051 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

 least once within 12 months NCQA 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 109: Asthma Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0047/ 

53 

Asthma: Pharmacologic Therapy for Persistent Asthma: Percentage of patients aged 5 

through 50 years with a diagnosis of mild, moderate, or severe persistent asthma who were 

prescribed either the preferred long-term control medication (inhaled corticosteroid) or an 

acceptable alternative treatment 

AMAPCPI/ 

NCQA 

0001/ 

64 

Asthma: Assessment of Asthma Control: Percentage of patients aged 5 through 50 years 

with a diagnosis of asthma who were evaluated during at least one office visit within 12 

months for the frequency (numeric) of daytime and nocturnal asthma symptoms 

AMAPCPI/ 

NCQA 

N/A/ 

231 

Asthma: Tobacco Use: Screening - Ambulatory Care Setting: Percentage of patients (or 

their primary caregiver) aged 5 through 50 years with a diagnosis of asthma who were 

queried about tobacco use and exposure to second hand smoke within their home 

environment at least once during the one-year measurement period 

AMAPCPI/ 

NCQA 

N/A/ 

232 

Asthma: Tobacco Use: Intervention - Ambulatory Care Setting: Percentage of patients 

(or their primary caregiver) aged 5 through 50 years with a diagnosis of asthma who were 

identified as tobacco users (patients who currently use tobacco AND patients who do not 

currently use tobacco, but are exposed to second hand smoke in their home environment) 

who received tobacco cessation intervention at least once during the one-year measurement 

period 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 110: Chronic Obstructive Pulmonary Disease (COPD) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0091/ 

51 

Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation: Percentage 

of patients aged 18 years and older with a diagnosis of COPD who had spirometry 

evaluation results documented 

AMAPCPI 

0102/ 

52 

Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy: Percentage 

of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC 

less than 70 percent and have symptoms who were prescribed an inhaled bronchodilator 

AMAPCPI 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older who received an influenza immunization during the flu season (October 1 

through March 31) 

AMAPCPI 

0043/ 

111 

Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and 

Older: Percentage of patients aged 65 years and older who have ever received a 

pneumococcal vaccine 

NCQA 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 111: Inflammatory Bowel Disease (IBD) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 
1052 

NQF/ 

PQRS Measure Title and Description Measure Developer 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI 

N/A/ 

269 

Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All 

Documented: Percentage of patients aged 18 years and older with a diagnosis of 

inflammatory bowel disease who have documented the disease type, anatomic location and 

activity, at least once during the reporting period 

AGA 

N/A/ 

270 

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy: 

Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel 

disease who have been managed by corticosteroids greater than or equal to 10mg/day for 60 

or greater consecutive days that have been prescribed corticosteroid sparing therapy in the 

last reporting year 

 AGA 

N/A/ 

271 

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related 

Iatrogenic Injury – Bone Loss Assessment: Percentage of patients aged 18 years and older 

with a diagnosis of inflammatory bowel disease who have received dose of corticosteroids 

greater than or equal to 10 mg/day for 60 or greater consecutive days and were assessed for 

risk of bone loss once per the reporting year 

AGA 

N/A/ 

272 

Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization: 

Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel 

disease for whom influenza immunization was recommended, administered or previously 

received during the reporting year 

AGA 

N/A/ 

273 

Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization: 

Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel 

disease that had pneumococcal vaccination administered or previously received 

AGA 

N/A/ 

274 

Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before 

Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 

years and older with a diagnosis of inflammatory bowel disease for whom a tuberculosis 

(TB) screening was performed and results interpreted within 6 months prior to receiving a 

first course of anti-TNF (tumor necrosis factor) therapy 

AGA 

N/A/ 

275 

Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status 

Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients 

aged 18 years and older with a diagnosis of inflammatory bowel disease who had Hepatitis 

B Virus (HBV) status assessed and results interpreted within one year prior to receiving a 

first course of anti-TNF (tumor necrosis factor) therapy 

AGA 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 112: Sleep Apnea Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

N/A/ 

276 

Sleep Apnea: Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 

years and older with a diagnosis of obstructive sleep apnea that includes documentation of 

an assessment of symptoms, including presence or absence of snoring and daytime 

sleepiness 

AMAPCPI/ 

NCQA 

N/A/ 

277 

Sleep Apnea: Severity Assessment at Initial Diagnosis: Percentage of patients aged 18 

years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea 

index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial 

diagnosis 

AMAPCPI/ 

NCQA 

N/A/ 

278 

Sleep Apnea: Positive Airway Pressure Therapy Prescribed: Percentage of patients 

aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea 

who were prescribed positive airway pressure therapy 

AMAPCPI/ 

NCQA 

N/A/ 

279 

Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy: 

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive 

AMAPCPI/ 
1053 

NQF/ 

PQRS Measure Title and Description Measure Developer 

sleep apnea who were prescribed positive airway pressure therapy who had 

documentation that adherence to positive airway pressure therapy was objectively 

measured 

NCQA 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 113: Dementia Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A / 

280 

Dementia: Staging of Dementia: Percentage of patients, regardless of age, with a 

diagnosis of dementia whose severity of dementia was classified as mild, moderate or 

severe at least once within a 12 month period 

AMA-PCPI 

N/A / 

281 

Dementia: Cognitive Assessment: Percentage of patients, regardless of age, with a 

diagnosis of dementia for whom an assessment of cognition is performed and the results 

reviewed at least once within a 12 month period 

AMA-PCPI 

N/A / 

282 

Dementia: Functional Status Assessment: Percentage of patients, regardless of age, 

with a diagnosis of dementia for whom an assessment of patient’s functional status is 

performed and the results reviewed at least once within a 12 month period 

AMA-PCPI 

N/A / 

283 

Dementia: Neuropsychiatric Symptom Assessment: Percentage of patients, regardless 

of age, with a diagnosis of dementia and for whom an assessment of patient’s 

neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month 

period 

AMA-PCPI 

N/A / 

284 

Dementia: Management of Neuropsychiatric Symptoms: Percentage of patients, 

regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric 

symptoms who received or were recommended to receive an intervention for 

neuropsychiatric symptoms within a 12 month period 

AMA-PCPI 

N/A / 

285 

Dementia: Screening for Depressive Symptoms: Percentage of patients, regardless of 

age, with a diagnosis of dementia who were screened for depressive symptoms within a 

12 month period 

AMA-PCPI 

N/A / 

286 

Dementia: Counseling Regarding Safety Concerns: Percentage of patients, regardless 

of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred 

for counseling regarding safety concerns within a 12 month period 

AMA-PCPI 

N/A / 

287 

Dementia: Counseling Regarding Risks of Driving: Percentage of patients, regardless 

of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding 

the risks of driving and driving alternatives within a 12 month period 

AMA-PCPI 

N/A / 

288 

Dementia: Caregiver Education and Support: Percentage of patients, regardless of age, 

with a diagnosis of dementia whose caregiver(s) were provided with education on 

dementia disease management and health behavior changes AND referred to additional 

sources for support within a 12 month period 

AMA-PCPI 

 *This measures group is reportable through claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 114: Parkinson’s Disease Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

N/A / 

289 

Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review: All patients with 

a diagnosis of Parkinson’s disease who had an annual assessment including a review of 

current medications (e.g., medications than can produce Parkinson- like signs or 

symptoms) and a review for the presence of atypical features (e.g., falls at presentation and 

early in the disease course, poor response to levodopa, symmetry at onset, rapid 

progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at 

least annually 

AAN 

N/A / Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment: All patients AAN 
1054 

NQF/ 

PQRS Measure Title and Description Measure Developer 

290 with a diagnosis of Parkinson’s disease who were assessed for psychiatric disorders or 

disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control 

disorder) at least annually 

N/A / 

291 

Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment: All patients 

with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or 

dysfunction at least annually 

AAN 

N/A / 

292 

Parkinson’s Disease: Querying about Sleep Disturbances: All patients with a diagnosis 

of Parkinson’s disease (or caregivers, as appropriate) who were queried about sleep 

disturbances at least annually 

AAN 

N/A / 

293 

Parkinson’s Disease: Rehabilitative Therapy Options: All patients with a diagnosis of 

Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options 

(e.g., physical, occupational, or speech therapy) discussed at least annually 

AAN 

N/A / 

294 

Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options 

Reviewed: All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as 

appropriate who had the Parkinson’s disease treatment options (e.g., non-pharmacological 

treatment, pharmacological treatment, or surgical treatment) reviewed at least once 

annually 

AAN 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 115: Hypertension Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/ 

295 

Hypertension: Appropriate Use of Aspirin or Other Antiplatelet or Anticoagulant 

Therapy: Percentage of patients aged 15 through 90 years old with a diagnosis of 

hypertension who were prescribed aspirin or other anticoagulant/antiplatelet therapy 

ABIM 

N/A/ 

296 

Hypertension: Complete Lipid Profile: Percentage of patients aged 15 through 90 years 

old with a diagnosis of hypertension who received a complete lipid profile within 24 

months 

ABIM 

N/A/ 

297 

Hypertension: Urine Protein Test: Percentage of patients aged 15 through 90 years old 

with a diagnosis of hypertension who either have chronic kidney disease diagnosis 

documented or had a urine protein test done within 36 months 

ABIM 

N/A/ 

298 

Hypertension: Annual Serum Creatinine Test: Percentage of patients aged 15 through 

90 years old with a diagnosis of hypertension who had a serum creatinine test done within 

12 months 

ABIM 

N/A/ 

299 

Hypertension: Diabetes Mellitus Screening Test: Percentage of patients aged 15 

through 90 years old with a diagnosis of hypertension who had a diabetes screening test 

within 36 months 

ABIM 

N/A/ 

300 

Hypertension: Blood Pressure Control: Percentage of patients aged 15 through 90 years 

old with a diagnosis of hypertension who had most recent blood pressure level under 

control (at goal) 

ABIM 

N/A/ 

301 

Hypertension: Low Density Lipoprotein (LDL-C) Control: Percentage of patients aged 

15 through 90 years old with a diagnosis of hypertension who had most recent LDL 

cholesterol level under control (at goal) 

ABIM 

N/A/ 

302 

Hypertension: Dietary and Physical Activity Modifications Appropriately 

Prescribed: Percentage of patients aged 15 through 90 years old with a diagnosis of 

hypertension who received dietary and physical activity counseling at least once within 12 

months 

ABIM 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 116: Cardiovascular Prevention Measures Group*

NQF/ 

PQRS Measure Title and Description 

Measure 

Developer 
1055 

NQF/ 

PQRS Measure Title and Description 

Measure 

Developer 

0064/ 

2 

Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus: 

Percentage of patients aged 18 through 75 years with diabetes mellitus who had most 

recent LDL-C level in control (less than 100 mg/dL) 

NCQA 

0068/ 

204 

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic: 

Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) with 

documented use of aspirin or other antithrombotic 

NCQA 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: 

Percentage of patients aged 18 years and older who were screened for tobacco use one or 

more times within 24 months AND who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI 

0018/ 

236 

Hypertension (HTN): Controlling High Blood Pressure: Percentage of patients aged 

18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose BP 

was adequately controlled (< 140/90 mmHg) 

NCQA 

0075/ 

241 

Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density 

Lipoprotein (LDL-C) Control: Percentage of patients aged 18 years and older with 

Ischemic Vascular Disease (IVD) who received at least one lipid profile within 12 months 

and whose most recent LDL-C level was in control (less than 100 mg/dL) 

NCQA 

N/A/ 

317 

Preventive Care and Screening: Screening for High Blood Pressure: Percentage of 

patients aged 18 and older who are screened for high blood pressure 

CMS/ 

QIP 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2013. 

TABLE 117: Cataracts Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0565/ 

191 

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery: 

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract 

who had cataract surgery and no significant ocular conditions impacting the visual outcome 

of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) 

achieved within 90 days following the cataract surgery 

AMAPCPI/ 

NCQA 

0564/ 

192 

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring 

Additional Surgical Procedures: Percentage of patients aged 18 years and older with a 

diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified 

list of surgical procedures in the 30 days following cataract surgery which would indicate 

the occurrence of any of the following major complications: retained nuclear fragments, 

endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence 

AMAPCPI/ 

NCQA 

N/A/ 

303 

Cataracts: Improvement in Patient’s Visual Function within 90 Days Following 

Cataract Surgery: Percentage of patients aged 18 years and older in sample who had 

cataract surgery and had improvement in visual function achieved within 90 days following 

the cataract surgery, based on completing a pre-operative and post-operative visual 

function survey 

AAO 

N/A/ 

304 

Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery: 

Percentage of patients aged 18 years and older in sample who had cataract surgery and 

were satisfied with their care within 90 days following the cataract surgery, based on 

completion of the Consumer Assessment of Healthcare Providers and Systems Surgical 

Care Survey 

AAO 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 118: Oncology Measures Group*
1056 

NQF/ PQRS 

Measure Title and Description 

Measure Developer 

0387/ 

71 

Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen 

Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer: 

Percentage of female patients aged 18 years and older with Stage IC 

through IIIC, ER or PR positive breast cancer who were prescribed 

tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period 

AMAPCPI/ 

ASCO/

NCCN 

0385/ 

72 

Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients: 

Percentage of patients aged 18 years and older with Stage IIIA through IIIC 

colon cancer who are referred for adjuvant chemotherapy, prescribed 

adjuvant chemotherapy, or have previously received adjuvant chemotherapy 

within the 12-month reporting period 

AMAPCPI/ 

ASCO/

NCCN 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of 

patients aged 6 months and older who received an influenza immunization 

during the flu season (October 1 through March 31) 

AMAPCPI 

0419/ 

130 

Documentation of Current Medications in the Medical Record: 

Percentage of specified visits for patients aged 18 years and older for which 

the eligible professional attests to documenting a list of current medications 

to the best of his/her knowledge and ability. This list must include ALL 

prescriptions, over-the-counters, herbals, vitamin/mineral/dietary 

(nutritional) supplements AND must contain the medications’ name, 

dosage, frequency and route 

CMS/ 

QIP 

0384/ 

143 

Oncology: Medical and Radiation – Pain Intensity Quantified: 

Percentage of patient visits, regardless of patient age, with a diagnosis of 

cancer currently receiving chemotherapy or radiation therapy in which pain 

intensity is quantified 

AMAPCPI 

0383/ 

144 

Oncology: Medical and Radiation – Plan of Care for Pain: Percentage of 

patient visits, regardless of patient age, with a diagnosis of cancer currently 

receiving chemotherapy or radiation therapy who report having pain with a 

documented plan of care to address pain 

AMAPCPI 

0386/ 

194 

Oncology: Cancer Stage Documented: Percentage of patients, regardless 

of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the 

ambulatory setting who have a baseline AJCC cancer stage or 

documentation that the cancer is metastatic in the medical record at least 

once within 12 months 

AMAPCPI/ 

ASCO 

0028/ 

226 

Preventive Care and Screening: Tobacco Use: Screening and Cessation 

Intervention: Percentage of patients aged 18 years and older who were 

screened for tobacco use one or more times within 24 months AND who 

received cessation counseling intervention if identified as a tobacco user 

AMAPCPI 

 *This measures group is reportable through registry-based reporting only 

 This measures group is available for reporting beginning in 2013. 

TABLE 119: Osteoporosis Measures Group*

NQF/ 

PQRS Measure Title Measure Developer 

0046/ Osteoporosis: Screening or Therapy for Osteoporosis for Women Aged 65 Years AMA 
1057 

NQF/ 

PQRS Measure Title Measure Developer 

39 and Older: Percentage of female patients aged 65 years and older who have a central 

dual-energy X-ray absorptiometry (DXA) measurement ordered or performed at least 

once since age 60 or pharmacologic therapy prescribed within 12 months 

0049/ 

41 

Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and 

Older: Percentage of patients aged 50 years and older with a diagnosis of osteoporosis 

who were prescribed pharmacologic therapy within 12 months 

AMA 

AQA 

Selected 

/154 

Falls: Risk Assessment for Falls: Percentage of patients aged 65 years and older with a 

history of falls who had a risk assessment for falls completed within 12 months 

NCQA 

AQA 

Selected 

/155 

Falls: Plan of Care for Falls: Percentage of patients aged 65 years and older with a 

history of falls who had a plan of care for falls documented within 12 months 

NCQA 

N/A / 

TBD 

Osteoporosis: Status of Participation in Weight-Bearing Exercise and Weightbearing Exercise Advice: Percentage of patients aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low impact fracture; women age 65 and older; or men 

age 70 and older whose status regarding participation in weight-bearing exercise was 

documented and for those not participating regularly who received advice within 12 

months to participate in weight-bearing exercise

ABIM 

N/A / 

TBD 

Osteoporosis: Current Level of Alcohol Use and Advice on Potentially Hazardous 

Drinking Prevention: Percentage of patients aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low impact fracture; women age 65 and older; or men 

age 70 and older whose current level of alcohol use was documented and for those 

engaging in potentially hazardous drinking who received counseling within 12 months

ABIM 

N/A / 

TBD 

Osteoporosis: Screen for Falls Risk Evaluation and Complete Falls Risk Assessment 

and Plan of Care: Percentage of patients aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low impact fracture; women age 65 and older; or men 

age 70 and older who had a screen for falls risk evaluation within the past 12 months and 

for those reported as having a history of two or more falls, or fall-related injury who had 

a complete risk assessment for falls and a falls plan of care within the past 12 months 

ABIM 

N/A / 

TBD 

Osteoporosis: Dual-Emission X-ray Absorptiometry (DXA) Scan: Percentage of 

patients aged 18 and older with a diagnosis of osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and older; or men age 70 and older who had a DXA scan 

and result documented

ABIM 

N/A / 

TBD 

Osteoporosis: Calcium Intake Assessment and Counseling: Percentage of patients

aged 18 and older with a diagnosis of osteoporosis, osteopenia, or prior low impact 

fracture; women age 65 and older; or men age 70 and older who had calcium intake 

assessment and counseling at least once within 12 months

ABIM 

N/A / 

TBD 

Osteoporosis: Vitamin D Intake Assessment and Counseling: Percentage of patients

aged 18 and older with a diagnosis of osteoporosis, osteopenia, or prior low impact 

fracture; women age 65 and older; or men age 70 and older who had vitamin D intake 

assessment and counseling at least once within 12 months

ABIM 

N/A / 

TBD 

Osteoporosis: Pharmacologic Therapy: Percentage of patients aged 18 and older with 

a diagnosis of osteoporosis, osteopenia, or prior low impact fracture; women age 65 and 

older; or men age 70 and older who were prescribed pharmacologic therapy approved by 

the Food and Drug Administration

ABIM 

 *This measures group is reportable through claims and registry-based reporting 

 This measures group is available for reporting beginning in 2014. 

TABLE 120: Total Knee Replacement Measures Group*

NQF/ 

PQRS Measure Title Measure Developer 
1058 

NQF/ 

PQRS Measure Title Measure 

Developer 

N/A / 

TBD 

Total Knee Replacement: Coordination of Post Discharge Care: Percentage of patients 

undergoing total knee replacement who received written instructions for post discharge care 

including all the following: post discharge physical therapy, home health care, post 

discharge deep vein thrombosis (DVT) prophylaxis and follow-up physician visits

AAHKS/A

MA-PCPI 

N/A / 

TBD 

Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk 

Evaluation: Percentage of patients undergoing a total knee replacement who are evaluated 

for the presence or absence of venous thromboembolic and cardiovascular risk factors 

within 30 days prior to the procedure including history of deep vein thrombosis (DVT), 

pulmonary embolism (PE), myocardial infarction (MI), arrhythmia and stroke

AAHKS/A

MA-PCPI 

N/A / 

TBD 

Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet: 

Percentage of patients undergoing a total knee replacement who had the prophylactic 

antibiotic completely infused prior to the inflation of the proximal tourniquet

AAHKS/A

MA-PCPI 

N/A / 

TBD 

Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report: 

Percentage of patients undergoing total knee replacement whose operative report identifies 

the prosthetic implant specifications including the prosthetic implant manufacturer, the 

brand name of prosthetic implant and the size of prosthetic implant

AAHKS/A

MA-PCPI 

 *This measures group is reportable through and registry-based only 

 This measures group is available for reporting beginning in 2014. 

TABLE 121: Radiation Dose Optimization Measures Group*

NQF/ 

PQRS Measure Title Measure Developer 

TBD/ 

TBD 

Radiation Dose Optimization: Utilization of a Standardized Nomenclature for CT 

Imaging Description: Percentage of computed tomography (CT) imaging reports for all 

patients, regardless of age, with the imaging study named according to a standardized 

nomenclature (e.g., RadLex®) and the standardized nomenclature is used in institutions 

computer systems 

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: Cumulative Count of Potential High Dose Radiation 

Imaging Studies: Computed Tomography (CT) Scans and Cardiac Nuclear Medicine 

Scans: Percentage of CT and cardiac nuclear medicine (myocardial perfusion) imaging 

reports for all patients, regardless of age, that document a count of known previous CT 

studies (any type of CT) and cardiac nuclear medicine (myocardial perfusion studies) studies 

that the patient has received in the 12-month period prior to the current study

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: Reporting to a Radiation Dose Index Registry:

Percentage of total computed tomography (CT) studies performed for all patients, regardless 

of age, that are reported to a radiation dose index registry AND that include at a minimum 

selected data elements 

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: Images Available for Patient Follow-up and 

Comparison Purposes: Percentage of final reports for imaging studies performed for all 

patients, regardless of age, which document that Digital Imaging and Communications in 

Medicine (DICOM) format image data are available reciprocally to non-affiliated external 

entities on a secure, media free, searchable basis with patient authorization for at least a 12-

month period after the study 

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: Search for Prior Imaging Studies Through a Secure, 

Authorized, Media-Free, Shared Archive: Percentage of final reports of imaging studies 

performed for all patients, regardless of age, which document that a search for Digital 

Imaging and Communications in Medicine (DICOM) format images was conducted for 

prior patient imaging studies completed at non-affiliated external entities within the past 12-

months and are available through a secure, authorized, media free, shared archive prior to 

an imaging study being performed 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2014. 
1059 

TABLE 122: Preventive Cardiology Measures Group*

NQF/ 

PQRS Measure Title Measure 

Developer 

N/A/ 

TBD 

Preventive Cardiology Composite: Blood Pressure at Goal: Percentage of patients in the 

sample whose most recent blood pressure reading was at goal 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Low Density Lipids (LDL) Cholesterol at Goal: 

Percentage of patients in the sample whose LDL cholesterol is considered to be at goal, 

based upon their coronary heart disease (CHD) risk factors

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Timing of Lipid Testing Complies with Guidelines: 

Percentage of patients in the sample whose timing of lipid testing complies with guidelines 

(lipid testing performed in the preceding 12-month period (with a 3-month grace period) for 

patients with known coronary heart disease (CHD) or CHD risk equivalent (prior 

myocardial infarction (MI), other clinical CHD, symptomatic carotid artery disease, 

peripheral artery disease, abdominal aortic aneurysm, diabetes mellitus); or in the preceding 

24-month period (with a 3-month grace period) for patients with > 2 risk factors for CHD 

(smoking, hypertension, low high density lipid (HDL), men > 45 years, women > 55 years, 

family history of premature CHD; HDL > 60 mg/dL acts as a negative risk factor); or in the 

preceding 60-month period (with a 3-month grace period) for patients with < 1 risk factor 

for CHD) 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Diabetes Documentation or Screen Test: Percentage 

of patients in the sample who had a screening test for type 2 diabetes or had a diagnosis of 

diabetes 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Correct Determination of Ten-Year Risk for 

Coronary Death or Myocardial Infarction (MI): Number of patients in the sample whose 

ten-year risk of coronary death or MI is correctly assessed and documented 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Counseling for Diet and Physical Activity: 

Percentage of patients in the sample who received dietary and physical activity counseling 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Appropriate Use of Aspirin or Other 

Antiplatelet/Anticoagulant Therapy: Percentage of patients in the sample who are: 1) 

taking aspirin or other anticoagulant/antiplatelet therapy, or 2) under age 30, or 3) age 30 or 

older and who are documented to be at low risk. Low-risk patients include those who are 

documented with no prior coronary heart disease (CHD) or CHD risk equivalent (prior 

myocardial infarction (MI), other clinical CHD, symptomatic carotid artery disease, 

peripheral artery disease, abdominal aortic aneurysm, diabetes mellitus) and whose ten-year 

risk of developing CHD is < 10% 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Smoking Status and Cessation Support: Percentage 

of patients in the sample whose current smoking status is documented in the chart, and if 

they were smokers, were documented to have received smoking cessation counseling during 

the reporting period 

ABIM 

 *This measures group is reportable through both claims and registry-based reporting 

 This measures group is available for reporting beginning in 2014. 

(5) Physician Quality Reporting System Measures for Eligible Professionals and Group 

Practices that Report Using Administrative Claims for the 2015 Payment Adjustment 

 We proposed 19 measures – including 15 process and 4 outcome measures derived from 

administrative claims – for eligible professionals and group practices that report using 

administrative claims for the 2015 and 2016 payment adjustments (see Table 63 of the CY 2013 

PFS proposed rule, 77 FR 44981). Our proposals on how to attribute beneficiaries to groups of 
1060 

physicians that elect the administrative claims option were discussed in the value-based payment 

modifier in section III.K. of the proposed rule. We considered all of the 28 process measures 

included in the program year 2010 individual Physician Feedback reports that can be calculated 

using administrative claims but proposed only a subset of the measures that were included in the 

program year 2010 individual Physician Feedback reports. We proposed this subset of measures 

for both the PQRS payment adjustment and the value-based modifier because we believe these 

measures are clinically meaningful, focus on highly prevalent conditions among beneficiaries, 

have the potential to differentiate physicians, and be statistically reliable (77 FR 44980). We 

also sought comment on whether to include any of the remaining 13 measures included in the 

program year 2010 individual Physician Feedback Reports (77 FR 44998) (see Table 65 of the 

CY 2013 PFS proposed rule, 77 FR 45000). The utilization of the administrative claims 

measures will allow PQRS to implement different reporting options which capture a wider venue 

of participants without using the traditional methods of reporting. 

 We invited public comment on these proposed measures. The following is a summary of 

the comments we received regarding the proposed measures for eligible professionals and group 

practices that report using the administrative claims-based reporting mechanism for the 2015 

and/or 2016 PQRS payment adjustments. Please note that, since we are not finalizing an 

administrative claims-based reporting option for the 2016 PQRS payment adjustment, they will 

only be available for the purpose of reporting for the 2015 PQRS payment adjustment. 

 Comment: Most commenters agreed with assessing performance rates for the measures 

in the PQRS administrative claims-based reporting option at the TIN level. 

Response: We thank commenters for their support for this proposal and we are finalizing 

our proposal to calculate the Administrative Claims based measures at the single TIN level and 

applying the TIN’s performance to the TIN or to an individual NPI that elects the Administrative 
1061 

Claims option at the individual level. 

 Comment: One commenter opposed assessing ophthalmologists against the proposed 

administrative claims-based measures. The commenter notes that only 1 proposed administrative 

claims-based measure is applicable to ophthalmology. Although an ophthalmologist would be 

able to elect the administrative claims option and meet the measure targets based on the care 

their patients received from other physicians, the commenter does not believe it is appropriate for 

CMS to attribute care of non-eye conditions by other physicians to the ophthalmologist. 

 Response: We appreciate the commenter's feedback and realize that the proposed 

administrative claims-based measures may not adequately assess the specific scope of care 

furnished by ophthalmologists or other specialists to their patients. However, we believe this 

reporting option promotes shared accountability and care coordination for the quality of care furnished 

to beneficiaries and therefore provides important and actionable information for physicians about their 

beneficiaries. We also expect physicians and groups of physicians to report data on quality 

measures that reflect the care they furnish. We are therefore allowing ophthalmologists and 

other specialists to elect to be assessed against the administrative claims-based measures for 

purposes of the 2015 PQRS payment adjustment, both to provide ophthalmologists and other 

specialists with multiple options to meet the criteria for satisfactory reporting for the 2015 PQRS 

payment adjustment and to provide them with actionable information about shared accountability 

and care coordination important to their beneficiaries. We note that establishing the 

administrative claims-based reporting option for eligible professionals does not preclude 

ophthalmologists and other specialists to participate in PQRS using other reporting mechanisms 

and reporting other PQRS measures. 

Process Quality Measures. Of the 19 measures we proposed for reporting under the 

administrative claims-based reporting mechanism, 15 of these proposed measures were process 
1062 

measures. The following is a summary of the comments we received on these proposed process 

measures. 

Comment: Most commenters supported the Administrative Claims option and proposed 

process measures and saw it as a “low burden method to avoid the PQRS and value-based 

payment modifier adjustment,” although many expressed their dissatisfaction with 

administrative-claims-based measures in general, since these measures are derived from billing 

data and, as a result, lack the nuances of clinical data. Other commenters noted that the proposed 

measures were most applicable to the care of chronic conditions and preventive care and would 

not apply to the practice of many specialists and subspecialists. Commenters recommended that 

CMS include only measures that are NQF endorsed and that they be endorsed at the physician 

and/or group practice level. 

Response: We thank the commenters for their suggestions. As commenters stated, while 

administrative claims-based measures have shortcomings for clinical process measurement due 

to their lack of clinical data, we have chosen to preferentially use claims-based process measures 

that have NQF endorsement and were found to have high reliability in the program year 2010 

physician feedback reports. As we have stated above, by providing physicians with information 

about their beneficiaries outside of their specialty, we are promoting shared accountability and 

care coordination for beneficiaries, which we believe are important domains promoted by the 

National Quality Strategy. We are finalizing 13 of the proposed 15 process measures and are 

adding NQF 0022, “Use of High Risk Medicines in the Elderly,” which we had used in the 2010 

physician feedback reports. We agree with the comments that we should, where possible, use 

NQF-endorsed measures for this reporting option, but we do not believe that CMS should change 

or update measures that have been endorsed. We believe updating measure specifications is the 

responsibility of the measure steward. With that being said, we do plan to monitor NQF 
1063 

endorsement activity and will adjust the measures in the Administrative Claims option in future 

years accordingly. 

We are not finalizing NQF 0021 measure titled “Annual Monitoring for Beneficiaries on 

Persistent Medications,” for the Administrative Claims option. The measure steward, NCQA, 

has withdrawn this measure from consideration during NQF Steering Committee review and will 

update and resubmit the measure at a later date. Instead, we will substitute NQF 0022 “Use of 

High Risk Medicines in the Elderly,” which was included in Table 65 of the CY 2013 PFS 

proposed rule (77 FR 45000) and on which we had sought comment for including in the 

administrative claims option. Like NQF 0021, this process measure is a patient safety measure 

for medication management in the elderly. Additionally, the measure was suggested for inclusion 

by several commenters due to its importance in beneficiary care and broad applicability to 

physicians. Additionally, based on our 2010 analysis of its use in the physician feedback 

program, it has a high level of reliability. Unlike NQF 0021, NQF 0022 remains endorsed by 

NQF. 

Comment: Some commenters identified attribution of patients to physicians and risk 

adjustment as challenges with administrative claims-based measures in general. Others noted that 

the current administrative claims-based measure set is primary care oriented and lacks measures 

appropriate for specialists. 

Response: We appreciate these comments and have acknowledged above the challenges 

commenters associated with administrated claims-based measures that make them an imperfect 

data source for measuring certain aspects of quality. Administrative claims-based measures will 

likely continue to comprise part of the measure set for the value-based modifier, such as the cost 

measures and measures that extend across the continuum of care. CMS developed the 

administrative claims option to create an opportunity for physician practices that have not yet 
1064 

invested in the infrastructure and capabilities otherwise required to participate in PQRS to 

engage meaningfully in quality measurement and quality improvement. Ultimately, we believe 

that physician practices should actively gather and report quality data, such as through EHRs or 

registries. Thus, we do not anticipate that an option to participate in PQRS and the value-based 

payment modifier exclusively using administrative claims will continue beyond the first few 

years of the program. 

Comment: Commenters also suggested removing NQF 0549 measure titled 

“Pharmacotherapy Management of COPD Exacerbation,” because not all COPD patients should 

receive a corticosteroid and the measure does not take into account if a patient has possession of 

the medication at home. 

Response: We are not finalizing NQF 0549 “Pharmacotherapy Management of COPD 

Exacerbation.” This measure was submitted and reviewed by NQF this year and was not 

recommended for continued endorsement due to questions raised about the measure’s validity. 

Comment: Commenters suggested removing the proposed NQF 0576 measure titled 

“Follow-up After Hospitalization for Mental Illness” from the administrative claims-based 

measure set, because the measure would have minimal potential to distinguish physicians who 

are not mental health specialists from those who are thus making attribution a concern. 

Response: We appreciate this comment and concur that psychiatrists treating patients 

who have been hospitalized for mental illness should be held accountable for ensuring 

appropriate follow up after discharge. However, we believe that our objective of effective care 

coordination and safe care transitions for patients with mental illness are best served when all 

physicians and providers involved in the care of a patient with mental illness who has been 

discharged from an inpatient care setting share accountability for effective care coordination. We 

are therefore finalizing this measure in the claims-based option as supported by many other 
1065 

commenters. 

Comment: Commenters suggested removing the proposed NQF 0543 measure titled 

“Statin Therapy for Beneficiaries with Coronary Artery Disease” from the administrative claimsbased measure set, because there are multiple influences on why patients may not obtain the 

medication. 

 Response: We recognize that physicians play a critical role in influencing patient 

medical adherence, and the point made would obviate the use of all medication measures. We are 

therefore finalizing this measure in the claims-based option as supported by many other 

commenters. 

Outcome Measures. Of the 19 measures we proposed for reporting using the 

administrative claims-based reporting mechanism, 4 of these proposed measures were outcome 

measures – All Cause Readmission, 30 day Post Discharge Visit, and the Acute and Chronic 

Preventive Quality Indicator (PQI) Composites. The following is a summary of the comments 

received on the proposed outcome measures available for the administrative claims-based 

reporting mechanism. 

Comment: Many commenters were opposed to the four outcome measures due to lack of 

NQF endorsement at the group or physician level, inadequate risk adjustment, lack of ability for 

verification by the physician group using their own data, or the lack of actionability by the 

physician groups. The PQIs were cited as population level measures, unlikely to be valid at the 

provider or smaller group level. Other commenters stated that planned hospital readmissions 

may constitute appropriate care. And for the 30-day post-discharge follow-up visit measures, 

commenters pointed out that surgeons are subject to the 90-day global payment period and 

cannot generate a claim for a 30-day post-discharge follow-up visit, thus questioning the 

accuracy of the measure. Commenters also indicated that there may be other ways to ensure 
1066 

sufficient care coordination after a hospitalization that does not involve a visit within 30 days of 

discharge. Many commenters suggested four recently NQF endorsed care coordination measures 

to replace these four care coordination outcome measures. 

A substantial number of commenters from the consumer advocacy and physician value 

community supported all four of the outcome measures as moving quality measurement in the 

forward direction and in particular singled out the use of composite scores as a method to 

increase reliability. 

Response: We appreciate the commenters’ suggestions. We are finalizing the all cause

readmission measure and the Acute and Chronic Preventive Quality Indicator composites for use 

in the PQRS Administrative Claims option and for all groups of physicians subject to the valuebased payment modifier (see discussion below in Section III.K.2). The all cause readmission 

measure is NQF endorsed at the hospital level, has been respecified for groups of physicians, and 

we are using the all-cause readmission measure in the Medicare Shared Savings Program. 

Likewise, the individual PQI measures, while currently endorsed at the population level, have 

been respecified for medical groups and used in the physician feedback reports. Furthermore, we 

are collaborating with AHRQ, the measure steward for the PQIs, about our use of PQI 

composite measures. We will be seeking NQF endorsement of the respecified all cause 

readmission measure and PQI composite measures. Both the all-cause readmission measure and 

the PQI measures have been respecified using rigorous risk adjustment methods. We are 

redesigning our physician feedback reports to allow groups of physicians to verify who the 

patients included in these measures are, so that they can take appropriate actions. We are 

persuaded by the comments about the 30-day post-discharge visit measure and we will not 

finalize that measure. 

We believe an effective Administrative Claims option and a meaningful value-based 
1067 

payment modifier in the long-run will place greater emphasis on outcome measures and we 

believe it is important to include outcome measures that highlight key areas for achieving better 

care for beneficiaries. 

 

 With regard to the suggestions to replace these outcome measures for four recently 

endorsed AMA-PCPI care coordination measures that were recently NQF endorsed, we note that 

these suggested care coordination measures are all process measures, and they will be considered 

for the claims option of the PQRS program in 2014 in future rulemaking. 

 Therefore, based on the comments received, as specified in Tables 123 and 124, we are 

finalizing 17 measures, comprised of 14 process and 3 outcome measures (2 of which are PQI 

composite measures), for inclusion in the PQRS administrative claims-based measure set for 

reporting for the 2015 PQRS payment adjustment only. 

TABLE 123: Process Measures for Eligible Professionals and Group Practices Who 

Report Using Administrative Claims for the 2015 PQRS Payment Adjustment 

Measures for the Administrative Claims Options for 2015 

NQF 

Number 

Measure Title Measure 

Steward 

Domain of 

Care 

0576 Follow-Up After Hospitalization for Mental Illness 

Percentage of discharges for patients who were hospitalized for treatment of selected mental 

health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial 

hospitalization with a mental health practitioner 

NCQA Care 

Coordination 

0022 Use of High-Risk Medications in the Elderly: (a) Patients Who Receive 

At Least One Drug To Be Avoided 

Percentage of patients ages 65 years and older who received at least one high-risk medication 

in the measurement year 

(b) Patients Who Receive At Least Two Different Drugs To Be 

Avoided 

Percentage of patients 65 years of age and older who received at least two different high-risk 

medications in the measurement year 

NCQA Patient 

Safety 

0555 Lack of Monthly INR Monitoring for Beneficiaries on Warfarin 

Average percentage of 40-day intervals in which Part D beneficiaries with claims for 

warfarin do not receive an INR test during the measurement period.

CMS Patient 

Safety 

0577 Use of Spirometry Testing to Diagnose COPD 

Percentage of patients at least 40 years old who have a new diagnosis or newly active chronic 

obstructive pulmonary disease (COPD) who received appropriate spirometry testing to 

confirm the diagnosis.

NCQA Clinical Care 

0543 Statin Therapy for Beneficiaries with Coronary Artery Disease 

Medication Possession Ratio (MPR) for statin therapy for individuals over 18 years of age 

with coronary artery disease.

CMS Clinical Care 
1068 

0583 Lipid Profile for Beneficiaries Who Started Lipid-Lowering 

Medications 

Percentage of patients age 18 or older starting lipid-lowering medication during the 

measurement year who had a lipid panel checked within 3 months after starting drug therapy

Resolution 

Health 

Clinical Care 

0053 Osteoporosis Management in Women ≥ 67 Who Had a Fracture 

Percentage of women 67 years and older who suffered a fracture and who had either a bone 

mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the 6 

months after the date of fracture.

NCQA Clinical Care 

0055 Dilated Eye Exam for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 years who received a dilated eye exam 

by an ophthalmologist or optometrist during the measurement year, or had a negative retinal 

exam (no evidence of retinopathy) by an eye care professional in the year prior to the 

measurement year.

NCQA Clinical Care 

0057 HbA1c Testing for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 years receiving one or more A1c test(s) 

per year.

NCQA Clinical Care 

0062 Urine Protein Screening for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult diabetes patients aged 18-75 years with at least one test nephropathy 

screening test during the measurement year or who had evidence existing nephropathy 

(diagnosis of nephropathy or documentation of microalbuminuria or albuminuria).

NCQA Clinical Care 

0063 Lipid Profile for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 who had an LDL-C test performed 

during the measurement year.

NCQA Clinical Care 

0075 Lipid Profile for Beneficiaries with Ischemic Vascular Disease 

Percentage of patients 18 years of age and older who were discharged alive for acute 

myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary 

interventions (PCI) from January 1–November 1 of the year prior to the measurement year, or 

who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the 

year prior to measurement year, who had a complete lipid profile during the measurement 

year.

NCQA Clinical Care 

0105 Antidepressant Treatment for Depression 

Percentage of patients who were diagnosed with a new episode of depression and treated with 

antidepressant medication and who remained on an antidepressant medication treatment for: 

(a) at least 84 days (12 weeks) and (b) 180 days (6 months). 

NCQA Clinical Care 

0031 Breast Cancer Screening for 

Women ≤ 69 

Percentage of eligible women 40-69 who receive a mammogram in during the measurement 

year or in the year prior to the measurement year.

NCQA Clinical Care 

Table 124: Outcome Measures for Eligible Professionals and Group Practices Who Report 

Using Administrative Claims for the 2015 PQRS Payment Adjustment 

NQF 

Number 

Measure Title Measure 

Steward 

Domain of 

Care 

N/A 1. Composite of Acute Prevention Quality Indicators (PQIs) N/A Care 

Coordinatio

n

0279 Bacterial Pneumonia

The number of admissions for bacterial pneumonia per 100,000 

population.

AHRQ

0281 UTI

The number of discharges for urinary tract infection per 100,000 

population Age 18 Years and Older in a one year time period

AHRQ

0280 Dehydration

The number of admissions for dehydration per 100,000 population.

AHRQ

N/A 2. Composite of Chronic Prevention Quality Indicators (PQIs) N/A Care 

Coordinatio

n

Diabetes Composite 
1069 

0638 Uncontrolled diabetes

The number of discharges for uncontrolled diabetes per 100,000 

population Age 18 Years and Older in a one year time period.

AHRQ

0272 Short Term Diabetes complications

The number of discharges for diabetes short-term complications per 

100,000 Age 18 Years and Older population in a one year period.

AHRQ

0274 Long term diabetes complications 

The number of discharges for long-term diabetes complications per 

100,000 population Age 18 Years and in a one year time period. 

AHRQ

0285 Lower extremity amputation for diabetes

The number of discharges for lower-extremity amputation among 

patients with diabetes per 100,000 population Age 18 Years in a one 

year time period.

AHRQ

0275 COPD

 The number of admissions for chronic obstructive pulmonary 

disease (COPD) per 100,000 population.

AHRQ

0277 Heart Failure

Percent of the population with admissions for CHF.

AHRQ

N/A 3. All Cause Readmission

The rate of provider visits within 30 days of discharge from an acute 

care hospital per 1,000 discharges among eligible beneficiaries 

assigned.

CMS Care 

Coordinatio

n

7. Maintenance of Certification Program Incentive: Self-Nomination and Qualification Process 

for Entities Wishing to be Qualified for the 2013 and 2014 Maintenance of Certification Program 

Incentives 

We proposed that new and previously qualified entities wishing to become qualified to 

provide their members with an opportunity to earn the 2013 and/or 2014 Maintenance of 

Certification Program incentives undergo a self-nomination and qualification process (77 FR 

44982). Once qualified, we proposed that the entity would be able to submit data on behalf of its 

eligible professionals. 

Maintenance of Certification Program Incentive: Self-Nomination Process. For the selfnomination process, we proposed that an entity wishing to be qualified for the 2013 and/or 2014 

Maintenance of Certification Program incentive would be required to submit a self-nomination 

statement containing all of the following information via the web: 

● Provide detailed information regarding the Maintenance of Certification Program with 
1070 

reference to the statutory requirements for such program. 

● Indicate the organization sponsoring the Maintenance of Certification Program, and 

whether the Maintenance of Certification Program is sponsored by an American Board of 

Medical Specialties (ABMS) board. If not an ABMS board, indicate whether and how the 

program is substantially equivalent to the ABMS Maintenance of Certification Program process. 

● Indicate that the program is in existence as of January 1 the year prior to the year in 

which the entity seeks to be qualified for the Maintenance of Certification Program incentive. 

For example, to be qualified for the 2013 Maintenance of Certification Program incentive, the 

entity would be required to be in existence by January 1, 2012. 

● Indicate that the program has at least one (1) active participant. 

● The frequency of a cycle of Maintenance of Certification for the specific Maintenance 

of Certification Program of the sponsoring organization, including what constitutes "more 

frequently" for both the Maintenance of Certification Program itself and the practice assessment 

for the specific Maintenance of Certification Program of the sponsoring organization. 

● Confirmation from the board that the practice assessment will occur and be completed 

in the year the physician is participating in the Maintenance of Certification Program Incentive. 

● What was, is, or will be the first year of availability of the Maintenance of 

Certification Program practice assessment for completion by an eligible professional. 

● What data is collected under the patient experience of care survey and how this 

information would be provided to CMS. 

● Describe how the Maintenance of Certification program monitors that an eligible 

professional has implemented a quality improvement process for their practice. 

● Describe the methods, and data used under the Maintenance of Certification Program, 

and provide a list of all measures used in the Maintenance of Certification Program for the year 
1071 

prior to which the entity seeks to be qualified for the Maintenance of Certification Program 

incentive (for example, measures used in 2012 for the 2013 Maintenance of Certification 

Program incentive), 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 invited but received no public comment on our proposed self-nomination process for 

entities who wish to be qualified for the 2013 and 2014 Maintenance of Certification Program 

incentive. Therefore, we are finalizing the self-nomination process for boards wishing to 

participate in the Maintenance of Certification Program incentive, as proposed. 

Maintenance of Certification Program Incentive: Qualification Process. For the 

qualification process, we proposed that an entity must meet all of the following requirements to 

be considered for qualification for purposes of the 2013 and 2014 Maintenance of Certification 

Program incentives (77 FR 44983): 

● The name, NPI and applicable TINs of eligible professionals who would like to 

participate for the 2013 and/or 2014 Maintenance of Certification Program incentives. 

● Attestation from the board that the information provided to CMS is accurate and 

complete. 

● The board has signed documentation from eligible professional(s) that the eligible 

professional wishes to have the information released to us. 

● Information from the patient experience of care survey. 

● Information certifying the eligible professional has participated in a Maintenance of 

Certification Program for a year, “more frequently” than is required to qualify for or maintain 

board certification status, including the year the physician met the board certification 
1072 

requirements for the Maintenance of Certification Program, and the year the eligible professional 

participated in the Maintenance of Certification Program “more frequently” than is required to 

maintain or qualify for board certification. 

● Information certifying the eligible professional has completed the Maintenance of 

Certification Program practice assessment at least one time each year the eligible professional 

participates in the Maintenance of Certification Program Incentive. 

We proposed this self-nomination and qualification process because the process is 

identical to the self-nomination and qualification process finalized for the 2011 and 2012 

Maintenance of Certification Program incentives and we felt such requirements remain 

appropriate. Because the incentives only run through 2014, we felt it was important to keep the 

requirements consistent with what has been required for the 2011 and 2012 Maintenance of 

Certification Program incentives. 

We invited public comment on the proposed qualification process for entitles entities who 

wish to be qualified for the 2013 and 2014 Maintenance of Certification Program incentive. The 

following is summary of the comments we received regarding these proposals. 

Comment: One commenter suggested that those entities that have previously undergone 

the qualification process and were previously qualified to participate in this Maintenance of 

Certification Program incentive be automatically qualified for the following year. 

Response: We agree with the commenter’s suggestion to allow boards that were fully 

qualified in a prior program year and successfully submitted data to be fully qualified after CMS 

review of their application. Since the qualification process is the same from year to year, CMS 

believes that requiring boards to undergo this process every year is redundant. CMS agrees that 

this will allow more time for returning boards to encourage participation with their diplomats. 

Comment: One commenter suggested that newly participating boards be allowed to 
1073 

bypass the qualification process if they administer a qualified registry. 

Response: We agree with the commenter’s suggestion. The data submission process for 

Maintenance of Certification entities is similar to the registry data submission process. 

Therefore, it would seem redundant for a specialty board that already possesses a qualified 

registry to have to undergo another separate qualification process to participate in the 

Maintenance of Certification Program incentive, as the entity’s products and characteristics have 

already been vetted when it submitted its registry for qualification under PQRS. Therefore, we 

do not believe it is necessary for specialty boards that administer PQRS qualified registries to 

undergo a separate qualification process for purposes of the Maintenance of Certification 

Program incentive. Therefore, we are not requiring boards who wish to participate in the 

Maintenance of Certification Program incentive for the first time to undergo the Maintenance of 

Certification Program incentive qualification process if they also maintain a PQRS qualified 

registry. However, we note that these specialty boards must still self-nominate for each year the 

specialty board wishes to participate in Maintenance of Certification Program incentive. 

Comment: One commenter believed that the requirements for receiving a Maintenance of 

Certification incentive payment are too onerous for both physicians and participating boards. 

Response: We appreciate the commenter's feedback. We understand that physicians 

already participating in Maintenance of Certification programs are already taking proactive steps 

to maintain their clinical skills and education. In fact, we defer to the boards for what is 

necessary to demonstrate a physician's ability to maintain certification. However, given the 

requirement that a physician participate in a Maintenance of Certification program "more 

frequently" than is required to maintain board certification, we believe that earning an additional 

Maintenance of Certification incentive under PQRS involves extra effort by the physician. 

Please note that we work with the participating boards to determine what extra steps are 
1074 

necessary to earn this incentive. 

Comment: One commenter seeks clarification on how physicians are to participate in a 

Maintenance of Certification Program "more frequently" than is required to maintain or qualify 

for board certification. 

Response: Please note that more information and guidance about how to participate in a 

Maintenance of Certification Program incentive "more frequently" for purposes of the 

Maintenance of Certification Program incentive is available on the PQRS website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. 

Comment: One commenter requested that CMS explore opportunities to leverage the 

Maintenance of Certification structure that exists within the specialty boards to reduce redundant 

reporting requirements and enhance the value of PQRS for physicians and their patients. 

Response: We appreciate the commenter's feedback. CMS has worked closely with the 

specialty boards to establish requirements for earning the additional Maintenance of Certification 

Program incentive under PQRS. In fact, the boards provide the guidelines for determining what 

is necessary to demonstrate a physician's ability to maintain certification. 

Based on the comments received and for the reasons discussed above, we are finalizing 

the qualification process for boards wishing to become qualified to participate in the 

Maintenance of Certification Program incentive. However, , boards that were previously 

qualified as a Maintenance of Certification Program entity or newly participating boards that 

utilize a previously qualified registry for their Maintenance of Certification Program data will 

not need to undergo the qualification process annually. Rather, these entities will be qualified 

after these entities complete their self-nomination statements. However, please note that 

previously qualified boards or boards that use a previously qualified registry must still self-
1075 

nominate to participate in the Maintenance of Certification Program incentive for each year the 

boards wish to participate. For boards wishing to newly become qualified, we note that, due to a 

delay in the availability of the testing tool to qualify the boards, this qualification process will 

occur later in time for 2013. Please note that we are also making technical changes in 

§414.90(d) due to changes in the composition of §414.90(c) to specify the incentive amounts for 

the 2013 and 2014 PQRS incentives. We are also making a technical change at 

§414.90(d)(1)(iii)(B)(2)(i), as this section incorrectly references (d)(2)(11); the correct reference 

is (d)(1)(iii). 

8. Informal Review 

 We established an informal review process for 2012 and beyond in the CY 2012 

Medicare PFS final rule (76 FR 73390). In this final rule with comment period, we addressed 

the additional parameters we proposed for eligible professionals and group practices subject to a 

PQRS payment adjustment requesting an informal review. For eligible professionals and group 

practices that are subject to the payment adjustments that wish to request an informal review, in 

addition to the requirements we previously established, we proposed the following: 

● An eligible professional electing to utilize the informal review process must request an 

informal review by February 28 of the year in which the payment adjustment is being applied. 

For example, if an eligible professional requests an informal review related to the 2015 payment 

adjustment, the eligible professional would be required to submit his/her request for an informal 

review by February 28, 2015. We felt this deadline provided ample time for eligible 

professionals and group practices after their respective claims begin to be adjusted due to the 

payment adjustment. 

● Where we find that the eligible professional or group practice did satisfactorily report 

for the payment adjustment, we would to cease application of the payment adjustment and 
1076 

reprocess all claims that have been erroneously adjusted to date (77 FR 44983). 

 We invited public comment on our proposals for the PQRS informal review process. The 

following is a summary of the comments we received regarding the proposed additional 

parameters for the PQRS informal review process. 

 Comment: Several commenters supported our proposal to establish an informal review 

process for the PQRS payment adjustment. 

 Response: We appreciate the commenters' feedback and are finalizing an informal review 

process for the PQRS payment adjustments that is similar to the informal review process 

established for the PQRS incentives. 

 Comment: One commenter supported our proposed deadline of February 28 of the 

payment adjustment year for eligible professionals and group practices to request an informal 

review of the PQRS payment adjustment. 

 Response: Based on the comments received, we are finalizing a deadline of February 28 

of the payment adjustment year for eligible professionals and group practices to request an 

informal review of the PQRS payment adjustment. 

 Comment: One commenter supported CMS' proposal to provide written responses to 

those eligible professionals and group practices seeking an informal review request. 

 Response: We appreciate the commenter's feedback and we are finalizing our proposal to 

provide a timely, written response to eligible professionals and group practices seeking an 

informal review of the applicability of the PQRS payment adjustment. 

 Comment: One commenter supported our proposal to make eligible professionals and 

group practices whole should CMS find error. 

Response: We believe it is important to rectify error should CMS find that an error has 

occurred in application of the PQRS payment adjustment during the informal review process. 
1077 

Therefore, where we find that the eligible professional or group practice did satisfactorily report 

for the payment adjustment, we will cease application of the payment adjustment and reprocess 

all claims that have been erroneously adjusted to date. 

Based on the comments received and for the reasons stated previously, we are finalizing 

these additional parameters for the PQRS informal review process as it relates to the PQRS 

payment adjustments. We are finalizing changes to §414.90 to reflect the PQRS informal review 

process for the PQRS incentives and payment adjustments. 

H1. The Electronic Prescribing (eRx) Incentive Program

 We established the requirements for the 2013 and 2014 eRx Incentive Program in the CY 

2012 Medicare PFS final rule (76 FR 73393). This section addresses additional final 

requirements for the 2013 and 2014 eRx Incentive Program. 

Please note that, during the comment period following the proposed rule, we received 

comments that were not related to our specific proposals for the eRx Incentive Program in the 

CY 2013 Medicare PFS proposed rule. While we appreciate the commenters' feedback and 

intend to use these comments to better develop the eRx Incentive Program, these comments will 

not be specifically addressed in this CY 2013 Medicare PFS final rule. 

1. Definition of Group Practice 

 Under §414.92(b) a group practice is one that, defined at §414.90(b), that is participating 

in the Physician Quality Reporting System; or in a Medicare-approved demonstration project or 

other Medicare program, under which Physician Quality Reporting System requirements and 

incentives have been incorporated; and has indicated its desire to participate in the electronic 

prescribing group practice option. Please note that the definition of group practice for the eRx 

Incentive Program is therefore tied to the definition of group practice under PQRS. Since we are 

changing the definition of group practice in PQRS to allow groups of 2-24 eligible professionals 
1078 

to participate in PQRS as a group practice, accordingly, group practices of 2-24 eligible 

professionals will be able to participate in the eRx Incentive Program as a group practice in 2013 

(that is, for the 2013 incentive and 2014 payment adjustment). 

 In addition, we would like to clarify the requirement under §414.92(b) that a group 

practice under the eRx Incentive Program must be “participating in the Physician Quality 

Reporting System”. We developed this definition in light of our goals for group practices to 

report under both programs, as well as operational considerations for administering the group 

practice reporting option under the PQRS and ERx Incentive Program. In particular, we expect 

that group practices participating in the eRx Incentive Program as a group practice will also be 

participating in PQRS as a group practice. With regard to “participation,” we note that we have 

never required nor indicated that group practices under the eRx GPRO must report PQRS quality 

measures to demonstrate participation in the PQRS for purposes of this definition. In the past, 

we have required that group practices wishing to participate in the eRx Incentive Program under 

the group practice reporting option (eRx GPRO) must complete a self-nomination statement 

stating the group practice’s intent to participate in PQRS as a group practice. We have viewed 

that as an example of “participation.” However, because we believe submission of a selfnomination statement for PQRS as an extra administrative step we have required in order for 

group practices to participate in the eRx GPRO, in 2013, we no longer view completion of a selfnomination statement to participate in PQRS under the PQRS group practice reporting option 

(PQRS GPRO) as necessary to demonstration “participation” by group practices under the eRx 

Incentive Program. Therefore, the statement to be “participating in the Physician Quality 

Reporting System” is merely an indication but not a requirement that we expect that group 

practices participating in the eRx Incentive Program as a group practice will also be participating 

in PQRS as a group practice. 
1079 

2. Alternative Self-Nomination Process for Certain Group Practices Under the eRx GPRO 

 In the CY 2012 Medicare PFS final rule (76 FR 73394), we established that a group 

practice wishing to participate in the eRx Incentive Program under the eRx GPRO must selfnominate via the web. However, we proposed an alternative submission mechanism for selfnomination by groups participating in the Medicare Shared Savings Program, Pioneer ACO, PGP 

Demonstration, or other Medicare-approved demonstration project or other Medicare program 

(77 FR 44983). Specifically, we proposed that the participating TINs within these groups that 

wish to participate in the eRx Incentive Program using the eRx GPRO would be required to 

submit a self-nomination statement by sending a letter indicating its intent to participate in the 

eRx Incentive Program under the eRx GPRO. We also proposed that the group practice would 

be required to submit an XML file describing the eligible professionals included in the group 

practice. We proposed this alternative submission mechanism for group practices that are 

participating as groups in the Medicare Shared Savings Program, Pioneer ACO, or PGP 

Demonstration because it is not technically feasible for CMS to receive this information from 

these group practices via the web. We invited public comment on this proposed alternative 

mechanism for submitting self-nomination statements for groups participating in the Medicare 

Shared Savings Program, Pioneer ACO, and PGP demonstration and the proposed requirement to 

provide an XML file to CMS for the types of group practices identified above that want to 

participate in the eRx Incentive Program using the eRx GPRO. We received no comments 

regarding these proposed alternative methods related to the self-nomination process for group 

practices participating in the Medicare Shared Savings Program, Pioneer ACO, and PGP 

demonstration that wish to participate in the eRx Incentive Program using the eRx GPRO. 

Therefore, we are finalizing an alternative self-nomination process for these aforementioned 

groups. However, as we believe that it would be more efficient to accept self-nomination 
1080 

statements electronically, we will not accept these self-nomination statements via U.S. mail. 

Rather, we will accept these self-nomination statements via email. We are also not finalizing the 

requirement that these group practices provide an XML file to CMS. The XML file typically 

provides CMS with a list of the eligible professionals (defined by their individual rendering 

National Provider Identification numbers or NPIs) within the group practice. Since we do not 

need NPI-level information to analyze group practice reporting, we no longer need this XML 

file. 

 In addition, in the CY 2012 PFS final rule with comment period, we stated we would 

accept self-nomination statements for group practices that want to participate in the GPROs for 

PQRS and the eRx Incentive Program via the web (76 FR 73315 and 76 FR 73394). We note 

that this web page is only available for those group practices who wish to submit a selfnomination statement to participate in both the PQRS and eRx Incentive Program under the 

respective GPROs. Therefore, it will not be technically feasible to accept self-nomination 

statements via this web page from group practices who wish to submit a self-nomination 

statement to participate in the eRx GPRO only. Group practices wishing to submit a separate 

GPRO self-nomination statement to participate in the eRx Incentive Program only must follow 

the alternative self-nomination process that group practices participating in the Medicare Shared 

Savings Program using the eRx GPRO follow (76 FR 73395). 

 We also note that, in the CY 2012 Medicare PFS final rule, we established a deadline of 

January 31 of the applicable program year (for example, January 31, 2013 for the 2013 program 

year) for group practices to submit a self-nomination statement to participate in the eRx GPRO 

(76 FR 73316). Although, as discussed in section III.G, we have extended the deadline for group 

practices wishing to participate in the GPRO in PQRS to the Fall of the applicable program year 

(for example, Fall 2013 for the 2013 program year), for operational reasons, group practices 
1081 

wishing to participate in the eRx Incentive Program under the eRx GPRO for 2013 must submit 

its self-nomination statement by January 31, 2013 as finalized in the CY 2012 Medicare PFS 

final rule. We understand that having two separate deadlines for submitting GPRO selfnomination statements for PQRS and the eRx Incentive Program may cause confusion for group 

practices who have submitted self-nomination statements for PQRS and eRx simultaneously in 

previous years. However, because the 2014 6-month payment adjustment reporting period (that 

is, January 1, 2013 – June 30, 2013) occurs prior to Fall 2013, we must maintain a deadline of 

January 31, 2013 for those group practices wishing to participate in the eRx Incentive Program 

as a group practice using the eRx GPRO for reporting periods occurring 2013. 

 We realize that having two separate self-nomination dates of January 31, 2013 and Fall 

2013 for self-nominating to participate in the GPRO for the eRx Incentive Program and PQRS 

respectively may cause additional administrative concerns, such as situations where a group 

practice may change its TIN between June 30, 2013 (after the 6-month 2014 payment adjustment 

reporting period) and Fall 2013. We will try to work with group practices so that they are aware 

of the applicable deadlines and procedure. 

2. The 2013 Incentive: Criterion for Being a Successful Electronic Prescriber for Groups 

Comprised of 2-24 Eligible Professionals Selected to Participate under the eRx GPRO 

We proposed to add another criterion for becoming a successful electronic prescriber 

under the program for the 2013 Incentive for groups of 2-24 eligible professionals that may now 

participate in the eRx Incentive Program using the eRx GPRO in 2013 (77 FR 44983-44984). 

(For the other criteria we previously adopted for the eRx GPRO, please see 76 FR 73407). 

Specifically, we proposed the following criterion for being a successful electronic prescriber for 

group practices participating in the eRx GPRO comprised of 2-24 eligible professionals for 

purposes of the 2013 eRx incentive: report the electronic prescribing measure’s numerator code 
1082 

during a denominator-eligible encounter for at least 225 times during the 12-month 2013 

incentive reporting period (January 1, 2013—December 31, 2013). We proposed a lower 

criterion for group practices participating under the eRx GPRO with 2-24 eligible professionals 

because we understand that their smaller sizes necessitate a lower reporting threshold. We 

proposed this reporting threshold because this reporting threshold is familiar to group practices, 

as this was the threshold established for group practices comprised of 11-25 eligible 

professionals that participated in the GPRO II in 2011 (75 FR 73509). 

We invited public comment on our proposed criterion for being a successful electronic 

prescriber for the 2013 incentive for groups comprised of 2-24 eligible professionals. The 

following is a summary of the comments we received on this proposal. 

Comment: Several commenters generally supported our proposal to establish criteria for 

being a successful electronic prescriber for group practices comprised of 2-24 eligible 

professionals. However, some commenters stated that our proposed reporting threshold for a 

group practice of 2-24 eligible professionals to become a successful electronic prescriber is too 

high, particularly for a group comprised of 2 eligible professionals. One commenter suggested 

applying a percentage threshold, similar to the electronic prescribing criteria established under 

the EHR Incentive Program. Other commenters suggested a tiered approach similar to the 

criteria for becoming a successful electronic prescriber previously established under eRx GPRO 

II (75 FR 73509). One of these commenters also suggested that, in the alternative, the proposed 

threshold be lowered. Commenters stated that group practices of 2-24 eligible professionals 

should be required report the electronic prescribing measure at least 75 times to become a 

successful electronic prescriber for the 2013 incentive. 

Response: We believe it is important to establish an electronic prescribing threshold that 

group practices of 2-24 eligible professionals can reasonably attain to become successful 
1083 

electronic prescribers. As we explain in greater detail further below, we agree with the 

commenters’ suggestion and therefore, we are finalizing a reporting threshold of 75 times. 

For the suggestion to adopt a percentage threshold, we prefer to establish a reporting 

count as the established criteria for becoming a successful electronic prescriber for larger groups 

utilize a reporting count rather than a percentage. Therefore, we would like to remain consistent 

in the reporting criteria that were previously established for larger group practices participating 

in the eRx GPRO. 

For the tiered approach, we believe that adding several tiers for reporting for smaller 

group practices would add to the complexity of the eRx Incentive Program. To streamline the 

requirements for becoming a successful electronic prescriber for the eRx Incentive Program, we 

prefer one criterion for all group practices of 2-24 eligible professionals using the eRx GPRO. 

We believe that the proposed threshold of 75 offered by commenters is reasonable, particularly 

because the eRx Incentive Program previously required group practices of 2-10 eligible 

professionals participating in the eRx GPRO II to report the electronic prescribing measure at 

least 75 times (75 FR 73509). We note that our proposed threshold of reporting the electronic 

prescribing measure was also consistent with criteria we established under GPRO II in 2011, but 

we understand the desire to lower the threshold to 75. We believe that the reporting threshold of 

75 also achieves the program goal of ensuring that eligible professionals are generating 

prescriptions electronically. Therefore, based on the comments received, we are finalizing a 

lower threshold for reporting the electronic prescribing measure of 75 rather than 225. To be a 

successful electronic prescriber for the 2013 incentive, group practices comprised of 2-24 

eligible professionals that are participating in the eRx GPRO must report the electronic 

prescribing measure at least 75 times during the applicable 12-month reporting period (that is, 

January 1, 2013 – December 31, 2013) for the 2013 incentives. 
1084 

3. The 2014 Payment Adjustment: Criterion for Being a Successful Electronic Prescriber for 

Group Practices Comprised of 2-24 Eligible Professionals Selected to Participate under the eRx 

GPRO 

We proposed to change the minimum group practice size from 25 to 2 accordingly with 

PQRS and proposed to add another criterion for being a successful electronic reporter under the 

program for the 2014 payment adjustment (77 FR 44984). (For the other criteria we previously 

adopted for the eRx GPRO Reporting Option, please see 76 FR 73412-73414). Specifically, we 

proposed the following criterion for being a successful electronic prescriber for purposes of the 

2014 payment adjustment for group practices comprised of 2-24 eligible professionals 

participating under the eRx GPRO: Report the electronic prescribing measure's numerator code 

at least 225 times for the 6-month 2014 payment adjustment reporting period (January 1, 2013—

June 30, 2013). We proposed this lower criterion for group practices participating under the eRx 

GPRO with 2-24 eligible professionals because we understand that their smaller sizes necessitate 

a lower reporting threshold. In addition, we noted that this reporting threshold is familiar to 

group practices, as this was the threshold established for group practices comprised of 11-25 

eligible professionals that participated in the GPRO II in 2011 (75 FR 73509). 

We invited public comment on the proposed criterion for being a successful electronic 

prescriber for the 2014 eRx payment adjustment for the 6-month payment adjustment reporting 

period for group practices composed of 2-24 eligible professionals. The following is a summary 

of comments we received regarding this proposal. 

Comment: Commenters generally provided the same comments regarding this proposed 

criterion for becoming a successful electronic prescriber for the 2014 payment adjustment as 

provided for the proposed criterion for becoming a successful electronic prescriber for the 2013 

incentive. Specifically, several commenters generally supported our proposal to establish criteria 
1085 

for becoming a successful electronic prescriber for group practices comprised of 2-24 eligible 

professionals. However, some commenters stated that our proposed reporting threshold for a 

group practice of 2-24 eligible professionals to become a successful electronic prescriber is too 

high. One commenter suggested applying a percentage threshold, similar to the electronic 

prescribing criteria established under the EHR Incentive Program. Other commenters suggested 

a tiered approach similar to the criteria for becoming a successful electronic prescriber 

previously established under eRx GPRO II (75 FR 73509). One of these commenters also 

suggested that, in the alternative, the proposed threshold be lowered. Group practices of 2-24 

eligible professionals should be required report the electronic prescribing measure at least 75 

times to become a successful electronic prescriber for the 2014 payment adjustment. 

In addition to these comments, some commenters supported our proposed criteria to 

report the electronic prescribing measure at least 225 times to become a successful electronic 

prescriber for the 2013 incentive but believed that this 225 threshold is too high for the 2014 

payment adjustment, as group practices will only have 6 months as opposed to 12 months to 

meet this threshold. The commenters added that the threshold is especially high for 

dermatologists who may not see this many Medicare Part B patients during the 6-month 2014 

payment adjustment reporting period. 

Response: For the same reasons we discussed above with regard to the threshold for the 

2013 incentive, we agree with the points raised by commenters. In addition, for reporting under 

the eRx GPRO, it is our desire to keep with the trend of establishing similar criteria for the 

incentives as payment adjustments. It is our desire to finalize the same criterion for the 2014 

payment adjustment as finalized for the 2013 incentive. Therefore, based on the comments 

received and for the reasons we stated for establishing a lower threshold of 75 for the 2013 

incentive, we are finalizing a lower threshold for reporting the electronic prescribing measure for 
1086 

the 2014 payment adjustment of 75 instead of 225. To be a successful electronic prescriber for 

the 2014 payment adjustment, group practices comprised of 2-24 eligible professionals that are 

participating in the eRx GPRO must report the electronic prescribing measure at least 75 times 

during the applicable 2014 6-month payment adjustment reporting period. 

4. Analysis for the Claims-based Reporting Mechanism 

 We understand that, in certain instances, it is permissible for an eligible professional to 

have their Medicare Part B claims reprocessed. However, we raised concerns about eligible 

professionals resubmitting claims for the sole reason of attaching a G-code for purposes of 

reporting under the ERx Incentive Program (rather than reporting such data at the time the claim 

was initially submitted). Therefore, we proposed to modify §414.92 to indicate that under the 

eRx Incentive Program, if an eligible professional re-submits a claims for reprocessing, the 

eligible professional may not attach a G-code at that time. The following is a summary of 

comments we received on this proposal. 

 Comment: Some commenters disagreed with our proposal to modify § 414.92 to indicate 

that G-codes cannot be attached to claims that are re-submitted for reprocessing for purposes of 

the eRx Incentive Program. Commenters urged us to allow the reopening or resubmission of 

claims for the sole purpose of attaching a reporting code on a claim. 

 Response: To avoid the reprocessing of claims solely to report quality measure for the 

eRx Incentive Program, we believe such a policy is needed and therefore, we are finalizing our 

change to the regulation at §414.92. In addition, we note that even though professionals may 

prefer this practice, it is not practically feasible to allow eligible professionals and group 

practices to resubmit a claim for the sole purpose of attaching a reporting code on a claim for 

purposes of the eRx Incentive Program. Allowing eligible professionals to resubmit claims for 

reporting purposes opens the potential for the reprocessing of millions of claims, which would be 
1087 

overly burdensome and costly for CMS. Therefore, we are finalizing our proposal to add 

§414.92(f)(2)(i)(A) to indicate if an eligible professional re-submits a Medicare Part B claim for 

reprocessing, the eligible professional may not attach a G-code at that time for reporting on the 

electronic prescribing measure. We note that has been CMS’ policy not to accept quality data 

from claims that were resubmitted since the inception of PQRS (where the electronic prescribing 

measure was first available for reporting) in 2007. 

5. Proposed Significant Hardship Exemptions 

 Section 1848(a)(5)(B) of the Act provides that the Secretary may, on a case-by-case 

basis, exempt an eligible professional from the application of the payment adjustment, 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. In the CY 2012 final 

rule with comment period, we finalized, as set forth at §414.92(c)(2)(ii)(B), four circumstances 

under which an eligible professional or eRx GPRO can request consideration for a significant 

hardship exemption for the 2013 and 2014 eRx payment adjustments (76 FR 73413): 

• The eligible professional or group practice practices in a rural area with limited high speed 

internet access. 

• The eligible professional or group practice practices in an area with limited available 

pharmacies for electronic prescribing. 

• The eligible professional or group practice is unable to electronically prescribe due to local, 

state, or Federal law or regulation. 

• The eligible professional or group practice has limited prescribing activity, as defined by an 

eligible professional generating fewer than 100 prescriptions during a 6-month reporting 

period. 
1088 

 We have received feedback from stakeholders requesting significant hardship exemptions 

from application of the payment adjustment based on participation in the EHR Incentive 

Program, a program which requires a certain level of electronic prescribing activity. Under the 

EHR Incentive Program, eligible professionals4

 may receive incentive payments beginning in 

CY 2011 for successfully demonstrating “meaningful use” of Certified EHR Technology 

(CEHRT) and will be subject to payment adjustments beginning in CY 2015 for failure to 

demonstrate meaningful use. For further explanation of the statutory authority and regulations 

for the EHR Incentive Program, we refer readers to the EHR Incentive Program—Stage 1 final 

rule (75 FR 44314) and the EHR Incentive Program—Stage 2 final rule (77 FR 53968). As a 

result of such feedback, we believe that in certain circumstances it may be a significant hardship 

for eligible professionals and group practices who are participants of the EHR Incentive Program 

to comply with the successful electronic prescriber requirements of the eRx Incentive Program. 

Therefore, we proposed to revise the regulation at §414.92(c)(2)(ii)(B) (77 FR 44984) to add the 

following two additional significant hardship exemption categories for the 2013 and 2014 

payment adjustments: 

• Eligible professionals or group practices who achieve meaningful use during certain 

eRx payment adjustment reporting periods. 

• Eligible professionals or group practices who demonstrate intent to participate in the 

EHR Incentive Program and adoption of Certified EHR Technology. 

 The following is a summary of general comments we received regarding our proposal to 

add these two additional significant hardship exemption categories for the 2013 and 2014 

payment adjustments: 

 

4

 “Eligible professional” is defined for the EHR Incentive Program at 42 CFR 495.4, 495.100, and 495.304. 
1089 

 Comment: One commenter opposed our proposal to add two new additional significant 

hardship exemption categories related to participation in the EHR Incentive Program. The 

commenter notes that CMS implemented the eRx Incentive Program in 2009 and eligible 

professionals have had sufficient time in which to make arrangements to implement the program. 

The commenter is concerned these two new hardship exemptions may have the unintended 

consequence of discouraging eligible providers’ rapid participation in the electronic prescribing 

program. 

 Response: We appreciate the commenter's concern and note that it is not our intention to 

discourage participation in the eRx Incentive Program through the establishment of these 

significant hardship exemption categories. We note that incentives under the eRx Incentive 

Program are available until 2013 and hope that the potential to earn an incentive under the eRx 

Incentive Program will encourage eligible professionals who are not also receiving incentives 

under the Medicare EHR Incentive Program to participate in the eRx Incentive Program. 

 With respect to the argument that eligible professionals have had adequate time to 

acquire systems capable for electronic prescribing, we note that although the eRx Incentive 

Program was established in 2009, and has transitioned from bonus incentives to payment 

adjustments beginning in 2012, we believe that with the establishment of the EHR Incentive 

Program, which also includes an electronic prescribing objective, eligible professionals and 

group practices choosing to participate in the eRx Incentive Program and the EHR Incentive 

Program may have had difficulties with regard to searching for products that had the capabilities 

to meet requirements for both programs. As we noted in the proposed rule (77 FR 44984), we 

received stakeholder feedback regarding the difficulties of choosing, purchasing, and setting up 

an EHR system that is capable for use for both programs. Therefore, we believe that these 
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significant hardship exemption categories are appropriate for eligible professionals and group 

practices such as these. 

 Comment: Several commenters supported our proposed two additional significant 

hardship exemption categories related to participation in the EHR Incentive Program for the 

2013 and 2014 payment adjustments. 

 Response: We agree with the commenters’ general support of these two additional 

significant hardship exemptions. Therefore, based on the comments received and for the reasons 

stated previously, we are finalizing, as discussed in greater detail, these two additional significant 

hardship exemptions related to participation in the EHR Incentive Program for the 2013 and 

2014 payment adjustments. 

a. Eligible professionals or group practices who achieve meaningful use during the 2013 and 

2014 payment adjustment reporting periods. 

 Under Stage 1 of meaningful use for the EHR Incentive Program, an eligible professional 

is required to meet certain objectives and associated measures to achieve meaningful use. One of 

these objectives is for the eligible professional to generate and transmit permissible prescriptions 

electronically, and the measure of whether the eligible professional has met this objective is 

more than 40 percent of all permissible prescriptions written by the eligible professional are 

transmitted electronically using Certified EHR Technology (§495.6(d)(4)). We note that the 

EHR Incentive Program and the eRx Incentive Program share a common goal of encouraging 

electronic prescribing and the adoption of technology that enables eligible professionals to 

electronically prescribe. This goal is advanced under each program via the respective program 

requirements – the electronic prescribing objective under the EHR Incentive Program and the 

requirement that an EP be a “successful electronic prescriber” under the eRx Incentive Program. 

Indeed, both programs require that the eligible professionals indicate their electronic prescribing 
1091 

activity. Under the EHR Incentive Program, an eligible professional must attest to the 

percentage of his or her permissible prescriptions that were generated and transmitted 

electronically using Certified EHR Technology during the applicable EHR reporting period, 

which must exceed 40 percent. Under the eRx Incentive Program, to avoid the payment 

adjustment, an eligible professional must be a successful electronic prescriber, which is achieved 

by the reporting of the eRx quality measure a certain number of instances during the applicable 

reporting period (each instance of reporting of the eRx quality measure, which includes reporting 

of specific quality data codes, signifies that the professional generated an electronic prescription 

for a specified service or encounter). In most cases, we believe the electronic prescribing 

objective of meaningful use would be a more rigorous standard for eligible professionals to meet 

than the standard adopted under the eRx Incentive Program (as demonstrated via the reporting of 

the eRx quality measure). In addition, there seems to be no added benefit with regard to 

reporting (presumably lower) electronic prescribing activity under the eRx Incentive Program 

given that the identical goals (encouraging electronic prescribing) of both programs would have 

been fulfilled through the eligible professional’s achievement of meaningful use. For those 

reasons, we believe it may pose a significant hardship for eligible professionals who are 

meaningful EHR users to additionally comply with the requirements of being a successful 

electronic prescriber under the eRx Incentive program. 

For the reasons stated, under this proposed significant hardship category, we proposed 

that individual eligible professionals (and every eligible professional member of a group practice 

using the eRx GPRO for the 2014 payment adjustment only) would need to achieve meaningful 

use of Certified EHR Technology for a continuous 90-day EHR reporting period (as defined for 

the EHR Incentive Program) that falls within the 6-month reporting period (January 1 - June 30, 

2012) for the 2013 eRx payment adjustment or the 12- or 6-month reporting periods (January 1- 
1092 

December 31, 2012 or January 1 – June 30, 2013, respectively) for the 2014 eRx payment 

adjustment to be eligible for this significant hardship exemption (77 FR 44985). We also 

proposed that for purposes of the 2013 and 2014 eRx payment adjustments this hardship 

exemption category would apply to individual EPs and group practices (that is, every member of 

the group) who instead achieve meaningful use of Certified EHR Technology for an EHR 

reporting period that is the full CY 2012. 

 We invited public comment on this proposed significant hardship exemption category. 

The following is a summary of the comments received related to the proposed significant 

hardship exemption category: eligible professionals or group practices who achieve meaningful 

use during the 2013 and 2014 payment adjustment reporting periods. 

 Comment: One commenter specifically supported this proposed significant hardship 

exemption category. The commenter noted that establishing this significant hardship exemption 

category will help alleviate concerns from eligible professionals and group practices that are 

transitioning their EHR systems. 

 Response: We appreciate the commenter's positive feedback and are finalizing this 

significant hardship exemption category. 

 Comment: One commenter took exception that this significant hardship exemption 

category would only apply to those eligible professionals participating in the EHR Incentive 

Program for the first time. The commenter requested that CMS expand the applicability of this 

significant hardship exemption category to all eligible professionals who achieve meaningful use 

regardless of when an eligible professional first participated in the EHR Incentive Program. 

 Response: We appreciate the commenter's feedback. This significant hardship exemption 

category was intended to be applicable to eligible professionals and group practices who achieve 

meaningful use during certain 2013 and 2014 eRx payment adjustment reporting periods, 
1093 

regardless of whether it is the first time the EP (or EPs in a group practice) achieves meaningful 

use under the EHR Incentive Program. Therefore, we clarify that this significant hardship 

exemption category will apply regardless of whether an EP has previously achieved meaningful 

use under the EHR Incentive Program. 

 Comment: Some commenters suggested that this significant hardship exemption category 

include EPs who have achieved meaningful use in 2011, 2012, and 2013. 

Response: We appreciate the commenters’ feedback. We proposed that individual EPs or 

EPs within a group practice would be eligible for this significant hardship exemption category if 

the eligible professionals achieve meaningful use for an EHR reporting period that falls within 

(1) the 6-month 2013 payment adjustment reporting period (January 1 - June 30, 2012) for the 

2013 payment adjustment and/or (2) the 12-month (January 1 - December 31, 2012) or 6-month 

(January 1 - June 30, 2013) 2014 payment adjustment reporting period for the 2014 payment 

adjustment. We also proposed that for the 2013 and 2014 payment adjustments, individual EPs 

or EPs within a group practice would be eligible for this significant hardship exemption category 

if they achieve meaningful use for an EHR reporting period that is the full CY 2012. As such, 

our proposal covers those EPs who achieved meaningful use under the EHR Incentive Program 

in 2012 and the first 6 months of 2013. For expanding this significant hardship exemption 

category to cover EPs who have achieved meaningful use in 2011, we understand the desire for 

EPs who achieved meaningful use in 2011 to be exempt from the 2013 payment adjustment. 

Since 2011 was the 12-month payment adjustment reporting period for the 2013 payment 

adjustment, and as proposed this significant hardship exemption category would cover EPs who 

achieve meaningful use during the 12 and 6-month payment adjustment reporting periods for the 

2014 payment adjustment, for the reasons previously stated for proposing this significant 

hardship category, we will extend this category to include individual EPs and EPs within a group 
1094 

practice who achieve meaningful use under the EHR Incentive Program for an EHR reporting 

period that fell within 2011 (that is, during the 12-month 2013 payment adjustment reporting 

period). 

 We cannot expand this significant hardship exemption category for the 2014 payment 

adjustment to include eligible professionals who achieve meaningful use during the last 6 months 

of 2013 (July 1, 2013 - December 31, 2013) because the last 6 months of 2013 do not coincide 

with the 2014 payment adjustment reporting period. 

 Based on the comments received and for the reasons previously stated, we are finalizing 

this significant hardship exemption category– eligible professionals or group practices who 

achieve meaningful use during the 2013 and 2014 payment adjustment reporting periods – as 

follows: To qualify for a significant hardship exemption under this category for the 2013 

payment adjustment, an eligible professional (or every eligible professional in a group practice 

participating in the eRx GPRO for the 2013 payment adjustment) must have achieved 

meaningful use of Certified EHR Technology under the EHR Incentive Program for a continuous 

90-day EHR reporting period that fell within the 12-month (January 1, 2011 – December 31, 

2011) or 6-month (January 1, 2012 – June 30, 2012) payment adjustment reporting period or for 

an EHR reporting period that is the full CY 2012. To qualify for a significant hardship 

exemption under this category for the 2014 payment adjustment, an eligible professional (or 

every eligible professional in a group practice participating in the eRx GPRO) must achieve 

meaningful use of Certified EHR Technology under the EHR Incentive Program for a continuous 

90-day EHR reporting period that falls within the 12-month (January 1, 2012 – December 31, 

2012) or 6-month (January 1, 2013 – June 30, 2013) payment adjustment reporting period or for 

an EHR reporting period that is the full CY 2012. 
1095 

b. Eligible professionals or group practices who demonstrate intent to participate in the EHR 

Incentive Program and adoption of Certified EHR Technology 

 We note that we finalized at §414.92(c)(2)(ii)(A)(3) a significant hardship exemption 

category for the 2012 eRx payment adjustment, under which eligible professionals and group 

practices seeking consideration for an exemption were required to register to participate in the 

EHR Incentive Program and adopt CEHRT (76 FR 54958). That significant hardship category 

addressed significant hardships relating to the selection, purchase and adoption of eRx 

technology (for example, potential significant financial hardship of purchasing two sets of eRx 

equipment for both programs) that may have occurred as a result of the timing of the release of 

the standards and requirements for CEHRT and the Certified Health IT Product List, the 

establishment of the respective program requirements for the eRx and EHR Incentive Programs, 

and the 2012 eRx payment adjustment reporting periods. Given that eligible professionals have 

had adequate time to identify EHR products that have been certified and that the requirements 

for these programs have been implemented and, various stages of reporting are underway, we do 

not believe this significant hardship exemption category would continue to be applicable for the 

2013 and 2014 eRx payment adjustments. We understand, however, that although an eligible 

professional may now have the requisite information about requirements for CEHRT and each 

respective program, there may nevertheless exist a significant hardship with regard to 

compliance with the requirements for being a successful electronic prescriber under the eRx 

Incentive Program, given the nature of CEHRT and how it is used/implemented in one’s 

practice. 

When an eligible professional or eligible professional in a group practice first adopts 

CEHRT, we understand significant changes may be required with regard to how the eligible 

professional’s practice operates. Further, necessary steps are involved in fully implementing 
1096 

CEHRT once it has been adopted, including: installation, configuration, customization, training, 

workflow redesign and the establishment of connectivity with entities that facilitate electronic 

health information exchange (such as for electronic prescriptions). Thus, we believe it would be 

difficult for an eligible professional or eligible professional in a group practice who has adopted 

CEHRT to be able to begin electronically prescribing on day one. Rather, we expect a natural 

lag time would likely occur between an eligible professional’s adoption of CEHRT and the point 

at which CEHRT has been fully implemented such that an eligible professional could begin 

electronically prescribing. We believe this implementation timeline may pose a significant 

hardship for an eligible professional or group practice who seeks to comply with the 

requirements for being a successful electronic prescriber under the eRx Incentive Program and 

also participate for the first time in the EHR Incentive Program. Under the EHR Incentive 

Program, an eligible professional who is demonstrating meaningful use of CEHRT for the first 

time must do so for any continuous 90-day period within the calendar year (the “EHR reporting 

period”). In the absence of this significant hardship exemption category, eligible professionals 

or group practices who choose a 90-day EHR reporting period that falls later in the year may 

potentially have to adopt two systems (for example, a stand-alone electronic prescribing system 

for purposes of participating in the eRx Incentive Program, and CEHRT for purposes of 

participating in the EHR Incentive Program), which could be financially burdensome. 

Alternatively, such eligible professionals who wish to use CEHRT for purposes of participating 

in both programs may potentially have to adopt and implement CEHRT well in advance of their 

90-day EHR reporting period to meet an earlier reporting period for the eRx Incentive Program. 

Therefore, for the 2013 and 2014 payment adjustments, we proposed a significant 

hardship exemption category to address this situation (77 FR 44985). We believe, however, that 

for this category it is necessary for eligible professionals and group practices to show they intend 
1097 

to participate in the EHR Incentive Program for the first time and have adopted CEHRT. 

Therefore, to be eligible for consideration for an exemption under this proposed significant 

hardship exemption category for the 2013 and 2014 payment adjustments, we proposed that 

eligible professionals or group practices must register to participate in the Medicare or Medicaid 

EHR Incentive Programs and adopt CEHRT by a date specified by CMS. We further note that, 

given the nature of the significant hardship at issue under this category, this proposal would be 

limited to eligible professionals and group practices (that is, every individual eligible 

professional of the group practice): (1) who have not previously adopted CEHRT or received an 

incentive payment under the Medicare or Medicaid EHR Incentive Programs; and (2) who 

attempt to participate in the Medicare or Medicaid EHR Incentive Programs from January 2, 

2012 through October 15, 2012, or the effective date of the final rule (which includes the 6-

month 2013 eRx payment adjustment reporting period of January 1, 2012-June 30, 2012) for the 

2013 eRx payment adjustment, or during the 6-month payment adjustment reporting period for 

the 2014 eRx payment adjustment (January 1, 2013 through June 30, 2013). 

For eligible professionals or group practices who intend to adopt EHR technology in the 

future or have not yet taken the steps required to apply for this significant hardship exemption, 

we believe that mere intent to adopt CEHRT or attest at a later date does not sufficiently 

demonstrate that an eligible professional will adopt CEHRT to participate in the Medicare or 

Medicaid EHR Incentive Programs. Unlike those eligible professionals who would have 

registered for the Medicare or Medicaid EHR Incentive Programs and have adopted CEHRT 

available for immediate use, we would have to monitor and provide oversight over those eligible 

professionals who have not yet taken these steps to participate in the Medicare or Medicaid EHR 

Incentive Programs. We also do not believe that such eligible professionals or group practices 

would necessarily be facing a significant hardship as contemplated in this proposed exemption 
1098 

category. Accordingly, all of the proposed requirements to qualify for an exemption under this 

significant hardship exemption category would need to be met by the time the eligible 

professional requests an exemption. In section III.H1.5.b. below, we discuss the proposed 

deadlines and procedures for requesting consideration of an exemption under this proposed 

significant hardship exemption category. 

We invited public comment on this proposed significant hardship exemption category for 

the 2013 and 2014 payment adjustments. The following is a summary of the comments received 

specific to this proposed significant hardship exemption category: eligible professionals or group 

practices who demonstrate intent to participate in the EHR Incentive Program and adoption of 

Certified EHR Technology. 

Comment: One commenter suggested that this significant hardship exemption category 

apply to eligible professionals who register for the EHR Incentive Program in 2011, 2012, and 

2013. 

Response: This significant hardship exemption category does not apply to eligible 

professionals who in 2011 demonstrated intent to participate in the EHR Incentive Program and 

adopted Certified EHR Technology. We note that this significant hardship exemption category 

was intended to apply to eligible professionals and group practices dealing with issues related to 

fully implementing CEHRT once it has been adopted, including: installation, configuration, 

customization, training, workflow redesign and the establishment of connectivity with entities 

that facilitate electronic health information exchange (such as for electronic prescriptions). We 

believe these eligible professionals and group practices who adopted CEHRT and demonstrated 

intent to participate in the EHR Incentive Program in 2011 would have had ample time to fully 

implement their CEHRT in time for the payment adjustment reporting periods for the 2013 and 

2014 payment adjustments. Therefore, this significant hardship exemption category does not 
1099 

apply to eligible professionals or group practices that adopted CEHRT and demonstrated intent 

to participate in the EHR Incentive Program in 2011. 

For the 2013 payment adjustment, it was our intent to apply this significant hardship 

exemption category to eligible professionals or group practices that adopt CEHRT as well as 

demonstrate intent to participate in the EHR Incentive Program during a certain timeframe in 

2012. We proposed that, for the 2013 payment adjustment, an eligible professional would be 

required to meet the qualifications for this significant hardship exemption category by October 

15, 2012 or the effective date of this final rule, whichever is later. 

For the 2014 payment adjustment, it was our intent to apply this significant hardship 

exemption category to eligible professionals or group practices that adopt CEHRT, as well as 

demonstrate intent to participate in the EHR Incentive Program during a certain timeframe in 

2013. We proposed that an eligible professional would be required to meet the qualifications for 

this significant hardship exemption category by the end of the 6-month 2014 payment adjustment 

reporting period (January 1, 2013 – June 30, 2013). We established this deadline as it coincides 

with the deadline for requesting exemptions under the four previously established significant 

hardship exemption categories. Therefore, we decline to extend this significant hardship 

exemption category beyond June 30, 2013. 

 Based on the comments received and for the reasons stated above, we are finalizing this 

significant hardship exemption category – eligible professionals or group practices who 

demonstrate intent to participate in the EHR Incentive Program and adoption of Certified EHR 

Technology. However, to provide CMS with additional time to gather information on who 

qualifies for a significant hardship exemption under this category, we are extending the proposed 

deadline. For the 2013 payment adjustment, this significant hardship exemption category would 

apply to eligible professionals (or every eligible professional in a group practice participating in 
1100 

the eRx GPRO) who demonstrate intent to participate in the EHR Incentive Program by 

registering for the program between January 2, 2012 and January 31, 2013 and adopt Certified 

EHR Technology. We note that eligible professionals who achieved meaningful use of Certified 

EHR Technology under the EHR Incentive Program for an EHR reporting period that ended on 

or before June 30, 2012, or for an EHR reporting period that is the full CY 2012, are not eligible 

for this significant hardship exemption category (nor is a group practice participating in the eRx 

GPRO eligible if any of its member eligible professionals achieved meaningful use during those 

timeframes). 

 For the 2014 payment adjustment, this significant hardship exemption category applies to 

eligible professionals (or every eligible professional in a group practice participating in the eRx 

GPRO) who demonstrate intent to participate in the EHR Incentive Program by registering for 

the program between January 1, 2013 and June 30, 2013 and adopting Certified EHR 

Technology. Eligible professionals who achieve meaningful use of Certified EHR Technology 

under the EHR Incentive Program for an EHR reporting period that ends on or before June 30, 

2013, or for an EHR reporting period that is the full CY 2013, are not eligible for this significant 

hardship exemption category (nor is a group practice participating in the eRx GPRO eligible if 

any of its member eligible professionals achieve meaningful use during those timeframes). 

Please note that, should the deadline for submitting requests for the four previously established 

significant hardship exemption categories be extended for any reason, it is our intent that the 

deadline for this significant hardship exemption category would be extended accordingly with all 

other significant hardship exemption categories to the 2014 payment adjustment. 

c. Deadlines and Procedures for Requesting Significant Hardship Exemptions 

 In the CY 2012 final rule with comment period, we established a process whereby 

eligible professionals would submit significant hardship exemptions for the existing significant 
1101 

hardship exemption categories for the eRx payment adjustments (76 FR 54963). Unfortunately, 

for submitting these proposed significant hardship exemptions for the 2013 payment adjustment, 

it would not be operationally feasible to accept significant hardship exemption requests in the 

manner we previously established. Therefore, we proposed that, to request a significant hardship 

under the two proposed significant hardship exemption categories for the 2013 eRx payment 

adjustment, CMS would analyze the information provided to us in the Registration and 

Attestation System under the EHR Incentive Program to determine whether the eligible 

professional or group practice (that is, every EP member of the group practice) has either (1) 

achieved meaningful use under the EHR Incentive Program during the applicable reporting 

periods we noted previously, or (2) registered to participate in the EHR Incentive Program via 

the Registration and Attestation system for the EHR Incentive Program (located at 

https://ehrincentives.cms.gov/hitech/login.action) and adopted CEHRT, or both, if applicable. 

We understand that providing an eligible professional’s CEHRT product number is an optional 

field in the Registration Page. We noted that if requesting a significant hardship exemption 

under proposed category 2, the eligible professional must provide its CEHRT product number 

when registering for the EHR Incentive Program. In the event that it is not operationally feasible 

to accept this information via the Registration and Attestation system for the EHR Incentive 

Program, we proposed that we would accept requests for significant hardship exemptions under 

these two proposed categories via a mailed letter to CMS to the following address: Centers for 

Medicare & Medicaid Services, Office of Clinical Standards and Quality, Quality Measurement 

and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 

21244-1850. 

 We also proposed that eligible professionals would be required to submit this significant 

hardship request by October 15, 2012 or the effective date of the final rule for this provision, 
1102 

whichever is later. For those eligible professionals who request a significant hardship exemption 

based on achieving meaningful use under the EHR Incentive Program during the 12- or 6-month 

reporting periods for the 2013 payment adjustment, we also proposed that the eligible 

professional would be required to have attested under the EHR Incentive Program by October 

15th of 2012 (or if later, the effective date of the final rule), to qualify for a significant hardship 

exemption for the 2013 payment adjustment. For those eligible professionals requesting a 

significant hardship exemption for the 2013 eRx payment adjustment under the second proposed 

significant hardship exemption category (that is, intent to participate in the EHR Incentive 

Program and adoption of CEHRT), we proposed that these eligible professionals who intend to 

participate in the EHR Incentive Program from January 1, 2011 through October 15, 2012 or the 

effective date of the final rule would be required to register for the EHR Incentive Program and 

adopt CEHRT by the same deadline noted above, to qualify for a significant hardship exemption 

for the 2013 payment adjustment. We note that we proposed a later deadline of October 15, 

2012 (or the effective date of the final rule, if later) for the submission of these requests because 

the deadline for submitting requests under other previously established significant hardship 

exemption categories to the 2013 eRx payment adjustment (June 30, 2012) has passed and other 

similar dates we might choose would likely have passed by the time the final rule is effective. 

 For submitting exemption requests for the two significant hardship exemption categories 

for the 2014 payment adjustment, we proposed the following method for submitting a request for 

a significant hardship exemption: Via the Communication Support Page (which is the method 

established for submitting the established significant hardship exemption categories). 

 In addition, we considered accepting significant hardship exemption requests for the two 

proposed significant hardship exemption categories for the 2014 payment adjustment by CMS 

receiving eligible professionals' information through the Registration and Attestation System for 
1103 

the EHR Incentive Program (similar to our proposed submission process for the 2013 payment 

adjustment) and via a mailed letter to CMS using the following address: Centers for Medicare & 

Medicaid Services, Office of Clinical Standards and Quality, Quality Measurement and Health 

Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850. 

We invited public comment on these considered submission options. 

 We proposed that the deadline for submitting these significant hardship exemption 

requests for the 2014 payment adjustment would be June 30, 2013, which is the same deadline 

established for submitting a significant hardship exemption request for the existing significant 

hardship exemption categories. Additionally, and consistent with our proposal for the 2013 

payment adjustment, we proposed that an eligible professional or group practice (that is, all 

members of the practice) that achieves meaningful use under the EHR Incentive Program during 

the 6- or 12-month reporting periods for the 2014 payment adjustment would be required to 

attest by June 30, 2013. Similarly, for eligible professionals requesting a significant hardship 

exemption for the 2014 payment adjustment under the second proposed significant hardship 

exemption category (that is, intent to participate in the EHR Incentive Program and adoption of 

CEHRT), we proposed that eligible professionals who intend to participate in the EHR Incentive 

Program during the last 6 months of 2013 would be required to register for the EHR Incentive 

Program and adopt CEHRT by June 30, 2013, to qualify for a significant hardship exemption for 

the 2014 payment adjustment. We noted that we understood that these deadlines may exclude 

some eligible professionals who attested or registered for the EHR Incentive Program at later 

dates, but these deadlines were necessary to avoid the reprocessing of claims. We note, 

however, that these proposed deadlines would not extend any deadlines applicable under the 

EHR Incentive Program. That is, for purposes of the EHR Incentive Program, an eligible 

professional would still be required to attest to being a meaningful user by the deadline 
1104 

established under the EHR Incentive Program, even if such deadline fell prior to the proposed 

eRx Incentive program significant hardship exemption deadline. 

 We noted that we only proposed submission of requests for significant hardship 

exemptions under these two categories under an individual eligible professional level only 

because it is not technically feasible for us to operationally analyze information on the EHR 

Incentive Program’s Registration and Attestation page using the TIN, as the information stored 

in this system is stored by NPI. However, we stated we would not preclude eligible 

professionals in an eRx GPRO for 2012 from submitting requests for significant hardship 

exemptions under these two categories. Therefore, to allow the submission of significant 

hardship requests for the 2013 eRx payment adjustment under these two proposed categories, we 

proposed that eligible professionals within an eRx GPRO must each request a significant 

hardship exemption under these two categories. 

 We invited public comment on this proposed process for submitting significant hardship 

exemption requests under these two proposed categories. The following is a summary of the 

comments received related to these proposals. 

 Comment: Several commenters requested that CMS utilize information contained in the 

EHR Incentive Program's Registration and Attestation page to determine who would qualify for 

the two additional significant hardship exemption categories for the 2013 and 2014 payment 

adjustment. Another commenter recommended that the process for requesting a significant 

hardship exemption under these two categories be streamlined. One commenter requested that 

CMS provide as many options as possible for eligible professionals to submit requests for 

significant hardship exemptions under the two proposed categories. One commenter suggested 

that requests be submitted electronically, not via U.S. mail. Overall, most commenters believe 

that using information already collected by CMS from the EHR Incentive Program's Registration 
1105 

and Attestation page to exempt eligible professionals from the 2013 and 2014 payment 

adjustment would reduce burden on eligible professionals and group practices as they would not 

be required to actively request a significant hardship exemption via the web. 

 Response: We agree that basing applicability of these two significant hardship exemption 

categories on information collected from the EHR Incentive Program's Registration and 

Attestation page for the 2013 and 2014 payment adjustments would relieve burden on eligible 

professionals as they would not be required to actively request a significant hardship exemption 

via the web. Based on the comments received, we are finalizing our proposal to use information 

collected from the EHR Incentive Program's registration and attestation page to exempt eligible 

professionals from the 2013 payment adjustment under these two additional significant hardship 

exemption categories. In addition, based on the comments received, we will use this same 

method to exempt eligible professionals from the 2014 payment adjustment under these two 

additional significant hardship exemption categories rather than requiring eligible professionals 

to request exemptions under these two significant hardship exemption categories via the web. 

We are not finalizing any other options for requesting an exemption under these two categories, 

because we believe that this method is the most efficient way to exempt eligible professionals. 

We note that we are able to internally analyze this data for the two additional significant hardship 

exemption categories, and not the other previously established four significant hardship 

exemption categories, because, unlike the previous four categories, CMS already has access to 

the information needed under the EHR Incentive Program's Registration and Attestation page to 

make our determination on whether an eligible professional should be exempt from the 2013 

and/or 2014 payment adjustments under these two significant hardship exemption categories. 

 Comment: Some commenters requested that CMS extend the proposed deadline to 

submit requests for significant hardship exemptions under these two additional categories. One 
1106 

commenter requested that eligible professionals and group practices be allowed at least 90 days 

to submit such a request. Other commenters suggested a deadline of October 31, 2012 to apply 

exemptions under these two proposed significant hardship exemptions for the 2013 payment 

adjustment. In addition, since the proposed deadlines for qualifying for these two additional 

significant hardship exemption categories are later than the established deadline for the four 

previously established significant hardship exemption categories, the commenter requested that 

the deadline for requesting exemptions under the four previously established significant hardship 

exemption categories be extended to coincide with the established deadline for these two 

additional significant hardship categories. 

 Response: For applying these two proposed significant hardship exemptions for the 2013 

payment adjustment, we proposed a deadline of October 15, 2012 or the effective date of the 

rule, whichever is later. Since our proposed deadline date of October 15, 2012 as well as the 

commenter's proposed deadline date of October 31, 2012 has passed, we considered finalizing 

our proposed deadline of the effective date of the CY 2013 Medicare PFS final rule. However, it 

is our understanding that certain eligible professionals that achieve meaningful use may have 

until February 28 of the following year to attest that they met the CQM component of achieving 

meaningful use. Although it is not practically feasible to extend the deadline for qualifying for 

the first significant hardship exemption category (related to achieving meaningful use under the 

EHR Incentive Program) due to the need to minimize the reprocessing of claims, it is feasible to 

extend the deadline for qualifying for this significant hardship exemption category to January 31, 

2013. To afford eligible professionals with more time to qualify for this exemption, we are 

therefore finalizing a deadline of January 31, 2013 to qualify for this significant hardship 

exemption category related to achieving meaningful use under the EHR Incentive Program. So 

that the deadlines for qualifying for these two additional significant hardship exemptions 
1107 

coincide, we are also finalizing a deadline of January 31, 2013 to qualify for the second 

significant hardship exemption category related to demonstrating intent to participate in the EHR 

Incentive Program. Therefore, for the 2013 payment adjustment, eligible professionals must 

qualify for consideration under these two additional significant hardship exemption categories by 

January 31, 2013. 

 We received no public comment regarding the proposed deadline for qualifying for an 

exemption under these two additional significant hardship exemption categories for the 2014 

payment adjustment. Based on the reasons stated previously, we are finalizing this proposal. 

We note, however, that in the event that the deadlines for requesting a significant hardship 

exemption under the four previously established exemption categories are extended, we intend to 

extend this deadline to coincide with the deadline for requesting exemptions under these other 

four categories. Additionally, we may extend this deadline should we run into operational 

concerns, such as receiving data from the EHR Incentive Program’s Registration and Attestation 

page. 

 With respect to extending the deadline to submit exemption requests under the four 

previously established significant hardship exemption categories for the 2013 payment 

adjustment, we will allow the extension of the deadline to request exemptions under these four 

previously established exemption categories to January 31, 2013. We finalized a deadline of 

June 30, 2012 to submit requests for exemptions under these four significant hardship categories 

primarily to avoid having to reprocess claims. Since we are extending this deadline to January 

31, 2013, we anticipate that, in some cases, particularly in instances where eligible professionals 

submit significant hardship exemption requests closer towards the deadline, we may not be able 

to complete our review of the requests before the claims processing systems updates are made to 

begin reducing eligible professionals’ and group practices’ PFS amounts in 2013. In such cases, 
1108 

if we ultimately approve the eligible professional or group practice’s request for a significant 

hardship exemption after January 1, 2013, we would need to reprocess all claims for services 

furnished up to that point in 2013 that were paid at the reduced PFS amount, which we anticipate 

may take several months. To avoid the reprocessing of claims, we encourage eligible 

professionals who would be submitting a significant hardship exemption request under these four 

significant hardship exemption categories to do so as soon as possible, rather than waiting until 

the deadline to submit such a request. 

 We note that we would like to be able to process all such requests before we begin 

making the claims processing systems changes to adjust eligible professionals’ or group 

practices’ payments starting on January 1, 2013 or 2014. However, we anticipate that, in some 

cases, particularly in instances where eligible professionals submit significant hardship 

exemption requests closer towards the deadline, we may not be able to complete our review of 

the requests before the claims processing systems updates are made to begin reducing eligible 

professionals’ and group practices’ PFS amounts in 2013. In such cases, if we ultimately approve 

the eligible professional or group practice’s request for a significant hardship exemption after 

January 1, 2013 or 2014, we would need to reprocess all claims for services furnished up to that 

point in 2013 that were paid at the reduced PFS amount, which we anticipate may take several 

months. To avoid the reprocessing of claims, we encourage eligible professionals who would be 

submitting a significant hardship exemption request under these two categories to do so as soon 

as possible, rather than waiting until the deadline to submit such a request. 

 Tables 125 and 126 provide a summary of the significant hardship exemption categories 

that are available to eligible professionals and group practices for the 2013 and 2014 payment 

adjustments. 

Table 125: Summary of Significant Hardship Exemption Categories for the 2013 eRx 

Payment Adjustment 
1109 

Significant Hardship Exemption Category Method of 

Submission 

Deadline for 

Submitting 

Exemption 

Request 

The eligible professional or group practice practices in 

a rural area with limited high speed internet access 

Web-based 

Communication 

Support Page 

Extended to 

January 31, 2013 

The eligible professional or group practice practices in 

an area with limited available pharmacies for 

electronic prescribing 

Web-based 

Communication 

Support Page 

Extended to 

January 31, 2013 

The eligible professional or group practice is unable to 

electronically prescribe due to local, state, or Federal 

law or regulation 

Web-based 

Communication 

Support Page 

Extended to 

January 31, 2013 

The eligible professional or group practice has limited 

prescribing activity, as defined by an eligible 

professional generating fewer than 100 prescriptions 

during a 6-month reporting period 

Web-based 

Communication 

Support Page 

Extended to 

January 31, 2013 

* Eligible professionals or group practices who 

achieve meaningful use during the 2013 12- and 6-

month eRx payment adjustment reporting periods 

(that is, January 1, 2011 – June 30, 2012) 

EHR Incentive 

Program’s 

Registration and 

Attestation Page 

January 31, 2013 

* Eligible professionals or group practices who 

demonstrate intent to participate in the EHR Incentive 

Program and adoption of Certified EHR Technology 

EHR Incentive 

Program’s 

Registration and 

Attestation Page 

January 31, 2013 

* Eligible professionals participating in the eRx Incentive Program under the eRx GPRO are eligible for these 

significant hardship exemption categories. However, each eligible professional in the eRx GPRO wishing to have 

this exemption applied must individually have provided the requisite information on the EHR Incentive Program’s 

Registration and Attestation page. 

Table 126: Summary of Significant Hardship Exemption Categories for the 2014 eRx 

Payment Adjustment 

Significant Hardship Exemption Category Method of 

Submission 

Deadline for 

Submitting 

Exemption 

Request 

The eligible professional or group practice practices in 

a rural area with limited high speed internet access 

Web-based 

Communication 

Support Page 

June 30, 2013 

The eligible professional or group practice practices in 

an area with limited available pharmacies for 

electronic prescribing 

Web-based 

Communication 

Support Page 

June 30, 2013 
1110 

Significant Hardship Exemption Category Method of 

Submission 

Deadline for 

Submitting 

Exemption 

Request 

The eligible professional or group practice is unable to 

electronically prescribe due to local, state, or Federal 

law or regulation 

Web-based 

Communication 

Support Page 

June 30, 2013 

The eligible professional or group practice has limited 

prescribing activity, as defined by an eligible 

professional generating fewer than 100 prescriptions 

during a 6-month reporting period 

Web-based 

Communication 

Support Page 

June 30, 2013 

* Eligible professionals or group practices who 

achieve meaningful use during the 2014 12- and 6-

month eRx payment adjustment reporting periods 

(that is, January 1, 2012 – June 30, 2013) 

EHR Incentive 

Program’s 

Registration and 

Attestation Page 

June 30, 2013 

* Eligible professionals or group practices who 

demonstrate intent to participate in the EHR Incentive 

Program and adoption of Certified EHR Technology 

EHR Incentive 

Program’s 

Registration and 

Attestation Page 

June 30, 2013 

* Eligible professionals participating in the eRx Incentive Program under the eRx GPRO are eligible for these 

significant hardship exemption categories. However, each eligible professional in the eRx GPRO wishing to have 

this exemption applied must individually have provided the requisite information on the EHR Incentive Program’s 

Registration and Attestation page. 

6. Informal Review 

 To better facilitate issues surrounding the issuance of incentives and payment 

adjustments, we proposed to establish an informal review process for the eRx Incentive Program 

(77 FR 44987). We proposed an informal review process similar to the informal review process 

established for the PQRS (76 FR 73390), because eligible professionals and group practices are 

already familiar with this process. We proposed the informal review process would only be 

available for the 2013 incentive payments and the 2014 payment adjustment. 

 For an informal review regarding the 2013 incentive, we proposed that an eligible 

professional or group practice must request an informal review within 90 days of the release of 

his or her feedback report, irrespective of when an eligible professional or group practice 
1111 

actually accesses his/her feedback report. 

 For an informal review regarding the 2014 payment adjustment, we proposed that an 

eligible professional or group practice must request an informal review by January 31, 2013 (77 

FR 44988). We believed this deadline would provide ample time for eligible professionals and 

group practices to discover that their respective claims are being adjusted due to the 2014 

payment adjustment and seek informal review. 

 We proposed that the request be submitted in writing and summarize the concern(s) and 

reasons for requesting an informal review. In his or her request for an informal review, an 

eligible professional may also submit other information to assist in the review. We proposed that 

an eligible professional may request an informal review through the web. We believe use of the 

web would provide a more efficient way for CMS to record informal review requests, as the web 

would guide the eligible professional through the creation of an informal review requests. For 

example, the web-based tool would prompt an eligible professional of any necessary information 

he or she must provide. Should it be technically not feasible to receive requests for informal 

reviews via the web, we proposed that an eligible professional would be able to request an 

informal review via email (77 FR 44988). 

 We further proposed that we would make our determination and provide the eligible 

professional or group practice with a written response to his or her request for an informal review 

within 90 days of receiving the request. 

 Based on our informal review and once we have made a determination, we proposed that 

we would provide the eligible professional or group practice a written response. Where we find 

that the eligible professional or group practice did successfully report for the 2013 incentive, we 

would provide the eligible professional or group practice with the applicable incentive payment. 

Where we find that the eligible professional or group practice did successfully report (that is, 
1112 

meet criteria for being a successful electronic prescriber) for purposes of the 2014 payment 

adjustment, we would cease application of the 2014 payment adjustment and reprocess all claims 

that have been adjusted. We further proposed that decisions based on the informal review would 

be final, and there would be no further review or appeal. 

 We invited public comment on our proposals for the eRx Incentive Program informal 

review process for the 2013 incentive and the 2014 payment adjustment. The following is a 

summary of comments we received on these proposals: 

 Comment: Several commenters supported our proposal to establish an informal review 

process for the 2013 incentive and 2014 payment adjustment. 

 Response: We appreciate the commenters' feedback and are finalizing our proposal to 

establish an informal review process for the 2013 incentive and 2014 payment adjustment. 

 Comment: One commenter urged CMS to create a more formal appeals process that 

provides eligible professionals with concurrent feedback on reporting. 

 Response: We appreciate the commenter's feedback. We note that the informal review 

process we have proposed has deadlines and a process similar to formal review processes. We 

believe the informal review process we are establishing is appropriate for this program and is an 

adequate venue for eligible professionals and group practices to seek a review of their eRx 

incentive or payment adjustment applicability. With respect to providing concurrent feedback on 

reporting, for the 2012 and 2013 incentives, feedback reports will be available to eligible 

professionals and group practices prior to the start of the informal review process. With respect 

to the 2013 and 2014 payment adjustments, with respect to reporting during the 12-month 2013 

and 2014 payment adjustment reporting periods (that is, January 1, 2011 – December 31, 2011 

and January 1, 2012 – December 31, 2012 respectively), we note that these feedback reports, 

which are the same feedback reports given for the 2011 and 2012 incentives respectively, will be 
1113 

provided prior to the start of the informal review process. While it may not be technically 

feasible to have feedback reports for the 6-month 2013 and 2014 payment adjustment reporting 

periods (that is, January 1, 2012—June 30, 2012 and January 1, 2013—June 30, 2013 

respectively), we note that we anticipate that payment adjustment status notifications to eligible 

professionals who report the electronic prescribing measure will be made available prior to the 

start of the informal review process. 

 Comment: One commenter urged that we align the PQRS and eRx informal review 

processes. 

 Response: To the extent possible, it is our intention to align the informal review 

processes for the eRx Incentive Program and PQRS. We established the same deadline for 

requesting an informal review under the eRx Incentive Program and PQRS. However, we stress 

that these two programs are separate and require separate methods of review. For example, the 

eRx Incentive Program involves the reporting of one measure, whereas PQRS involves the 

reporting of hundreds of measures. Therefore, the PQRS informal review process would require 

more intensive resources than the eRx Incentive Program's informal review process. 

 Comment: In addition to supporting our proposal to establish an informal review process 

for the 2013 eRx incentive and 2014 eRx payment adjustment, some commenters urged us to 

establish a similar informal review process for the 2012 eRx incentive and 2012 and 2013 eRx 

payment adjustments. The commenters believed that extending this informal review process 

would allow eligible professionals or group practices who have had administrative, operational, 

or technological issues to present their case to CMS. 

 Response: We understand the desire to establish a similar informal review process for the 

2012 eRx incentive and 2012 and 2013 eRx payment adjustments. As for establishing an 

informal review process for the 2012 eRx payment adjustment, we note that we have already 
1114 

reviewed cases where an eligible professional or group practice has sought a review of their 2012 

eRx payment adjustment applicability. We also note that it is not operationally feasible to 

establish an informal review process for the 2012 eRx payment adjustment until 2013, after the 

cessation of the application of the 2012 eRx payment adjustment for eligible professionals who 

were not successful electronic prescribers. However, we believe it will be operationally feasible 

to establish an informal review process for the 2012 eRx incentive and 2013 eRx payment 

adjustment. Therefore, we are finalizing an informal review process for the 2012 and 2013 eRx 

incentives and 2013 and 2014 eRx payment adjustments. The process and deadlines for the 

informal review process for the 2012 eRx incentive and 2013 eRx payment adjustment will 

mirror our established process and deadlines for the 2013 eRx incentive and 2014 eRx payment 

adjustment. 

 Comment: Some commenters recommended that eligible professionals be given until 

March 31, 2014 to request an informal review relating to issues surrounding the 2012 and 2013 

eRx incentives and 2012, 2013 and 2014 eRx payment adjustments. The commenters noted that 

eligible professionals and group practices need ample time to keep up with informal review 

deadlines that vary from program to program. 

 Response: We understand the need to provide eligible professionals with ample time to 

learn about the informal review process. However, it is not operationally feasible to establish an 

informal review request deadline of March 31, 2014 for the 2012 and 2013 eRx incentives and 

2012, 2013, and 2014 eRx payment adjustments. This would be overly burdensome and costly 

for CMS, as CMS would then have to potentially process claims from 2012—2014 for those who 

receive a favorable decision. To minimize the reprocessing of claims, the informal review 

process (which includes the time for submitting a request as well as the processing time to 

review these requests) would need to occur within the year the eligible professional or group 
1115 

practice’s payments are being adjusted (for example, in 2013 for the 2013 payment adjustment). 

However, we believe it is feasible to extend the deadline for requesting an informal review past 

January 31. Therefore, we are finalizing a deadline of February 28, 2013 to request an informal 

review related to issues surrounding the 2012 eRx incentive and 2013 eRx payment adjustment. 

We are finalizing a deadline of February 28, 2014 to request an informal review related to issues 

surrounding the 2013 eRx incentive and 2014 eRx payment adjustment. Please note that 

February 28 is the same deadline we established for the PQRS payment adjustment informal 

review process, thereby alleviating the issue of eligible professionals and group practices 

needing to keep up with different informal review request deadlines. 

 Comment: Some commenters supported our proposal to receive informal review requests 

via the web. 

 Response: We appreciate the commenter's feedback. Unfortunately, it is not technically 

feasible for us to accept informal review requests via an online tool. However, we believe that 

accepting informal review requests electronically will be the most efficient way to facilitate the 

informal review process as opposed to receiving mailed requests. Therefore, we will accept 

informal review requests via an email to CMS. 

 To summarize what we have finalized, we are establishing an informal review process for 

the 2012 and 2013 eRx incentives and 2013 and 2014 eRx payment adjustments. As such, we 

are also finalizing our proposed modifications to §414.92 that address the informal review 

process we are establishing. Eligible professionals and group practices wishing to request an 

informal review must do so via email. For the 2012 eRx incentive and 2013 eRx incentives, 

eligible professionals and group practices must submit a request for an informal review 90 days 

after the receipt of the respective feedback reports. For the 2013 and 2014 eRx payment 

adjustments, eligible professionals and group practices must submit a request for an informal 
1116 

review by February 28, 2013 and February 28, 2014, respectively. CMS will provide a written 

response to each informal review request. More information regarding this informal review 

process will be available on the eRx Incentive Program’s website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/ERxIncentive/index.html?redirect=/ERXincentive. 

H2. The PQRS-Medicare EHR Incentive Pilot 

 The Medicare EHR Incentive Program provides incentive payments to eligible 

professionals (EPs) who demonstrate meaningful use of certified EHR technology (CEHRT). 

EPs who fail to demonstrate meaningful use will be subject to payment adjustments beginning in 

2015. We established a phased approach to meaningful use, which we expect will include three 

stages (77 FR 53973), and all EPs are currently in Stage 1. In the CY 2012 Medicare PFS final 

rule, we established the PQRS-Medicare EHR Incentive Pilot in an effort to pilot the electronic 

submission of CQMs for the Medicare EHR Incentive Program and move towards the alignment 

of quality reporting requirements between Stage 1 of the Medicare EHR Incentive Program and 

the PQRS (76 FR 73422). We refer readers to the final rule for further explanation of the 

requirements of the Pilot (76 FR 73422 – 73425). Specifically, we established that an EP 

participating in the PQRS-Medicare EHR Incentive Pilot would be able to report clinical quality 

measures (CQMs) data extracted from Certified EHR Technology via use of a PQRS qualified 

direct EHR product or PQRS qualified EHR data submission vendor (76 FR 73422). We 

proposed to modify §495.8 to extend this Pilot for CY 2013 as it was finalized for CY 2012. We 

also proposed to remove from §495.8(a)(2)(v) the cross-reference to §495.6(d)(10) to conform to 

the proposed changes to §495.6(d) that were included in the EHR Incentive Program – Stage 2 

NPRM (77 FR 53976). This proposal includes the following: 

● For 2013 only, EPs intending to participate in the PQRS-Medicare EHR Incentive 
1117 

Pilot may use a PQRS qualified EHR data submission vendor that would submit CQM data 

extracted from the EP’s CEHRT to CMS. Under this option, identical to the submission process 

used for the Pilot in 2012, the PQRS qualified EHR data submission vendor would calculate the 

CQMs from the EP’s CEHRT and then submit the calculated results to CMS on the EP’s behalf 

via a secure portal for purposes of this Pilot. 

● For 2013 only, identical to the submission process used for the Pilot in 2012, EPs 

intending to participate in the PQRS-Medicare EHR Incentive Pilot may use a PQRS qualified 

direct EHR product to submit CQM data directly from his or her CEHRT to CMS via a secure 

portal using the infrastructure of the PQRS EHR-based reporting mechanism. 

In addition, for 2013, we proposed to extend the use of attestation as a reporting method 

for the CQM component of meaningful use for the EHR Incentive Program. For 2013, EPs 

would be able to continue to report by attesting CQM results as calculated by CEHRT, as they 

did for 2011 and 2012. For further explanation of the CQM reporting criteria for EPs and 

reporting by attestation, we refer readers to the EHR Incentive Program – Stage 2 final rule (77 

FR 54049 through 54089) and the EHR Incentive Program – Stage 1 final rule (75 FR 44386 – 

44411, 44430 – 44434). 

 We invited public comment on our proposal to extend to 2013 the PQRS-Medicare EHR 

Incentive Pilot as it was established for 2012 as well as reporting CQMs by attestation. The 

following is a summary of the comments we received regarding our proposals. 

 Comment: Several commenters supported our proposal to extend the PQRS-Medicare 

EHR Incentive Pilot to 2013. The commenters do not believe that there was sufficient 

participation in 2012 to move beyond the Pilot stage in 2013. The commenters noted that the 

extension of the Pilot will continue to encourage the adoption of health information technology 

(HIT). 
1118 

 Response: We appreciate the commenters’ feedback and agree with the commenters. 

Based on the comments received and for the reasons previously stated, we are finalizing our 

proposal to extend the PQRS-Medicare EHR Incentive Pilot to CY 2013 as proposed. We are 

also finalizing our proposal to extend the use of attestation to CY 2013 as a reporting method for 

the CQM component of meaningful use for the EHR Incentive Program. We are also finalizing 

our proposed revisions to § 495.8 as proposed. Please note we are only extending the Pilot for 

2013 because in the EHR Incentive Program – Stage 2 final rule (77 FR 53968), we established a 

policy that will require all EPs participating in the Medicare EHR Incentive Program that are 

beyond their first year of meaningful use to electronically submit CQM data. 

I. Medicare Shared Savings Program

1. Medicare Shared Savings Program and Physician Quality Reporting System Payment 

Adjustment 

 Under section 1899 of the Act, CMS has established a Medicare Shared Savings Program 

(Shared Savings Program) to facilitate coordination and cooperation among providers to improve 

the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of 

growth in healthcare costs. Eligible groups of providers and suppliers, including physicians, 

hospitals, and other healthcare providers, may participate in the Shared Savings Program by 

forming or participating in an Accountable Care Organization (ACO). The final rule 

implementing the Shared Savings Program appeared in the Federal Register on November 2, 

2011 (Medicare Shared Savings Program: Accountable Care Organizations Final Rule (76 FR 

67802)). 

 Section 1899(b)(3)(D) of the Act affords the Secretary discretion to “* * * incorporate 

reporting requirements and incentive payments related to the physician quality reporting 

initiative (PQRI), under section 1848 of the Act, including such requirements and such payments 
1119 

related to electronic prescribing, electronic health records, and other similar initiatives under 

section 1848 * * *” and permits the Secretary to “use alternative criteria than would otherwise 

apply [under section 1848 of the Act] for determining whether to make such payments.” Under 

this authority, we incorporated certain Physician Quality Reporting System (PQRS) reporting 

requirements and incentive payments into the Shared Savings Program (76 FR 67902). In the 

Shared Savings Program final rule, we finalized the following requirements with regard to PQRS 

incentive payments under the Shared Savings Program: (1) the 22 GPRO quality measures 

identified in Table 1 of the final rule (76 FR 67889-67890); (2) reporting via the GPRO web 

interface (76 FR 67893); (3) criteria for satisfactory reporting (76 FR 67900); and (4) January 1 

through December 31 as the reporting period. The regulation governing the incorporation of 

PQRS incentives and reporting requirements under the Shared Savings Program is set forth at 

§425.504. 

Under §425.504(a)(1), ACOs, on behalf of their ACO provider/suppliers who are eligible 

professionals, must submit the measures determined under §425.500 using the GPRO web 

interface established by CMS, to qualify on behalf of their eligible professionals for the PQRS 

incentive under the Shared Savings Program. ACO providers/suppliers that are eligible 

professionals constitute a group practice for purposes of qualifying for a PQRS incentive under 

the Shared Savings Program. Under §425.504(a)(2)(ii), an ACO, on behalf of its ACO 

providers/suppliers who are eligible professionals, must satisfactorily report the measures 

determined under the Shared Savings Program during the reporting period according to the 

method of submission established by CMS to receive a PQRS incentive under the Shared 

Savings Program. For the years in which a PQRS incentive is available, if eligible professionals 

that participate in an ACO as ACO providers/suppliers qualify for a PQRS incentive payment 

under the Medicare Shared Savings Program, the ACO participant TIN(s) under which those 
1120 

ACO providers/suppliers bill, will receive an incentive payment based on the allowed charges of 

those ACO providers/suppliers. Under §425.504(a)(4), ACO participant TINs and individual 

ACO providers/suppliers who are eligible professionals cannot earn a PQRS incentive outside of 

the Medicare Shared Savings Program. The PQRS incentive under the Medicare Shared Savings 

Program is equal to 0.5 percent of the Secretary’s estimate of the ACO’s eligible professionals’ 

total Medicare Part B PFS allowed charges for covered professional services furnished during 

the calendar year reporting period from January 1 through December 31, for years 2012 through 

2014. 

As discussed in section III.G of this final rule with comment period, as required by 

section 1848(a)(8) of the Act, a payment adjustment will apply under the PQRS beginning in 

2015. For eligible professionals who are not satisfactory reporters, the PFS amount for covered 

professional services furnished by the eligible professional during 2015 shall be equal to 98.5 

percent (and 98 percent for 2016 and each subsequent year) of the fee schedule amount that 

would otherwise apply to such services. Therefore, consistent with our authority under section 

1899(b)(3)(D) of the Act, we proposed to amend §425.504 to incorporate reporting requirements 

for the PQRS payment adjustment under the Shared Savings Program for eligible professionals 

that are ACO providers/suppliers (77 FR 44989). 

 We proposed to incorporate requirements for the PQRS payment adjustment that are 

consistent with requirements for PQRS incentives that we previously adopted in the Shared 

Savings Program final rule. Specifically, for purposes of the PQRS payment adjustment, we 

proposed to incorporate the same PQRS GPRO under the Shared Savings Program that is 

currently used for purposes of the PQRS incentive under the Shared Savings Program. Under 

this proposal, eligible professionals that are ACO providers/suppliers would constitute a group 

practice that would report quality measures via the GPRO data collection tool for purposes of 
1121 

both the PQRS incentive under the Shared Savings Program and the PQRS payment adjustment 

under the Shared Savings Program (77 FR 44989). 

For purposes of the payment adjustment, we proposed to use the final GPRO quality 

measures adopted under the Shared Shavings Program that appear in Table 1 of the Shared 

Savings Program final rule (76 FR 67899-67890). We further proposed to incorporate the same 

criteria for satisfactory reporting that were finalized for the PQRS incentive under the Shared 

Savings Program, which are described in the Shared Savings Program final rule (76 FR 67900). 

Specifically: 

● An ACO on behalf of its eligible professionals must report on all measures included in 

the GPRO data collection tool under the Shared Savings Program final rule. 

● Beneficiaries would be assigned to the ACO using the methodology described in 

§425.400. As a result, the GPRO tool would be populated based on a sample of the ACOassigned beneficiary population. ACOs must 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 domain, measures set, or individual measure if a separate denominator is required such as in 

the case of preventive care measures which may be specific to one sex. If the pool of eligible 

assigned beneficiaries is less than 411, the ACO must report on 100 percent of assigned 

beneficiaries for the domain, measures set, or individual measure. 

● The GPRO data collection tool must be completed for all domains, measure sets and 

measures described in Table 1 of the of the Shared Savings Program final rule (76 FR 67889-

67890). 

Under this proposal, ACOs would need to satisfactorily report the 22 GPRO quality 

measures identified in Table 1 of the Shared Savings Program final rule (76 FR 67889-67890) 

and would not need to report the other 11 Shared Savings Program quality performance measures 
1122 

for purposes of satisfactory reporting for the PQRS payment adjustment. However, under this 

proposal, the ACO would still be required to satisfy the ACO quality performance standards for 

purposes of determining eligibility for shared savings, as described in §425.502. 

 We note that the proposal that ACOs report the same quality measures for purposes of 

satisfactory reporting for both the PQRS payment adjustment and incentive payments under the 

Shared Savings Program was consistent with the proposal under the traditional PQRS GPRO 

Web Interface reporting option that the criteria for satisfactory reporting for the payment 

adjustments align with the satisfactory reporting requirements for the incentive payments (77 FR 

44824). 

 Comment: We received a number of comments supporting the proposal to incorporate the 

same PQRS GPRO measures used for the PQRS incentive payment under the Shared Savings 

Program and Shared Savings Program quality performance standards. We also received support 

for accepting quality data at the ACO level rather than requiring each ACO provider and supplier 

who is an eligible professional to submit measure data separately to PQRS outside of the 

Medicare Shared Savings Program. We did not receive any comments opposing our proposal or 

suggesting alternatives. 

 Response: We appreciate commenters’ support and are finalizing our proposal to use the 

final GPRO quality measures adopted under the Shared Shavings Program that appear in Table 1 

of the Shared Savings Program final rule (76 FR 67899-67890) for purposes of the PQRS 

payment adjustment satisfactory reporting criteria with the following modifications. Instead of 

requiring ACOs to report on all of the ACO GPRO quality measures for purposes of satisfactory 

reporting for the 2015 PQRS payment adjustment under the Shared Savings Program, ACOs 

must only report one of the ACO GPRO measures that were finalized for the PQRS incentive 

under the Shared Savings Program, as described above and in the Shared Savings Program final 
1123 

rule (76 FR 67900). As the intent of our proposal was to align with the traditional PQRS GPRO 

Web Interface reporting option policy regarding the PQRS payment adjustment, this policy for 

ACOs participating in PQRS under the Shared Savings Program, as finalized under §425.504(b), 

is consistent with the criteria for satisfactory reporting that we are finalizing for group practices 

that select the PQRS GPRO Web Interface reporting option, for the 2015 payment adjustment, as 

discussed in section III.G. of this final rule. We believe that aligning the satisfactory reporting 

requirements for the 2015 PQRS payment adjustment under the Medicare Shared Savings 

Program with the satisfactory reporting requirements for the payment adjustment under the 

traditional PQRS GPRO Web Interface reporting option is important for encouraging 

participation in the Medicare Shared Savings Program. That is, we do not wish to create a 

disincentive for eligible professionals to join an ACO or participate in the Medicare Shared 

Savings Program by setting the satisfactory reporting criteria for the 2015 PQRS payment 

adjustment at a higher level under the Medicare Shared Savings Program than under the 

traditional PQRS. We believe it is appropriate to set the satisfactory reporting criteria higher for 

purposes of the PQRS incentive than for the PQRS payment adjustment, under the Shared 

Savings Program, for the same reasons discussed in section III.G. of this final rule. 

 While satisfactorily reporting one measure would be required for purposes of avoiding 

the 2015 PQRS payment adjustment under the Medicare Shared Savings Program, we note that 

ACOs are still required to report all 22 GPRO measures for purposes of the PQRS incentive 

under the Shared Savings Program and for purposes of assessing ACOs’ quality performance 

under the Shared Savings Program and determining the percentage of shared savings that ACOs 

are eligible to receive. In addition, under the Shared Savings Program regulations at 

§425.500(e)(3), ACOs are required to report on all of the quality measures established by CMS, 

and the failure to report on those quality measures accurately, completely, and timely may 
1124 

subject the ACO to termination or other sanctions. Therefore, we expect PQRS eligible 

professionals who are ACO providers/suppliers to meet the satisfactory reporting criteria for the 

2015 PQRS payment adjustment, since they would need to continue to report beyond the one 

measure for purposes of the PQRS incentive payment and Shared Savings Program shared 

savings. Satisfactory reporting criteria for the PQRS payment adjustment under the Shared 

Savings Program for 2016 and beyond will be discussed in future rulemaking. 

Although we proposed to use the same timeframe of January 1 through December 31 that 

we adopted for the PQRS incentive under the Shared Savings Program as the reporting period for 

the PQRS payment adjustment, we proposed that the timing of the reporting period would differ 

for purposes of the PQRS payment adjustment (77 FR 44990). Specifically, we proposed that 

the reporting period for the payment adjustment would fall 2 years prior to when the payment 

adjustment would be assessed. For example, under the Shared Savings Program, the reporting 

period for the 2015 payment adjustment would be from January 1, 2013 through December 31, 

2013. 

We also noted that this policy results in overlapping reporting periods for both the PQRS 

incentive and payment adjustment. For example, the measure data collected for the 2013 

calendar year reporting period (January 1, 2013-December 31, 2013) would be used for purposes 

of both the Physician Quality Reporting System 2013 incentive and 2015 payment adjustment 

under the Shared Savings Program. We believed that using the same reporting period for 

purposes of both the incentive and payment adjustment would result in less reporting burden and 

that ACOs would perceive this as more efficient than requiring one set of measures reported 

during one timeframe for purposes of the PQRS incentive and another set during another 

timeframe for purposes of the payment adjustment. 

 Comments: We received several comments in support of the reporting period proposed 
1125 

for assessing the PQRS payment adjustment under the Shared Savings Program. Some of these 

commenters supported the proposal, because it aligned with the same reporting period proposed 

for group practices participating in the PQRS GPRO. We did not receive any comments 

opposing this proposal or suggesting alternatives. 

Response: We appreciate the commenters’ support and are finalizing our proposal that 

the reporting period for the payment adjustment fall 2 years prior to when the payment 

adjustment is assessed. For example, under the Shared Savings Program, the reporting period for 

the 2015 payment adjustment is from January 1, 2013 through December 31, 2013. 

It is necessary for us to use a reporting period that precedes the year in which the 

payment adjustment is applicable to avoid retroactive payments and the reprocessing of claims. 

In addition, it is not operationally feasible for us to use a full calendar year reporting period that 

falls closer to the year in which the payment adjustment is applicable because we need sufficient 

time to determine if the requirements for satisfactory reporting have been met and to adjust our 

claims systems prior to the start of the applicable year. We note that the length and timing of the 

reporting period that we are finalizing for the PQRS payment adjustment under the Shared 

Savings Program is consistent with the one finalized for the traditional PQRS (76 FR 73392). 

 Since the publication of the Shared Savings Program final rule, we have received a 

number of inquiries regarding whether ACO participant TINs need to self-nominate or register to 

participate in PQRS GPRO under the Shared Savings Program, since there are such registration 

and self-nomination requirements under the traditional PQRS GPRO. We wish to clarify that no 

registration or self-nomination is required for ACO providers/suppliers that are eligible 

professionals to earn a PQRS incentive or avoid the payment adjustment under the Shared 

Savings Program. 

Finally, just as ACO providers/suppliers that are eligible professionals in an ACO may 
1126 

only participate under their ACO participant TIN as a group practice under the PQRS GPRO 

under the Shared Savings Program for purposes of receiving an incentive under that TIN (76 FR 

67903), we proposed that ACO providers/suppliers that are eligible professionals within an ACO 

must participate under the ACO participant TIN as a group practice under the PQRS GPRO 

under the Shared Savings Program for purposes of the PQRS payment adjustment (77 FR 

44990). Thus, ACO providers/suppliers who are eligible professionals may not seek to avoid the 

payment adjustment by reporting either as an individual under the traditional PQRS or under the 

traditional PQRS GPRO. 

We recognize that some eligible professionals may move across programs and reporting 

options from year to year. For instance, an eligible professional that is an ACO provider/supplier 

and participates in the PQRS under the Shared Savings Program in 2013 may later exit the 

Shared Savings Program and participate in PQRS individual reporting in 2014. Alternatively, a 

group practice participating in the traditional PQRS GPRO in 2013 may be an ACO participant 

in 2014. In instances in which eligible professionals change their PQRS reporting option from 

year to year, we believe that as long as the eligible professional satisfactorily reported for 

purposes of the payment adjustment during the applicable reporting period, then the eligible 

professional should not be subject to the payment adjustment even if the eligible professional 

was reporting under a different reporting method than at the time the payment adjustment would 

be assessed. 

Comment: We received one comment applauding our recognition that providers may 

shift across programs and reporting options from year to year. Several commenters supported 

our proposal that as long as an eligible professional satisfactorily reported for purposes of the 

payment adjustment during the applicable reporting period, then the eligible professional would 

not be subject to the payment adjustment even if the eligible professional was reporting under a 
1127 

different reporting method than at the time the payment adjustment would be assessed. We did 

not receive any comments against our proposal or suggesting alternatives. 

Response: We appreciate commenters’ support and are finalizing our proposal that ACO 

providers/suppliers that are eligible professionals must participate under the ACO participant 

TIN as a group practice under the PQRS GPRO under the Shared Savings Program for purposes 

of the PQRS payment adjustment and that such ACO providers/suppliers who are eligible 

professionals may not seek to avoid the payment adjustment by reporting either as an individual 

under the traditional PQRS or under the traditional PQRS GPRO. For group practices and ACOs 

that may reorganize and individual providers and groups of providers that may move in and out 

of ACOs from year to year, as long as the eligible professional satisfactorily reported for 

purposes of the payment adjustment during the applicable reporting period, then the eligible 

professional will not be subject to the payment adjustment even if the eligible professional was 

reporting under a different reporting method than at the time the payment adjustment is assessed, 

as long as that eligible professional is still billing under the same TIN at the time the payment 

adjustment is assessed as they were during the applicable reporting period. We believe this 

approach offers maximum flexibility for eligible professionals and groups of providers to make 

appropriate decisions regarding their participation in an ACO and allows ACOs to recruit new 

participants, by eliminating any risk that eligible professionals will be assessed with the payment 

adjustment as a result of such changes. We also believe it would be unfair to assess the payment 

adjustment on an eligible professional on the basis of the decision to either join or leave an ACO, 

if the eligible professional had satisfactorily reported during the applicable reporting period. 

Accordingly, we are finalizing the proposed amendment to the regulations at §425.504(b) 

with two modifications. We have revised §425.504(b)(2)(ii) to provide that an ACO, on behalf 

of its ACO providers/suppliers who are eligible professionals, must satisfactorily report one of 
1128 

the GPRO measures during the reporting period according to the method of submission 

established by CMS under the Shared Savings Program for purposes of the 2015 Physician 

Quality Reporting System payment adjustment. Satisfactory reporting criteria for the PQRS 

payment adjustment under the Shared Savings Program for 2016 and beyond will be discussed in 

future rulemaking. 

Please note that, in this final rule with comment period, we also address final policies for 

ACO data to be publicly reported on Physician Compare in section III.G. of this final rule with 

comment period and under Medicare Shared Savings Program regulations at §425.308. ACOs 

and the Value-Based Modifier are discussed in section III.I of this final rule with comment 

period. 

J. Discussion of Budget Neutrality for the Chiropractic Services Demonstration

Section 651 of MMA requires the Secretary to conduct a demonstration for up to 2 years 

to evaluate the feasibility and advisability of expanding coverage for chiropractic services under 

Medicare. Current Medicare coverage for chiropractic services is limited to treatment by means 

of manual manipulation of the spine to correct a subluxation described in section 1861(r)(5) of 

the Act provided such treatment is legal in the state or jurisdiction where performed. The 

demonstration expanded Medicare coverage to include: “(A) care for neuromusculoskeletal 

conditions typical among eligible beneficiaries; and (B) diagnostic and other services that a 

chiropractor is legally authorized to perform by the State or jurisdiction in which such treatment 

is provided.” The demonstration 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 
1129 

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 that BN would be assessed by determining the change in costs based 

on a pre-post comparison of total 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 for other services. 

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 BN. In the “All Neuromusculoskeletal Analysis,” which compared the total 

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 on Medicare spending was $114 million higher costs for beneficiaries in areas that 

participated in the demonstration. 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 
1130 

similar characteristics who used chiropractic services as was 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 on Medicare spending was a $50 million 

increase in costs. 

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, as the latter included those who 

did not use chiropractic services and who may not have become users of chiropractic services 

even with expanded coverage for them (74 FR 61926 through 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, from 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. 

For the CY 2012 PFS, our Office of the Actuary (OACT) estimated chiropractic 

expenditures to be approximately $470 million, which reflected the statutory 29.4 percent 

reduction to physician payments scheduled to take effect that year. As noted above, the statute 

was subsequently amended to impose a zero percent update for CY 2012 instead of the 29.4 
1131 

percent reduction. OACT now estimates CY 2012 chiropractic expenditures to be approximately 

$630 million. We are currently recouping $10 million through adjustments to the chiropractic 

CPT codes in CY 2012, and the percent of this reduction is approximately 1.5 percent. 

We are continuing the implementation of the required BN adjustment by recouping $10 

million in CY 2013. Our Office of the Actuary estimates chiropractic expenditures in CY 2013 

will be approximately $470 million based on Medicare spending for chiropractic services for the 

most recent available year and reflecting an approximate 30.9 percent reduction to physician 

payments scheduled to take effect under current law. To recoup $10 million in CY 2013, the 

payment amount under the PFS for the chiropractic CPT codes (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 relative value units (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. 

Therefore, as finalized in the CY 2010 PFS regulation and reiterated in the CYs 2011-

2012 PFS regulations, we are implementing this methodology and recouping from the 

chiropractor fee schedule codes set forth above. Our methodology meets the statutory 

requirement for BN and appropriately impacts the chiropractic profession that is directly affected 

by the demonstration. 

The following is a summary of the comments we received and our responses. 

Comment: One commenter, representing chiropractors, indicated that they continue to 

oppose our methodology for assuring budget neutrality under the demonstration. Instead of the 

application of an adjustment to the national chiropractor fee schedule, the commenter believes 

the Congressional intent was for CMS to make an adjustment to the totality of services payable 

under the Part B Trust Fund because of the language in Section 651(f)(A) of the MMA, which 
1132 

directs the Secretary to "provide for the transfer from the Federal Supplementary Insurance Trust 

Fund...of such funds as are necessary for the costs of carrying out the demonstration projects 

under this section." 

 Response: Section 651(f)(1)(B) of the MMA requires that the Secretary "shall 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." The statute does not specify a 

particular methodology for ensuring budget neutrality, but leaves that decision to the Secretary. 

In the CY 2010 Payment Policies under the Physician Fee Schedule and other Revisions to Part 

B for CY 2010 final rule with comment period (74 FR 61738, 61926-61928), we discussed our 

strategy for assessing budget neutrality and finalized the methodology for reducing the payment 

amount of the chiropractic CPT codes under the Physician Fee Schedule in order to ensure the 

demonstration is budget neutral. See also the CY 2006, 2007, and 2008 Physician Fee Schedule 

final rules with comment period (70 FR 70266-70267, 71 FR 69707-69708, 72 FR 66325-

66326, respectively). Our methodology for reducing the payment of the chiropractic CPT codes 

(98940, 98941, and 98942) ensures budget neutrality, meets the statutory requirements in 

§651(f)(1) of the MMA, and appropriately impacts the chiropractic profession that is directly 

affected by the demonstration. The final evaluation report, which describes, among other things, 

our methodology for calculating budget neutrality for this demonstration, is located on our 

website at http://www.cms.gov/reports/downloads/Stason_ChiroDemoEvalFinalRpt_2010.pdf. 

 Comment: The commenter referenced in the previous comment also noted that the 

increase in costs from the demonstration was completely due to the Illinois site, and not the other 

four sites. The commenter "has concerns that the Chicago area did not meet the criteria for an 

appropriate demonstration site for this project." The commenter believes it is "premature to use 
1133 

demonstration findings to estimate the cost of a national roll out of the expansion of chiropractic 

services without further analysis of the demonstration project data." 

 Response: Section 651(c)(1) of the Act required the demonstration be conducted in 4 

geographically diverse sites, specifically two rural and two urban regions, with each type 

including a Health Professional Shortage Area (HPSA). We discussed the design of this 

demonstration with the chiropractic industry and others prior to implementation. Based on these 

discussions, we included additional criteria for site selection in the design of this demonstration. 

The Chicago area met the site selection criteria for this demonstration. We refer readers to the 

January 28, 2005 Notice (70 FR 4130) for a discussion of our site selection criteria and the sites 

selected for participation based on these criteria. 

Regardless of the differences in the costs associated with the demonstration areas, the 

evaluation conducted by Brandeis University found that expanding coverage for chiropractic 

services under the demonstration resulted in increased Medicare expenditures, and the Secretary 

must recoup these costs in order to meet the budget neutrality requirement of the law. 

In response to the comment suggesting that the data from this demonstration should not 

be used to estimate the cost of a national rollout of the expansion of chiropractic services, we 

note the following. At the time of the final Report to Congress on the Chiropractic Services 

Demonstration, we estimated the costs of a national rollout of the expansion of chiropractic 

services. We based our estimate on the best available data at the time which was data from the 

demonstration. Further, data from the demonstration was the only information CMS had at the 

time of the Report to Congress for estimating the costs of a national rollout. 

After consideration of the public comments received, we are continuing the 

implementation of the required budget neutrality adjustment by recouping $10 million in 

CY 2013 by reducing the payment amount under the PFS for chiropractic codes (that is, CPT 
1134 

codes 98940, 98941, and 98942) by approximately 2 percent. 

K. Physician Value-Based Payment Modifier and the Physician Feedback Reporting Program

1. Overview 

 Section 1848(p) of the Act requires that we establish a value-based payment modifier and 

apply it to specific physicians and groups of physicians the Secretary determines appropriate 

starting January 1, 2015 and to all physicians and groups of physicians by January 1, 2017. On 

or after January 1, 2017, the section 1848(p)(7) of the Act provides the Secretary discretion to 

apply the value-based payment modifier to eligible professionals as defined in section 

1848(k)(3)(B) of the Act. Based on our initial experience with the program, we will consider 

whether to expand the application of the value-based payment modifier to additional eligible 

professionals as permitted by the Act. 

We proposed to apply the value-based payment modifier (a) to groups of physicians of 25 

or more eligible professionals, (b) to align quality measurement for purposes of the value-based 

payment modifier with the reporting requirements for data on quality measures under the 

Physician Quality Reporting System (PQRS), and (c) to implement the value-based payment 

modifier so that it does not affect payment for those groups that satisfactorily report information 

on quality measures under the PQRS unless the group of physicians expressly elect further 

assessment using a quality-tiering option. The statute requires the value-based payment modifier 

to be budget neutral. 

 We are finalizing our overall approach to the value-based payment modifier in which the 

value-based payment modifier adjustment is based on participation in the PQRS. Although we 

are refining many of the proposed value-based payment modifier policies in response to 

comments received, the major change from our proposals is that we will apply the value-based 

payment modifier to groups of physicians of 100 or more eligible professionals rather than to 
1135 

groups of physicians of 25 or more eligible professionals. We believe this change in policy is 

necessary in order for us to gain additional experience with, and to be able to produce data to 

enhance physician acceptance of, our methodologies and approach. We emphasize that even 

with this change we are committed to applying the value-based payment modifier to all 

physicians and groups of physicians by 2017 as required by Section 1848(p) of the Act. We urge 

solo practitioners and physicians in smaller groups to participate in the PQRS now, because 

when we propose in future rulemaking to apply the value-based payment modifier to smaller 

groups and solo practitioners, we anticipate basing the quality composite on PQRS quality data 

reported by such physicians. We also anticipate that we would propose to increase the amount of 

payment at risk under the value-based payment modifier as we gain additional experience with 

the methodologies used to assess the quality of care furnished, and the cost of care, by physicians 

and groups of physicians. 

2. Value-Based Payment Modifier Overview 

In the CY 2013 PFS proposed rule, we stated that the value-based payment modifier has 

the potential to help transform Medicare from a passive payer to an active purchaser of higher 

quality, more efficient and effective healthcare by providing upward payment adjustments under 

the PFS to high performing physicians (and groups of physicians) and downward adjustments for 

low performing physicians (and groups of physicians) (77 FR 44993). We recognize, however, 

that physicians are at the forefront of care delivery and that changes in payment policy can 

directly affect the medical care that physicians furnish to Medicare beneficiaries. Consistent 

with the National Quality Strategy, our aim is to promote preventive care and improve, rather 

than impede, the care that beneficiaries currently receive, especially for the chronically ill and 

those with the most complicated cases. 

We explained in the CY 2013 PFS proposed rule (77 FR 42908) that Medicare is 
1136 

beginning to implement value-based payment adjustments for other types of services, including 

inpatient hospital services. We have also outlined in reports to Congress strategies to implement 

value-based purchasing for skilled nursing facilities, home health services, and ambulatory 

surgical center services. In implementing value-based purchasing initiatives generally, we would 

meet the following goals: 

● Recognize and reward high quality care and quality improvements. 

 ++ Value-based payment systems and public reporting should rely on a mix of standards, 

processes, outcomes, and patient experience measures, including measures of care transitions and 

changes in patient functional status. Across all programs, we would move as quickly as possible 

to the use of outcome and patient experience measures. To the extent practicable and 

appropriate, we believe these outcome and patient experience measures should be adjusted for 

risk or other appropriate patient population or provider characteristics. 

 ++ To the extent possible, and recognizing differences in payment system readiness and 

statutory requirements and authorities, measures should be aligned across Medicare and 

Medicaid’s public reporting and payment systems. We would seek to evolve a focused core set 

of measures appropriate to each specific provider category that reflects the level of care and the 

most important areas of service and measures for that provider. 

 ++ The collection of information should minimize the burden on providers to the extent 

possible. As part of that effort, we will continuously seek to align our measures with the 

adoption of meaningful use standards for health information technology (HIT), so the collection 

of performance information is part of care delivery. 

 ++ To the extent practicable, the measures we use should be nationally endorsed by a 

multi-stakeholder organization. Measures should be aligned with best practices among other 

payers and the needs of the end users of the measures. 
1137 

● Promote more efficient and effective care through the use of evidence based measures, 

less rework and duplication, and less fragmented care. 

 ++ Providers should be accountable for the costs of care, being both rewarded for 

reducing unnecessary expenditures and responsible for excess expenditures. 

 ++ In reducing excess expenditures, providers should continually improve and maintain 

the quality of care they deliver. 

 ++ To the extent possible, and recognizing differences in payers’ value-based purchasing 

initiatives, providers should redesign care processes to deliver higher quality and more efficient 

care to their entire patient population. 

 Because of the centrality of physicians to high-quality, efficient, patient-centered care 

furnished in multiple settings, we believe that in the long run the value-based payment modifier 

should rely on measuring physician performance (both quality of care and cost) at four levels (to 

the extent practicable) – the individual physician level, the group practice level, the facility level 

(for example, hospital), and the community level. Physicians make decisions on a patient-bypatient basis as to what services are indicated and furnished. These decisions are made 

independently by physicians within multiple settings (that is, individual office practice, group 

practice, and hospital) and are dependent, in part, on how care is organized in a community. 

Consequently, physicians have the potential to drive both quality of care and costs at all levels of 

the health system and these decisions have an impact on patient outcomes and costs for 

populations of patients. We envision a physician value-based payment modifier in the future that 

blends performance at each of these levels (as applicable) and reinforces our objectives to 

encourage and reward physicians for furnishing high-quality, efficient, patient-centered clinical 

care. 

 Given this long range objective, we proposed that the following specific principles should 
1138 

govern the implementation of the value-based payment modifier. 

● A focus on measurement and alignment. It is difficult to maintain high quality care 

and improve quality and performance without measurement. Therefore, the value-based 

payment modifier should incorporate performance on more quality measures than those that we 

finalized in the CY 2012 PFS final rule (76 FR 73429 through 73432). These additional 

measures for the value-based payment modifier should consistently reflect differences in 

performance among physicians and physician groups and reflect the diversity of services 

furnished. These measures should be consistent with the National Quality Strategy and other 

CMS quality initiatives, including the PQRS, the Medicare Shared Savings Program, and the 

Medicare EHR Incentive Program. 

● A focus on physician choice. Physicians should be able to choose the level at which 

their performance will be assessed reflecting physicians’ choice over their practice 

configurations. The choice of level should align with the requirements of other physician quality 

reporting programs, such as the PQRS and the Medicare EHR Incentive program to reduce 

administrative burden and encourage greater program participation. 

● A focus on shared accountability. CMS has a role in fostering high value care for 

individual beneficiaries, but also focusing on how that beneficiary interacts with the healthcare 

system generally. We believe that the value-based payment modifier can facilitate shared 

accountability by assessing performance at the group practice level and by focusing on the total 

costs of care, not just the costs of care furnished by an individual physician. 

● A focus on actionable information. In conjunction with adjusting payment based on 

performance, CMS should provide meaningful and actionable information to help physicians 

identify clinical areas where they are doing well as well as areas in which performance could be 

improved. The Physician Feedback reports can serve this purpose and we plan to continue to 
1139 

provide groups of physicians with feedback reports on the quality and cost of care they furnish to 

their patients. 

● A focus on a gradual implementation. We believe that the value-based payment 

modifier should focus initially on outliers (that is, those groups of physicians that are 

demonstrably high or low performers as compared to their peers that treat like beneficiaries). 

We also believe that groups of physicians should be able to elect how the value-based payment 

modifier would apply to their payment under the PFS starting in 2015 as we phase-in the valuebased payment modifier. As we gain more experience with physician measurement tools and 

methodologies, we can broaden the scope of measures assessed to organize them around medical 

condition, refine physician peer groups to focus on how like beneficiaries are treated, create finer 

payment distinctions that focus on increasing value, and provide greater payment incentives for 

high performance. 

 We solicited comments on these principles as guides to our implementation of the valuebased payment modifier. The following is a summary of the comments we received and our 

response. 

Comment: Commenters generally supported the five principles that we proposed would 

govern the implementation of the value-based payment modifier. However, some commenters 

expressed concerns that the proposed implementation of the value-based payment modifier did 

not support all of the principles. 

One commenter stated that the proposed value-based modifier program was designed for 

large multispecialty group practices, not small single specialty groups. Another commenter 

indicated that long term care physicians currently lack the infrastructure to be able to achieve the 

proposed principles within the timeline proposed. Other commenters were concerned about the 

lag between the performance year (2013) and the application of the payment adjustment (2015) 
1140 

and urged CMS to further explore ways to realistically achieve the goal cited under “Focus on 

actionable information.” One of the commenters also raised several concerns related to group 

reporting of the quality data. 

Some of the commenters’ recommendations included providing the Physician Feedback 

reports to all physicians sooner so they have information before implementation of the valuebased payment modifier; making group reporting optional; expanding the reporting options for 

large groups; and evaluating the implementation proposals on small single specialty group 

practices and settings such as long term care settings. 

Response: We appreciate the commenters’ support of the five principles that we believe 

should govern the implementation of the value-based payment modifier. We address the 

narrower concerns raised by commenters later in this final rule with comment period, but 

continue to believe that the five principles we have identified here should guide the 

implementation of the value-based payment modifier. 

3. Proposals for the Value-Based Payment Modifier 

In the proposed rule, we described our proposals for each component of the value-based 

payment modifier (77 FR 44995). In this final rule with comment period, we discuss our 

proposed policies for each component of the value-based payment modifier, the comments 

received, our responses to the comments, and a brief statement of our final policy. 

a. Application of the Value-Based Payment Modifier 

 Section 1848(p)(4)(B)(iii) of the Act requires the Secretary to apply the value-based 

payment modifier to items and services furnished under the Medicare Physician Fee Schedule 

beginning on January 1, 2015, for specific physicians and groups of physicians the Secretary 

determines appropriate, and beginning not later than January 1, 2017 for all physicians and 

groups of physicians. For purposes of the value-based payment modifier we are finalizing in 
1141 

this final rule with comment period, physicians are defined in section 1861(r) of the Act to 

include doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors 

of podiatric medicine, doctors of optometry, and chiropractors. 

(1) Definition of a Group, Group Size, and Application of the Value-Based Payment Modifier 

to the Paid Amount 

We proposed to apply the value-based payment modifier beginning in calendar year 2015 

to all groups of physicians with 25 or more eligible professionals (77 FR 44995). For purposes 

of establishing group size, we proposed to use the definition of an eligible professional as 

specified in section 1848(k)(3)(B) of the Act. This section defines an eligible professional as any 

of the following: (1) a physician; (2) a practitioner described in section 1842(b)(18)(C) of the 

Act; (3) a physical or occupational therapist or a qualified speech-language pathologist; or (4) a 

qualified audiologist. We proposed to define a group of physicians as “a single Tax 

Identification Number (TIN).” We chose this definition in order to align with the reporting 

requirements for group practices and the definitions used in the PQRS. We also proposed to 

assess whether a group of physicians has 25 or more eligible professionals at the time the group 

of physicians is selected to participate under the PQRS GPRO. 

 In addition, we proposed to apply the value-based payment modifier to the Medicare 

paid amounts for the items and services billed under the PFS at the TIN level so that beneficiary 

cost-sharing would not be affected. We also proposed to apply it to the items and services billed 

by physicians under the TIN, not to other eligible professionals that also may bill under the TIN. 

Application of the value-based payment modifier at the TIN level means that we would not 

“track” or “carry” an individual physician’s performance from one TIN to another TIN. In other 

words, if a physician changes groups from TIN A in the performance period (calendar year 2013) 

to TIN B in the payment adjustment period (calendar year 2015), we would apply TIN B’s value-
1142 

based payment modifier to the physician’s payments for items and services billed under TIN B 

during 2015. We made this proposal for two reasons (77 FR 44995). First, payment at the group 

practice (TIN level) promotes shared accountability for the quality of care furnished at the group 

practice level. Second, we believed it will be more straightforward for groups of physicians to 

understand how the value-based payment modifier affects their TIN’s payment in the payment 

adjustment period if all physicians billing under the TIN received the same value-based payment 

modifier. 

Comment: Some commenters supported CMS’ proposal to apply the value-based 

payment modifier to only groups of 25 or more eligible professionals. They typically based 

their support on their agreement with the points CMS made in the proposed rule, stating that it 

would be premature to extend the value modifier to groups smaller than 25. However, many 

other commenters recommended that CMS apply the value-based payment modifier only to 

larger, multi-specialty groups, such as those with 100 or more physicians (MDs/DOs). Some of 

these commenters suggested that if single specialty or smaller groups were to be included, they 

should be limited to those groups that specifically request to be included. They reasoned that it 

would be important for CMS to devote resources to ensuring the program is successful with large 

groups before including smaller groups and solo practitioners. They stated that several issues are 

still untested and thus in need of further development (for example, attribution for cost purposes, 

new quality reporting methods, cost measure comparisons, and physician awareness). These 

commenters expressed concern, based on prior experience with CMS’ confidential feedback 

reports, about the ability of CMS to notify and sign up a large number of groups by the proposed 

deadline. They stated that applying the value-based payment modifier initially only to larger 

groups would reduce the number of physicians and groups that would need to be notified and 

would focus on practices that are most likely to follow the federal regulatory process and have 
1143 

staff devoted to value-based performance initiatives. Further, those commenters opined that 

tying the group size determination to the number of MDs and DOs rather than to all PQRSeligible professionals would also eliminate potential misunderstanding about the groups that are 

subject to the value-based payment modifier. Commenters also suggested that removing single 

specialty groups could mitigate a number of problems such as a lack of relevant quality measures 

available for many specialties under the group reporting options. 

On the other hand, a few commenters suggested we apply the value-based payment 

modifier to additional physicians, such as those in groups of 10 or more. This suggestion was 

based on a view that increasing participation in the value-based payment modifier for the first 2 

years of the program could facilitate a smoother transition to all physicians in 2017 (as required 

by law) and gain physician participation in the first few years. Another commenter 

recommended that CMS allow smaller practices to participate in the modifier in 2015 if they 

meet certain criteria, such as being Meaningful Users (MU) of certified Electronic Health 

Records (EHRs), or practicing in a rural state or other area where there are relatively few groups 

with 25 or more eligible professionals (for example, Health Professional Shortage Areas). These 

commenters reasoned that incorporating smaller practices into the value-based payment modifier 

would encourage all physicians, not only larger groups, to focus on high-quality, affordable care, 

reinforcing current private and other payers’ payment incentives. Commenters stated a belief 

that a broader definition of physician group is imperative if the value-based payment modifier is 

to promote value on a wide scale, given that most physicians practice in groups of less than 10 

physicians. Further, they argued that it would be feasible to include smaller practices in the 

value-based payment modifier because many of these smaller practices are participating in the 

EHR Incentive Program and they are currently reporting many of the same measures that are 

available to eligible professionals under the PQRS. In addition, it was also noted that some 
1144 

states with a high proportion of rural and other under-served areas may have comparatively few 

groups of 25 or more eligible professionals and thus be under-represented in the value-based 

payment modifier unless smaller groups are included. 

 Response: We are persuaded by the commenters that recommended we apply the valuebased payment modifier only to larger groups. We agree with commenters that suggested the 

minimum group size be defined as groups of physicians with 100 or more eligible professionals 

as a first step. We believe it would be reasonable to focus on groups with 100 or more eligible 

professionals before expanding the application of the value-based payment modifier to more 

groups. We believe that increasing the group size from 25 to 100, we would be addressing the 

concerns raised by commenters regarding attribution, new group reporting mechanisms, and cost 

comparisons. We also agree with commenters that we will be more successful in notifying and 

informing these large groups about the requirements of the value-based payment modifier than if 

we were to include groups of less than 100 eligible professionals. We do not agree, however, 

that the group size should be determined only by the number of physicians (MDs, DOs), because 

we still seek to align with the quality measure reporting criteria in the PQRS; that is, under the 

PQRS, group practices are defined by the number of eligible professionals as defined under 

section 1848(k)(3)(B), not just physicians. We believe it would be confusing to have the same 

group size (for example, 100) be calculated different ways (one way for the PQRS and another 

way for the value-based payment modifier), because the group’s participation in the PQRS 

informs how they are treated for the value-based payment modifier. 

 Comment: Some commenters believed it was essential for CMS to provide additional 

flexibility to allow groups to define themselves rather than using our proposed definition of a 

group of physicians as “a single Tax Identification Number (TIN).” For example, some 

commenters urged us to allow groups to aggregate TINs for the value modifier, indicating that 
1145 

due to a variety of business reasons unrelated to quality reporting, some practices have multiple 

TINs. In these practices, such as some faculty practice plans, the departments share common 

services and are perceived by the public as being part of the same practice. Other commenters 

suggested that CMS allow certain practices, such as large practices that operate under a single 

TIN, an option to disaggregate the TIN into separate component sub-groups in a way that 

represents how the groups functionally operate. 

 Response: We are finalizing our proposal to identify the group by its Medicare-enrolled 

TIN. Using TINs makes it possible for us to take advantage of infrastructure and methodologies 

already developed for PQRS group-level reporting and evaluation. We believe this approach 

affords us flexibility and statistical stability for monitoring and evaluating quality and outcomes 

for beneficiaries assigned to the group for quality reporting purposes. In contrast, adopting 

approaches suggested by some commenters to allow the disaggregation of a TIN (or aggregation 

of a collection of TINs) would create much greater operational complexity by requiring us to 

establish and maintain additional organizational IDs under each TIN (for disaggregation 

purposes) or among TINs (for aggregation purposes). It would be difficult operationally to 

maintain such an approach to accommodate future organizational changes among physicians and 

their practices. TINs are relatively stable over time, but still allow for some flexibility as 

individual physicians make choices about what TINs they establish. Despite these challenges 

and our decision to define a group of physicians as a “single TIN,” we intend to examine whether 

it is possible in future years to allow for the aggregation or disaggregation of TINs in order to 

better reflect physician group organization as suggested by the commenters. 

 Comment: Some commenters disagreed with the proposal to apply the value-based 

payment modifier to the items and services billed by eligible professionals who are physicians 

under the TIN and not to other eligible professionals that also may bill under the TIN. They 
1146 

reasoned it is inconsistent to apply the value-based payment modifier only to items or services 

billed by eligible professionals who are physicians, given that under the proposal CMS would 

count all eligible professionals for purposes of determining group size. These commenters 

generally requested consistency between the assessment of group size and application of the 

value-based payment modifier. By contrast, we also received suggestions that we ought to 

exclude non-physicians in the group size determination but apply the modifier to all eligible 

professionals within a medical group practice. These commenters argued that this approach 

would be more consistent with the view that high quality and coordinated care is a team effort. 

 Response: Section 1848(p)(7) of the Act requires us to apply the value-based payment 

modifier beginning in 2015 only to physicians as defined in section 1861(r) of the Act. On or 

after January 1, 2017, the Act provides the Secretary discretion to apply the value-based payment 

modifier to a broader set of eligible professionals (as defined in section 1848(k)(3)(B) of the 

Act). Thus, we are unable at this time to apply the value-based payment modifier to Medicare 

FFS payments paid to eligible professionals who are not physicians as suggested by the 

commenters. Based on our initial experience with the value-based payment modifier, we plan to 

consider whether to expand its application to additional eligible professionals in future years. As 

discussed previously, we believe it is important to use the same definition of group size (that is, 

eligible professionals) as the PQRS both to align the two programs (the PQRS and the valuebased payment modifier) and to help avoid physicians’ confusion as they determine the method 

by which they will participate in the PQRS. 

 Comment: We received few comments on our proposals to apply the value-based 

payment modifier to the Medicare paid amounts for the items and services billed under the PFS 

so that beneficiary cost-sharing or coinsurance would not be affected. These commenters 

generally agreed with the proposal to apply the value-based payment modifier to the Medicare 
1147 

paid amounts for the items and services billed under the PFS at the TIN level so that beneficiary 

cost-sharing would not be affected. 

 Response: We agree with these comments. We continue to believe it is important that 

beneficiary cost-sharing not be affected by the value-based payment modifier. 

 Comment: Several commenters requested clarification of when and how we would 

determine group size if the group of physicians did not participate in the PQRS. This 

determination is important, they reasoned, because these groups would be subject to the -1.0 

percent value-based payment downward adjustment under the value-based payment modifier if 

they were a group of physicians meeting the value-based payment modifier size requirement 

and they had not participated in the PQRS. 

 Response: We had proposed to assess the size of a group of physicians at the time the 

group of physicians is selected to participate under the PQRS GPRO. As discussed above with 

respect to the PQRS GPRO self-nomination process (section III.G.1) and below with respect to 

the election of the quality-tiering approach, we have extended to October 15, 2013, the time 

period for groups of physicians to submit their self-nomination statement to select their PQRS 

reporting method and to elect the quality-tiering methodology. As such, we will query 

Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) as of October 15, 

2013, to identify the groups of physicians with 100 or more eligible professionals. This query 

will produce a list of the groups of physicians that are subject to the value-based payment 

modifier. To ensure that the groups of physicians on this list have 100 or more eligible 

professionals during the performance period, we will analyze the group’s (TIN’s) claims 

submitted for services furnished during the performance year, including at least a 60-day claims 

runout (that is, we will analyze claims submitted through at least February 28, 2014 for services 

furnished during the calendar year 2013 performance year). We will remove a group of 
1148 

physicians from this list if the group does not have at least 100 eligible professionals that billed 

under the group’s TIN during the performance period. We note that we will not add groups to 

the October 15 list based on this claims analysis, rather we will only remove groups that, based 

on claims, do not have 100 or more eligible professionals. We also will engage in education 

and outreach during the performance year to encourage all groups of physicians, not just those 

to which the value-based payment modifier applies during 2015, to participate in the PQRS. 

 In response to the comments, we are finalizing that beginning in calendar year 2015 we 

will apply the value-based payment modifier to groups of physicians of 100 or more eligible 

professionals. We also are finalizing the following proposed policies related to the definition of 

a group and group size: 

● For purposes of establishing group size only, we use the definition of an eligible 

professional as specified in section 1848(k)(3)(B) of the Act; 

● We apply the value-based payment modifier to the Medicare paid amounts for the 

items and services billed under the PFS at the TIN level so that beneficiary cost-sharing is not 

be affected; and 

● We apply the value-based payment modifier to the items and services billed by 

physicians under the TIN, not to other eligible professionals that also may bill under the TIN. 

● We identify the groups of physicians subject to the value-based payment modifier 

(groups of 100 or more eligible professionals) based on a query of PECOS on October 15, 2013, 

and we remove any groups from this October 15 list if, based on a claims analysis, the group of 

physicians did not have 100 or more eligible professionals that submitted claims during the 

performance period. 

(2) Approach to Setting the Value-Based Payment Modifier Adjustment Based on PQRS 

Participation and the Quality-Tiering Option 
1149 

 We explained in the proposed rule that our proposals would allow groups of 25 or more 

eligible professionals to decide how the value-based payment modifier would be applied to their 

PFS payments (77 FR 44995). We proposed that in light of our desire to align CMS quality 

improvement programs, the value-based payment modifier methodology relies, in part, on the 

data submitted on quality measures by groups of physicians through the PQRS. We explained 

that quality measurement is necessary, but not sufficient, for quality improvement and a focus 

on value. Thus, we proposed to categorize groups of physicians eligible for the value-based 

payment modifier into two categories depending upon whether they had met the criteria for 

satisfactory reporting of data on the PQRS GRPO quality measures for the 2013 and 2014 

incentive payments under the PQRS or the criteria for satisfactory reporting using the 

administrative claims-based reporting mechanism, which was proposed for the 2015 and 2016 

PQRS payment adjustment. For those groups of physicians that met either of these PQRS 

satisfactory reporting criteria and requested that their value-based payment modifier be 

calculated using a quality-tiering approach, we proposed to use the performance rates on the 

quality measures reported through any of these PQRS reporting mechanisms available to them. 

 We proposed that the second category include those groups of physicians with 25 or 

more eligible professionals that have not met the PQRS satisfactory reporting criteria identified 

above (77 FR 44996). Because we would not have quality measure performance rates on which 

to assess the quality of care furnished by these groups, we proposed to apply a value-based 

payment modifier of -1.0 percent, meaning they would receive 99.0 percent of the paid amounts 

for the items and services billed under the PFS in CY 2015. 

 We explained that we were concerned, however, that some groups of physicians may 

attempt to submit data on PQRS quality measures and fail to meet the criteria for satisfactory 

reporting for the PQRS incentive and thus be placed into the second category of groups of 
1150 

physicians and, therefore, be subject to the -1.0 percent value-based payment modifier 

downward adjustment. To address this issue, we solicited comments on whether to assess 

performance on the measures included in the PQRS administrative claims-based reporting 

option as a default if a group of physicians attempts to participate in one of the PQRS GPRO 

reporting mechanisms and does not meet the PQRS criteria for satisfactory reporting. 

 Comments: The majority of commenters supported CMS’ use of the PQRS system as the 

foundation for the measurement of performance rates for physician groups for the value-based 

payment modifier. Many commenters stated this approach was a way to better align reporting 

requirements across physician programs and decrease burden. They also believed it was 

reasonable to phase-in the value-based payment modifier using this two-category structure. By 

contrast, some commenters suggested that applying the -1.0 percent downward adjustment to 

groups of physicians in the second category was penalizing these groups twice (once by the 

PQRS payment adjustment and once by the value-based payment modifier) for the same action, 

namely failure to report satisfactorily under the PQRS. Other commenters opposed allowing the 

use of performance rates on the quality measures reported through PQRS reporting mechanisms. 

They expressed concern that PQRS reporting methods are “overwhelming given the multiple 

methods of reporting, varying reporting periods, differing reporting requirements for each 

reporting mechanism.” One commenter stated that while it supported streamlining CMS quality 

programs, it had longstanding concerns with the PQRS program and as a result, opposed the 

concept of tying participation in the value-based payment modifier to participation in the PQRS. 

One commenter requested a value-based modifier of 0.0 percent be applied in 2015 for 

pathologists as there would be no applicable PQRS measures. 

 Response: We continue to believe that the two-category approach is a reasonable way to 

phase-in the value-based payment modifier in 2015. It is difficult to maintain high-quality care 
1151 

and improve quality and performance without measurement. We agree with commenters who 

stated that we should seek to align quality reporting mechanisms across physician programs. 

CMS has one physician quality reporting system and we intend to use it as the foundation for 

the value-based payment modifier. Although not satisfactorily reporting data under the PQRS 

will subject physicians and groups of physicians to a PQRS payment adjustment, the lack of 

quality data also prevents us from fully assessing the quality of care furnished compared to cost. 

At the same time, we also believe we should not affect the payment of those groups of 

physicians that have taken steps to participate in the PQRS and have developed systems within 

their practices to report data for quality measurement. Thus, in response to comments, we have 

decided to modify the two categories that we proposed and instead, we are finalizing a policy to 

apply the -1.0 percent downward value-based payment modifier adjustment only to those groups 

of physicians that do not participate in the PQRS in CY 2013 as described below 

 Comment: Many commenters urged CMS to hold groups harmless from the -1.0 percent 

value-based payment modifier downward adjustment if the group of physicians attempts, but is 

not a satisfactory reporter for the PQRS incentive payment. Commenters felt this was a good 

way to transition physician groups with little experience with PQRS reporting to do so without 

the threat of being subject to the value-based payment modifier and PQRS payment adjustments. 

Also, commenters stated that given the complexity of the PQRS, medical groups would be 

deterred from reporting data if they did not have a safety net to avoid being subject to both the 

value-based payment modifier and PQRS payment adjustments. 

 Response: We agree with commenters that we should encourage groups of physicians to 

participate in the PQRS GPRO. Accordingly, we are expanding the first category of groups of 

physicians to which we would apply a value-based payment modifier adjustment of 0.0 percent 

to include those groups that self-nominate for the PQRS GPRO and report at least one measure. 
1152 

Further, if such group of physicians had elected the quality-tiering option and did not meet the 

satisfactory reporting criteria for the PQRS payment incentive using the reporting method they 

selected in their self-nomination statement under the PQRS GPRO (such that we would not have 

performance information to create a quality composite), we will develop and use the group’s 

performance on the administrative claims-based reporting option as the basis for determining the 

group’s quality composite for purposes of the value-based payment modifier. We believe this 

policy will encourage groups to put systems in place in their practices to become satisfactory 

PQRS reporters. 

 Based upon the comments received, we are adopting our proposed policy, with one 

modification, to categorize groups of physicians eligible for the value-based payment modifier 

into two categories. Specifically, the first category of groups of physicians includes those that 

(a) have self-nominated for the PQRS as a group and reported at least one measure or (b) have 

elected the PQRS administrative claims option for CY 2013 We note that groups in category 

(a) also include those groups that have self-nominated and have met the satisfactory reporting 

criteria for the PQRS incentive payment. The value-based payment modifier for the groups of 

physicians in this first category (both (a) and (b)) will be 0.0 percent, meaning no payment 

adjustment will be applied to physicians in these groups for CY2015. For those groups of 

physicians within this first category that have requested that their value-based payment modifier 

be based on quality-tiering and have either met the satisfactory reporting criteria for the PQRS 

incentive or have chosen the administrative claims-based option, we will use the performance 

rates on the quality measures reported through these reporting mechanisms (that is, GPRO 

registries, web-interface, or administrative claims) to calculate their value-based payment 

modifier. Otherwise, we will use the group’s performance on the administrative claims 

measures for quality-tiering, because although the group self-nominated and reported at least 
1153 

one measure, we would not have sufficient quality information to construct a quality composite 

under the quality-tiering approach. 

 The second category includes those groups of physicians with 100 or more eligible 

professionals that do not fall within either of the two subcategories of category 1 described 

above. The value-based payment modifier for these groups of physicians will be -1.0 percent in 

CY 2015. 

Comment: Commenters requested that we clarify whether physicians that are reporting 

PQRS measures at the individual level and are members of groups subject to the value-based 

payment modifier would be able to continue to report as individuals using their currently 

preferred PQRS option at the individual level. They explained that they already have systems in 

place and staff that understands how to report under the PQRS at the individual level. They also 

opined that such flexibility allowed physicians in the group to choose PQRS measures that were 

most applicable to their practice and patients. 

 Response: We appreciate commenters’ support for the use of the PQRS as the 

foundation for quality reporting for the value-based payment modifier. We agree with the 

commenters that we should continue to encourage physicians in groups subject to the valuebased modifier and who are already satisfactorily reporting PQRS measures as individuals to 

have the option to remain individual PQRS reporters. We wish to clarify that in our proposals 

we did not intend to preclude individual participation in the PQRS. We specifically proposed 

that groups of physicians subject to the value-based payment modifier could elect the PQRS 

administrative-claims based option. Therefore, we are adopting a policy that physicians in 

groups of 100 or more eligible professionals that wish to report data for quality measures in the 

PQRS as individuals rather than as a group for the PQRS payment incentive must, as a group, 

elect the administrative claims-based reporting method under the PQRS by October 15, 2013. 
1154 

By doing so, the group of physicians would fall with category 1(b) and avoid the -1.0 percent 

downward value-based payment modifier. In future rulemaking, we anticipate proposing 

whether and how to combine quality measures reported at the individual level into a group 

quality score for the value-based payment modifier. 

 Comment: We received a substantial number of comments in support of the optional 

nature of having us evaluate performance based on the quality of care performance. One 

commenter recommended that quality-tiering remain voluntary until CMS has more confidence 

in its measures and composites. But we also received several comments that quality-tiering 

should not be optional. 

 Response: We agree with commenters that application of the quality-tiering 

methodology for calculating the value-based payment modifier should be optional. There will 

be many groups of physicians participating in the PQRS for the first time in 2013, many of them 

using the new group reporting mechanisms under the PQRS that are described in Table 92 

above. We believe it is reasonable for them to gain experience in reporting data for quality 

measurement under the PQRS. In addition, we will be establishing national benchmarks for the 

first time for the quality measures in the PQRS and we will be using these benchmarks in the 

quality-tiering calculation. We believe groups of physicians should have time to understand 

how their performance compares to these benchmarks, and to have time to adjust their 

performance based on these comparisons, before their payment is adjusted. Although we 

recognize the need to improve the quality of care furnished compared to cost, we believe it is 

unreasonable to make quality-tiering mandatory in the first year of the phase-in for the valuebased payment modifier. We anticipate for future years, as we collectively learn from our 

experiences with quality measurement and the value-based payment modifier, we will consider 

making quality-tiering mandatory. 
1155 

(3) Individual Physicians 

 We proposed that, starting in 2017, we would apply the value-based payment modifier 

to all physicians and groups of physicians as required by the statute (77 FR 44996). We also 

solicited comments on whether we should offer individual physicians and groups of physicians 

with fewer than 25 eligible professionals an option that their value-based payment modifier be 

calculated using a quality-tiering approach starting in 2015 (77 FR 44996). If we did so, we 

indicated that we could calculate a value-based payment modifier for groups of physicians with 

as few as two eligible professionals and apply the value-based payment modifier at the TIN 

level in the manner described in these proposals for groups of 25 or more eligible professionals. 

Likewise, we solicited comments on how to adapt our proposals to calculate a value-based 

payment modifier at the TIN level for physicians in solo practices (TINs comprised of one NPI). 

 Comment: There were a few commenters that supported application of the value-based 

payment modifier to individual physicians or EPs. For example, a commenter indicated that we 

should allow individuals that meet PQRS reporting requirements the option to participate in the 

quality-tiering option as early as possible as all physicians will be subject to the payment 

adjustment in 2017. However, most commenters agreed with the proposal to only apply the 

value-based payment modifier to groups at this time for the reasons outlined in the proposed rule 

(77 FR 44996). 

 Response: We appreciate the comments that were provided on this issue and will 

consider them further as we develop future plans to apply the value-based payment modifier to 

individual physicians. 

As discussed above, we are adopting a policy to apply the value-based payment modifier 

to groups of physicians of 100 or more eligible professionals. We will not offer smaller groups 

of physicians and individual physicians the ability to elect quality-tiering for the 2015 value-
1156 

based payment modifier as suggested by some commenters. Although we recognize that we 

must apply the value-based payment modifier to all physicians and groups of physicians starting 

January 1, 2017, we believe it is important to phase-in the value-based payment modifier to 

larger groups of physicians as we gain experience with the methodologies used in the valuebased payment modifier. We want to emphasize, however, that in future rulemaking we 

anticipate proposing for smaller groups and for individual physicians a value-based payment 

modifier structure similar to the policies we are adopting for groups of physicians of 100 or more 

eligible professionals. Importantly, we expect the value-based payment modifier structure for 

smaller groups and individuals would also be aligned with the PQRS. Thus, we strongly 

encourage smaller groups of physicians and individual physicians to participate in the PQRS so 

that they can prepare themselves and their practices for the application of value-based payment 

modifier in later years. 

(4) Hospital-Based Physicians 

 We also solicited comments on whether we should develop a value-based payment 

modifier option for hospital-based physicians to elect to be assessed based on the performance of 

the hospital at which they are based (77 FR 44996). In particular, hospital performance could be 

assessed using the measure rates for the quality measures in the Inpatient Quality Reporting 

(IQR) and the Outpatient Quality Reporting (OQR) programs. We solicited comments on which 

IQR and OQR measures (and applicable reporting period) would be appropriate to include in 

such an option and a way to identify and verify whether physicians are hospital-based. 

The following is a summary of the comments we received regarding whether we should 

develop a value-based payment modifier option for hospital-based physicians. 

 Comment: A few commenters, including some that represent or employ physicians that 

practice in hospital settings, submitted comments on this issue. These commenters generally 
1157 

agreed that CMS should develop a value-based payment modifier option for hospital-based 

physicians, some noting that this option should be voluntary and based on self-nomination. They 

believed this hospital-based option could create a shared incentive between hospital-based 

physician groups and their institutions to augment physician involvement in quality improvement 

initiatives relating to inpatient care. This alignment, particularly for hospitalists who are directly 

involved in the quality improvement efforts of the hospital, could enhance and refine the safety 

and quality of hospital care. 

 Some commenters urged CMS to be judicious when selecting measures from the IQR and 

OQR programs to ensure that hospitalist care is measured in a valid way. Some potential areas 

for performance measures were identified, such as to include transitions of care/discharges and 

common diagnoses like congestive heart failure (CHF), acute myocardial infarction (AMI), 

pneumonia and stroke. A number of these commenters requested that physicians and group 

practices should be able to identify themselves as “hospitalists” ensuring that they are compared 

to like-groups within the value-based payment modifier. Some commenters were concerned that 

our proposed beneficiary attribution approach and our total per capita cost measures could result 

in hospitalists being inaccurately measured, as they could be attributed the total cost of the 

patients’ stay at a hospital, when the hospitalist may have only been responsible for discharging 

the patient. Therefore, a commenter recommended that an attribution methodology be developed 

to accurately capture the role of hospitalists in patient care. 

 Response: We appreciate the comments received and will consider them as we develop 

future proposals for the value-based payment modifier as they relate to hospital-based 

physicians. 

(5) Quality-Tiering Election Process 

 We solicited comments on how best to ascertain whether a group of physicians subject 
1158 

to the value-based payment modifier requests the option that their value-based payment 

modifier be calculated using a quality-tiering approach (77 FR 44996). We are seeking to 

establish a system that is as simple as possible to reduce administrative burden on physicians 

and enable these groups of physicians to indicate how they plan to submit data on quality 

measures through the PQRS for purposes of the value-based payment modifier. We described 

three possible approaches to accomplish these objectives: (a) build off of the self-nomination 

process that we have proposed for groups of physicians to participate in the PQRS GPRO and 

which requires groups to submit a self-nomination application by January 31, 2013 for the 2013 

performance period, (b) create a separate web-based registration system that permits groups of 

physicians to, throughout calendar year 2013, request that their value-based payment modifier 

be calculated using the quality-tiering approach, or (c) require that groups of physicians submit 

a letter (in a prescribed format) to CMS in a timely manner. 

 Comment: Commenters indicated that they appreciated that CMS is seeking to reduce 

administrative burden when identifying the way groups of physicians would indicate that they 

request their value-based payment modifier to be calculated using a quality-tiering approach. 

These commenters generally support using a web-based registration system or other simple 

online approach to opt into the quality-tiering that allows for ongoing registration by groups 

throughout the relevant calendar year.

 Response: We thank commenters for their comments. To ease administrative burden 

and to align the quality-tiering election process with the self-nomination processes under the 

PQRS (as described in section III.G.1.b.(2) and III.G.1.c above), we are finalizing a web-based 

system for groups of physicians to request the quality-tiering methodology. Under this policy, 

groups of physicians would access the same web-based system to request the quality-tiering 

approach that they use either to submit their PQRS GPRO self-nomination statement or to elect 
1159 

administrative claims option. We also are finalizing a contingency plan to accept groups of 

physicians’ statements indicating their quality-tiering election via mail in the event the webbased functionality is not available in time to accept these statements, or in the event we 

experience issues with accepting self-nomination statements via the web. For the same reasons 

we discussed above with regard to other deadlines we are adopting under the PQRS, such 

quality-tiering elections must be received by October 15, 2013. We believe utilizing the same 

processes and deadlines finalized by the PQRS will ease administrative burden and facilitate the 

election of the quality-tiering option. 

 We want to emphasize that if a group of physicians with 100 or more eligible 

professionals does not self-nominate to participate in the PQRS GPRO or elect the 

administrative claims option for groups for CY 2013, its value-based payment modifier in CY 

2015 will be -1.0 percent. 

(6) Participants in the Medicare Shared Savings Program and Center for Medicare and Medicaid 

Innovation initiatives 

 We proposed that groups of physicians that are participating in the Medicare Shared 

Savings Program or the testing of the Pioneer ACO model, assuming they meet the PQRS 

satisfactory reporting criteria, would not have the option that their value-based payment 

modifier be calculated using the quality-tiering approach (77 FR 44996-44997). We made this 

proposal because we were mindful that the physicians and groups of physicians that are, or will 

be, participating in the Shared Savings Program and the testing of the Pioneer ACO model have 

made sizable investments to redesign care processes based on the incentives created by these 

programs and did not wish to unintentionally disturb these investments. Therefore, we solicited 

comments on ways to structure the value-based payment modifier starting in 2017 so it does not 

create incentives that conflict with the goals of the Shared Savings Program and the Pioneer 
1160 

ACO model. We also solicited comments on whether groups of physicians that are participating 

in these two initiatives should have the option that their value-based payment modifier be 

calculated using a quality-tiering approach and applied to their payments under the PFS starting 

in 2015. 

 Comment: Many commenters supported the proposal. A few commenters, especially 

those that supported broader opportunities for participation in the value-based payment modifier, 

likewise recommended that ACOs of both types (Shared Savings Program and Pioneer ACO 

model) should be permitted, but not required, to participate in the value-based payment modifier. 

Some recommended that ACOs be permitted to participate in the value-based payment modifier 

starting January 1, 2015. Such commenters believed that to the extent these groups furnish highquality, low-cost care, they should have the opportunity to be rewarded for the value they 

furnish. They also believed that having a broader array of participants in the early years of the 

value-based payment modifier would facilitate the full-scale implementation in later years. 

Some commenters also noted that providing ACOs this option would also promote alignment 

with the Hospital Value-Based Purchasing Program in which hospitals participating in ACOs are 

permitted to participate. Another commenter encouraged CMS to further explore how to apply a 

value modifier to ACO-participating groups’ PFS payments prior to 2017; for example, perhaps 

CMS could apply a value modifier to PFS payments for all patients who are not attributed to the 

ACO. A commenter noted that they were aware of several commercial plans with ACO-type 

contracts that simultaneously maintain ACO and pay-for-performance initiatives. In one case, 

the type of incentive follows the patient: providers receive the ACO program’s incentives for 

patients attributed to that arrangement, and pay-for-performance incentives are based on care 

furnished to other patients the practice treats, but who do not meet the ACO’s attribution criteria. 

The commenter believed this approach would avoid CMS’s concern about unintentionally 
1161 

disturbing providers’ ACO investments while encouraging a single standard of high-quality, 

affordable care for all patients seen by the practice. Several commenters that are participating in 

the Innovation Center’s Comprehensive Primary Care Initiative also suggested that we not apply 

the value-based payment modifier to them and/or not offer the quality-tiering approach, because 

they are collecting quality information, are eligible for shared savings, and are being held to a 

different programmatic structure with different incentives. 

 Response: We are finalizing and clarifying our proposal not to apply the value-based 

payment modifier for 2015 and 2016 to groups of physicians that are participating in the Shared 

Savings Program or the testing of the Pioneer ACO model. This policy means that such groups 

of physicians also will not have the option to elect quality-tiering because we will not apply the 

value-based payment modifier to them. At this early stage of the Medicare Shared Savings 

Program and the Innovation Center initiatives, we do not wish to unintentionally disturb their 

investments in implementing these programs. In addition, we also will not apply the value-based 

payment modifier in 2015 and 2016 to groups of physicians that are participating in other 

Innovation Center initiatives, such as the Comprehensive Primary Care initiative, or other CMS 

programs which also involve shared savings and participants making substantial investments to 

report quality measures and to furnish higher quality, more efficient and effective healthcare. 

 In sum, we will not apply the value-based payment modifier for 2015 and 2016 to groups 

of physicians that are participating in the Medicare Shared Savings Program, the testing of the 

Pioneer ACO model, or other similar Innovation Center or CMS initiatives. 

b. Performance Period 

We previously finalized CY 2013 as the initial performance period for the value-based 

payment modifier that will be applied in CY 2015 (76 FR 73436). This means that we will use 

performance on quality and cost measures during CY 2013 to calculate the value-based 
1162 

payment modifier that we would apply to items and services for which payment is made under 

the PFS during CY 2015. Likewise, we proposed that performance on quality and cost 

measures in CY 2014 be used to calculate the value-based payment modifier that is applied to 

items and services for which payment is made under the PFS during CY 2016 (77 FR 44997). 

 As we explained in the CY 2012 PFS final rule with comment period (76 FR 73435), we 

explored different options to close the gap between the performance period (that is, 2013) and 

the payment adjustment period (that is, 2015), but found that none of them would have 

permitted sufficient time for physicians and groups of physicians to report measures or have 

their financial performance measured over a meaningful period, or for us to calculate a valuebased payment modifier and notify physicians and groups of physicians of their quality and cost 

performance and value-based payment modifier prior to the payment adjustment period. We 

also explained that a system that adjusted payments to take into account the value-based 

payment modifier after claims have been paid would be onerous on physicians and 

beneficiaries. We continued to explore ways to provide more timely feedback to physicians and 

to narrow the gap between the performance period and the payment adjustment period and 

solicited comments on practical alternatives that we could implement to do so. We solicited 

comments on our proposal to use CY 2014 as the performance period for the 2016 value-based 

payment modifier (77 FR 44997). 

 Comment: Although we did not seek comment on the use of 2013 as the performance 

period for the value-based payment modifier starting in 2015, a number of commenters 

expressed concern that it was premature to use 2013 as the initial performance period for the 

2015 value-based modifier. These commenters suggested that under the proposal, CMS in effect 

advanced the statutory implementation date by 2 years. They expressed concern that there will 

be insufficient time for CMS to communicate to all of the affected physicians and groups that 
1163 

they must sign-up to participate in the PQRS GPRO in the 3-month span between the publication 

of this final rule and the proposed self-nomination deadline for participating in the PQRS GPRO. 

In addition, some commenters stated that additional testing and analysis is required to further 

refine the methodology and ensure that the modifier is fair and reliable. They suggested that 

CMS could and should use the time between now and 2015 to do further testing and refinement 

of the modifier’s components rather than establish 2013 as the initial performance period. In 

addition, commenters objected to the lag between the performance period (2013 or 2014) and the 

payment adjustment period (2015 or 2016, respectively). 

 Response: As previously noted, we already finalized our proposal to use 2013 as the 

performance period for the value-based payment modifier in 2015. For the reasons noted above 

and below, we are finalizing calendar year 2014 as the performance period for the value-based 

payment modifier in 2016. We have taken steps to phase-in the value-based payment modifier in 

a very gradual and cautious manner, as further evidenced by the fact that we are adjusting our 

policy to apply the value-based payment modifier to groups of physicians of 100 or more eligible 

professionals (rather than to groups of physicians of 25 or more eligible professionals) and the 

policy to allow such groups to select whether the quality-tiering approach would apply to the 

calculation of the value-based payment modifier. As we discussed above, our first principle 

guiding implementation of the value-based payment modifier is a focus on measurement. Thus, 

we believe it is essential to encourage greater reporting and we believe this activity should not be 

delayed. Although we agree with commenters suggestions to analyze different ways to structure 

and implement the value-based payment modifier, we need data on quality to do so. Thus, we 

believe it is imperative to begin phasing in the value-based payment modifier with an emphasis 

on encouraging all physicians and groups of physicians to participate in the PQRS. Moreover, 

given that all physicians will have to report data on quality measures under the PQRS or else be 
1164 

subject to the PQRS payment adjustment, we believe it is reasonable to align the programs to 

encourage greater reporting participation. Finally as discussed above in section III.G.1.b above, 

we have extended to October 15, 2013 the time period during which groups of physicians subject 

to the value-based payment modifier can indicate their preferred PQRS reporting mechanism and 

whether they choose the quality-tiering approach. Therefore, we are finalizing our proposal to 

use CY 2014 as the performance period for the 2016 value-based payment modifier. 

c. PQRS Quality Reporting Methods and Quality Measures 

In this section we discuss our policies to align quality measure reporting for the valuebased payment modifier with the PQRS reporting methods, and to expand the range of quality 

measures that we will use for the value-based payment modifier. 

(1) Alignment of Quality Reporting Options with the PQRS 

 In the proposed rule we proposed to categorize groups of physicians eligible for the 

value-based payment modifier into two categories depending upon their participation in the 

PQRS (77 FR 44997). We further elaborated on these proposals and proposed that groups of 

physicians subject to the value-based payment modifier would be able to submit data on quality 

measures using one of the following proposed PQRS reporting mechanisms: PQRS GPRO using 

the web-interface, claims, registries, or EHRs; or PQRS administrative claims-based option. We 

also sought comment on which PQRS reporting mechanisms we should offer to individual 

physicians if we were to apply the value-based payment modifier to their payments under the 

PFS starting in 2015 and 2016. 

Comment: As discussed previously, the majority of commenters supported CMS’ use of 

the PQRS as the foundation for measurement of the performance rates for groups of physicians 

subject to the value-based payment modifier. Several commenters, however, suggested using 

one PQRS reporting mechanism (rather than multiple mechanisms with varying criteria for 
1165 

becoming a satisfactory reporter for the PQRS incentive payment. They cited “significant 

problems when comparing data submitted via claims-based CPT II codes and data gathered from 

an EHR data submission vendor or a registry” due to the difference in reporting requirements. 

Response: We appreciate the commenters’ suggestions. We agree with commenters who 

stated that we should seek to align quality reporting mechanisms across physician programs. We 

intend to use the PQRS as the foundation for the value-based payment modifier. We also believe 

that if a group of physicians subject to the value-based payment modifier reports data for quality 

measurement using one of the available reporting mechanisms under the PQRS, then we should 

use performance on those quality measures for the value-based payment modifier. Thus, the 

PQRS reporting mechanisms available to groups of physicians subject to the value-based 

modifier will be available for these groups to report measures for purposes of the value-based 

payment modifier. Although we proposed to include four methods for groups of physicians to 

participate in the PQRS GPRO (web-interface, claims, registries, and EHRs), as discussed in 

section III.G (Table 92), we are finalizing for the PQRS the web-interface and registries methods 

for CY2013. Thus, to align with the PQRS, we will finalize the same reporting methods for the 

value-based payment modifier. We recognize commenters’ concern about the comparability of 

performance rates on measures reported through different reporting mechanisms. We intend to 

examine this issue more fully, especially as more physicians and groups of physicians utilize 

EHRs, to determine whether we should adjust our policies in future rulemaking. 

In summary, we are finalizing and clarifying our proposal that the groups of physicians 

subject to the value-based payment may utilize the PQRS GPRO reporting mechanisms available 

to them in Tables 92, as well as the PQRS administrative claims option as a group, for purposes 

of the value-based payment modifier. In addition, if physicians in a group of physicians subject 

to the value-based payment modifier wish to report data for quality measures in the PQRS as 
1166 

individuals for the PQRS payment incentive rather than as a group practice, the group must elect 

the PQRS administrative claims-based reporting method as a group by October 15, 2013 in order 

for the group to avoid the -1.0 percent downward value-based payment modifier adjustment. 

(2) Quality Measure Alignment with the PQRS 

We proposed to include all individual measures in the PQRS GPRO web-interface, 

claims, registries, and EHR reporting mechanisms for 2013 and beyond for the value-based 

payment modifier. We proposed to include the measures in the PQRS administrative claimsbased reporting option as well (77 FR 44998). We also proposed that four of the quality 

measures in the PQRS administrative claims-based reporting option (the four outcome measures) 

be used in the value-based payment modifier for all groups of physicians subject to the valuebased payment modifier (77 FR 45001-02). Finally, we solicited comments on the quality 

measures that we should propose for individual physicians if we were to provide individual 

physicians the ability to elect to have the value-based payment modifier apply to their payments 

under the PFS starting in 2015 or 2016 (77 FR 44998). In addition, we sought comment on the 

inclusion of community level measures in the value-based payment modifier (77 FR 45002). 

 Comment: The majority of commenters appreciated the flexibility of choice in reporting 

individual measures. The clinical community cited that allowing physician groups to report on 

the entire spectrum of PQRS measures “recognizes the diversity of services provided among 

physicians and physician groups and allows for more appropriate assessments of quality.” Other 

commenters objected to the PQRS system because groups can “cherry pick” measures and 

consequently felt that PQRS did not provide a strong enough incentive for improving 

performance. A couple of commenters did not support including all measures from the 2013 

GPRO interface in the value-based payment modifier and suggested we exclude both measures 

new to the GPRO web interface and measures which were not NQF-endorsed for physicians or 
1167 

group practices. One of these commenters also expressed concern about measures in the web 

interface with absolute thresholds and measures that do not allow a clinician to indicate that a 

patient has declined the service. Other commenters cited a lack of measures for many specialties 

and sub-specialties within PQRS as a cause for concern in using performance rates from PQRS 

quality measures in 2015. 

 Response: We agree with the majority of commenters that physician groups should have 

flexibility in which measures to report for the value-based payment modifier. We are finalizing 

all of the individual measures under the PQRS for 2013 and beyond for the value-based payment 

modifier. These measures are discussed in Tables 94, 95, 123, and 124 in section III.G above. 

We disagree with the commenters’ suggestion to exclude measures new to the GPRO web 

interface, measures which were not NQF-endorsed, measures with absolute thresholds, and 

measures that do not allow a clinician to indicate the patient has declined the service in the 

value-based payment modifier. We believe we have provided groups of physicians with 

sufficient flexibility to choose the quality reporting method as well as the measures on which to 

report information. Moreover, we reiterate that the quality-tiering election we are finalizing is 

optional, thus ensuring no payment consequences for potentially poor performance on such 

quality measures. 

 In addition as we described above in section III.G.6, we plan on expanding the specialty 

measures available in the PQRS in order to more accurately measure the performance on quality 

of care furnished by specialists. The expansion of the GPRO to registries in 2013 and to EHRs 

in 2014 means that sub-specialists may participate in the PQRS as members of a group practice, 

such that the group can report data on measures of broad applicability. We believe group 

reporting can ameliorate the commenters’ concerns that the current set of PQRS measures does 

not capture all of the clinical care that some specialists and sub-specialists furnish. We also 
1168 

recognize that the rules governing the PQRS are flexible in terms of the quality measures 

physicians and groups of physicians report and the methods by which they report them. 

Although some commenters stated this flexibility would lead to “cherry-picking” measures, we 

believe these two features of the PQRS are beneficial given that the first principle governing the 

value-based payment modifier is to encourage greater reporting of information for quality 

purposes by physicians and groups of physicians. 

 Comment: CMS received many comments about how to phase-in the value-based 

payment modifier at the individual level (for example, a solo practitioner) to allow them to report 

measures within any of the PQRS mechanisms for individual reporting (claims, registry, EHR) 

or by the method they had systems in place to report. Commenters supported the idea of 

flexibility of choice in reporting measures as stated above. 

Response: The vast majority of commenters have agreed with the application of the 

value-based payment modifier at the group level for the initial implementation of the program. 

We are not finalizing an option for solo practitioners to participate in the value-based payment 

modifier for 2015. We plan to make proposals for how the value-based payment modifier would 

apply to individual physicians and to smaller groups in future rulemaking. 

d. Cost Measures 

 Section 1848(p)(3) of the Act requires us to evaluate costs, to the extent practicable, 

based on a composite of appropriate measures of costs. In the CY 2012 PFS final rule with 

comment period (76 FR 73434), we finalized use of total per capita cost measures and per capita 

cost measures for beneficiaries with four specific chronic conditions (chronic obstructive 

pulmonary disease, heart failure, coronary artery disease, and diabetes) for the value-based 

payment modifier. Total per capita costs include payments under both Part A and Part B. Total 

per capita costs do not include Medicare payments under Part D for drug expenses. We 
1169 

proposed to use at least a 60-day claims run out with a completion factor from our Office of the 

Actuary (for example, claims paid through March 1 of the year following December 31, the close 

of the performance period) to calculate the total per capita cost measures (77 FR 45002). 

As described more fully in the composite scoring methodology discussion below, we 

proposed to make cost comparisons among groups of physicians using a similar beneficiary 

attribution methodology such that we make “apples to apples” comparisons. We believe that this 

would be an appropriate approach to using the total per capita cost measure in the value-based 

payment modifier. We sought comment on these proposals. 

The following is a summary of the comments we received regarding these proposals. 

Comment: A number of commenters expressed support for CMS’ proposal to implement 

the total per capita cost measure and per capita cost measures for the four chronic conditions. 

One commenter noted that the four chronic conditions align with the proposed quality measures. 

Some commenters who expressed support for the proposed cost measures encouraged CMS to 

refine and improve its cost measures in a transparent manner, including by working with 

specialty societies and other interested parties to fine tune the existing measures and potentially 

add other chronic conditions. One commenter encouraged CMS to continue looking into how to 

incorporate Medicare Part D data into physician cost measures. 

One commenter expressed concerns that the value-based payment modifier was based on 

“crude” per capita measures, while a number of specialists expressed concern that the cost 

measures are inappropriate for some specialties, particularly single specialty practices. A 

number of specialists objected to basing physician cost measures on total amount billed per 

patient, since the specialist is assumed to be held responsible for care and treatment decisions of 

the patient for which they have little control and for which they have limited ability to modify 

their practice to reduce costs. Commenters indicated that attribution of no costs or little costs to 
1170 

specialists is possible under any attribution method since the majority of specialists do not treat 

one of the four chronic conditions, so measuring costs using per capita measures would not 

create incentives to change behavior. Some commenters stated that Medicare Part A costs 

should be excluded from cost comparisons, because physicians cannot control Part A (for 

example, hospital) costs. A number of specialists supported CMS working closely with 

physicians to refine the cost measures prior to implementation of the value-based payment 

modifier. 

 Response: In the CY 2012 PFS final rule, we established a policy to use total per capita 

cost measures and per capita cost measures for beneficiaries with four specific chronic 

conditions (COPD, coronary artery disease, diabetes, and heart failure) in the value-based 

payment modifier to be implemented in 2015. We continue to believe that these measures are 

useful measures of the total volume of healthcare services furnished to Medicare beneficiaries 

attributed to a group of physicians. Moreover, use of total per capita cost measures reinforces 

one of the five principles governing implementation of the value-based payment modifier to 

encourage shared accountability for beneficiary care. We agree with specialty societies and 

other interested parties that suggested we continue to look for ways to refine the current 

measures and potentially add other chronic conditions. We will continue to explore the 

feasibility of including Part D data in the cost measures. 

 Comment: Many commenters suggested that CMS focus on episode-based cost measures 

in the value-based payment modifier, and some explicitly mentioned the importance of CMS’ 

work related to development of the Medicare Episode Grouper. A number of commenters 

agreed with CMS’ recommendation to first incorporate episode costs from the Medicare Episode 

Grouper in the Physician Feedback program prior to applying the measures to the value-based 

payment modifier. Some commenters recommended that CMS focus on chronic or high priority 
1171 

episode types during the initial states of the value-based payment modifier. Commenters 

suggested that CMS meet with specialty groups and other stakeholders to obtain feedback on the 

development and application of the Medicare Episode Grouper data and urged transparency 

through means other than just rulemaking. 

 Response: We agree with commenters about the potential value of episode-based cost 

measures in the value modifier, and we also agree with those that support our recommendation to 

first incorporate episode costs from the Medicare Episode Grouper in the Physician Feedback 

program before applying these measures to the value-based payment modifier. CMS plans to 

engage stakeholders through events that will provide details of the episode grouper methodology 

and to obtain feedback on episode based costs and utilization. 

 Comment: Several commenters noted that it would be useful to look at costs over a 

sufficiently long time period (for example, several years) to ensure that the full benefits of using 

the technology, diagnostic testing, or drug were captured. Some commenters also noted that per 

capita cost measures do not reflect savings in Medicare Part A that are due to the physician’s or 

groups’ care. Other commenters suggested that cost measures should be aligned with 

appropriate outcomes or quality measures. 

 Response: We agree that it would be useful to incorporate benefits of technology and 

drugs that might be realized in future years, and we may examine ways to measure costs, and 

changes in cost, over multiple years in the future for the value-based payment modifier. We 

believe that Part A savings during the performance year will be reflected in lower total per capita 

costs, and thus we disagree with the comments that suggest we should not include Part A costs in 

the total per capita cost measures. 

 Comment: A number of commenters recommended that all value-based payment 

modifier cost measures be submitted to NQF for endorsement. Some commenters stated that 
1172 

CMS should include only NQF-endorsed cost measures in the value-based payment modifier. 

They also suggested that CMS delay implementation of the value-based payment modifier until 

measure testing and the NQF process was complete. 

 Response: We plan to submit the total per capita cost measures and the four chronic 

condition-focused per capita measures for NQF endorsement. Although we generally agree that 

NQF-endorsed measures are preferable, we do not agree that we should only use NQF-endorsed 

measures for the value-based payment modifier. The development of cost measures is in its 

infancy and we believe that conditioning use of cost measures for the value-based payment 

modifier on NQF-endorsement would unduly delay implementation of the value-based payment 

modifier. 

 Comment: We received no comments specifically on using at least a 60-day claims run 

out, but one supporter of the five per capita cost measures noted that the run out period should be 

established such that an extension of the time period would only minimally improve accuracy. 

 Response: We are finalizing our proposal to use at least a 60-day run out with a 

completion factor from CMS’ Office of the Actuary to calculate the total per capita cost 

measures, because we believe it will provide an accurate calculation of these measures. 

As a result of the comments and for the reasons we articulated previously, we are 

finalizing the total per capita cost measures and per capita cost measures for beneficiaries with 

four specific chronic conditions (COPD, coronary artery disease, diabetes, and heart failure) in 

the 2015 value-based payment modifier and to use at least a 60-day claims run out. 

 (1) Proposed Payment Standardization Methodology for Cost Measures 

Section 1848(p)(3) of the Act requires that “...costs shall be evaluated, to the extent 

practicable, based on a composite of appropriate measures of costs established by the Secretary 

(such as the composite measure under the methodology established under section 
1173 

1848(n)(9)(C)(iii)) that eliminate the effect of geographic adjustments in payment rates (as 

described in subsection (e))...” We have interpreted this directive to require us to standardize 

Medicare payments to ensure fair comparisons of costs across geographic areas. 

Payment standardization removes local or regional price differences that may cause cost 

variation a physician cannot influence through practicing efficient care. In Medicare, an 

effective payment standardization methodology would exclude Medicare geographic adjustment 

factors such as the geographic practice cost index (GPCI) and the hospital wage index so that, for 

example, per capita costs for beneficiaries in Atlanta, Georgia can be compared to those of 

beneficiaries in Lincoln, Nebraska. Payment standardization, therefore, allows fair comparisons 

of resource use costs for physicians to those of peers who may practice in locations or facilities 

where Medicare payments are higher or lower. 

With industry input, we developed a Medicare payment standardization methodology that 

excludes such geographic payment rate differences. We update this methodology annually to 

reflect any change in CMS payment systems. We proposed to use the same standardization 

methodology as in the 2011 Physician Feedback reports and the Medicare Spending per 

Beneficiary (MSPB) measure that is used in CMS’ feedback reports to hospitals (77 FR 45003). 

The following is a summary of the comments we received regarding the payment 

standardization proposal. 

 Comment: Commenters expressed support for removing geographic and other 

adjustments when calculating cost measures. Several commenters agreed that cost measures in 

the value-based payment modifier must be standardized and explicitly supported the removal of 

indirect medical education (IME) and disproportionate share hospital (DSH) payments from the 

inpatient resource calculations. 

 Multiple commenters expressed concern about the Geographic Price Cost Indices 
1174 

(GPCIs). They stated that the GPCI results in downward adjustments that do not reflect the 

actual cost of physician practice. Some commenters referred to concerns about CMS cost 

measurement methodology issues that were raised in the May 2011 and July 2012 Institute of 

Medicine reports that questioned CMS policies regarding geographic adjustment.5

 These 

commenters claimed that, although the standardization method reverses the effects of the GPCI, 

it results in the perpetuation of some of the inaccuracies of the GPCI inputs that reduce payments 

for some regions. Some commenters stated that payment standardization does not account for 

regional differences in spending, so CMS should establish cost measures at the regional and 

national level. One commenter described concerns about efforts of poor physician supply on 

local cost measures. Several commenters noted that some areas might have high costs but lower 

rates of spending growth than nationally. 

 Response: We agree that standardization is important to ensure that groups of 

physicians’ cost measures are not higher or lower due to geographic differences and other 

adjustments (IME, DSH, etc.) that affect actual Medicare Part A and Part B payments. We note 

that the effects of the GPCIs are removed from payments under the CMS payment 

standardization methodology,6

 so services that would be subject to the GPCIs under Medicare 

payment rules are priced at the same level across all physicians within the same setting, 

regardless of geographic area in which they practice. Commenters’ concerns about the 

effectiveness of our geographic adjustment policies in general are outside the scope of this 

rulemaking. Commenters’ concern about the proposed standardization methodology not taking 

account of regional differences in spending appears to misinterpret our approach to 

 

5

 See http://iom.edu/Reports/2011/Geographic-Adjustment-in-Medicare-Payment-Phase-I-Improving-Accuracy.aspx

(May 2011; revised September 2011) and http://iom.edu/Reports/2012/Geographic-Adjustment-in-MedicarePayment-Phase-II.aspx (July 2012). 6

 See Quality Net, Measure Methodology Reports, available at: 

http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=122877

2057350. 
1175 

standardization. The per capita cost measures themselves will show regional differences in 

Medicare spending, but the standardization process ensures that differences in cost measures do 

not reflect differences in Medicare’s price indices such as the GPCI. Finally, standardization is 

not meant to measure growth in spending. 

As a result of the comments and for the reasons specified above, we are finalizing our 

proposal to apply the CMS payment standardization methodology, and any annual updates to the 

methodology, to the cost measures used for the value-based payment modifier. 

(2) Risk Adjustment Methodology for Cost Measures 

Section 1848(p)(3) of the Act requires that costs be adjusted to “...take into account risk 

factors[,] such as socioeconomic and demographic characteristics, ethnicity, and health status of 

individuals (such as to recognize that less healthy individuals may require more intensive 

interventions) and other factors determined appropriate by the Secretary.” 

Risk adjustment accounts for differences in patient characteristics not directly related to 

patient care, but that may increase or decrease the costs of care. In the Physician Feedback 

reports, after standardizing per capita costs for geographic factors, we also adjusted them based 

on the unique mix of patients attributed to the physician or group of physicians. Costs for 

beneficiaries with high risk factors (such as a history of chronic diseases, disability, or increased 

age) are adjusted downward, and costs for beneficiaries with low risk factors are adjusted 

upward. Thus, for individual physicians or physician groups who have a higher than average 

proportion of patients with serious medical conditions or other higher-cost risk factors, risk 

adjusted per capita costs are lower than the unadjusted costs, because costs of higher-risk 

patients are adjusted downward. Similarly, for individual physicians or physician groups who 

treated comparatively lower-risk patients, risk adjusted per capita costs were higher than 

unadjusted costs, because costs for lower-risk patients were adjusted upwards. 
1176 

We proposed to use the HCC model, which assigns prior year ICD-9-CM diagnosis codes 

to 70 high-cost clinical conditions (each with similar disease characteristics and costs) to capture 

medical condition risk (77 FR 45003-45004). The HCC risk scores also incorporate patient age, 

gender, reason for Medicare eligibility (age or disability), and Medicaid eligibility status, which 

is in part a proxy for socioeconomic status and reflects the greater resources typically used by 

beneficiaries eligible for both Medicare and Medicaid. The risk adjustment model also includes 

the beneficiary’s end stage renal disease (ESRD) status. More information about the risk 

adjustment model is on the CMS website at http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeedbackProgram/Downloads/122111_Slide_Presentation.pdf. 

We proposed to use the same risk adjustment model for risk adjusting total per capita 

costs and the total per capita costs for beneficiaries with four chronic diseases (coronary artery 

disease, COPD, diabetes, and heart failure) as we have used for the group and individual 2010 

Physician Feedback reports. 

The following is a summary of the comments we received regarding the risk adjustment 

proposal. 

 Comment: A number of commenters supported the HCC risk adjustment methodology, 

with one commenter stating that the risk adjustment approach that was used for the 2010 

physician feedback reports is the best currently available approach to risk adjustment of the 

value-based payment modifier with the best proxies for health status and socioeconomic status 

being used. Other commenters noted the need for or importance of risk adjustment of cost 

measures without explicitly stating support of the CMS method, with one commenter urging 

CMS to proceed with caution so that risk adjustment does not penalize physicians that treat 

sicker, more costly patients. 

 Many commenters expressed concerns about the proposed risk adjustment method. Some 
1177 

commenters indicated that they had long-standing concerns with the HCC risk adjuster that 

should be addressed before the value-based payment modifiers is applied to small and mid-sized 

practices, and they urged CMS to consider new approaches that have been suggested by 

MedPAC and by the Medicare Episode Grouper contractor. Some concerns about the HCC 

model that commenters expressed include that it does not fare as well with acute costs associated 

with surgeries that are not predictable. Some commenters argued that socioeconomic factors and 

compliance are not adequately captured in the model, and that the Medicaid dual eligible status 

alone does not capture these differences in risk. Commenters suggested including different 

factors to capture socioeconomic status, including poverty status, education, literacy, race, 

ethnicity, English proficiency, homelessness, and religion. A number of commenters urged that 

CMS do further analysis in testing and refining risk adjusters that address comorbid conditions or 

new disease onset, and suggested that CMS work with physician groups. 

 Response: We continue to believe that the current risk adjustment methodology, which is 

based on the HCC model7 and supported by a number of commenters, should be used in the 

value-based payment modifier. The HCC model is calibrated on Medicare fee for service 

beneficiaries and is accurate in predicting these costs. Moreover, one of the benefits of the HCC 

model is that CMS updates it regularly to reflect changes in treatment patterns and costs. In 

addition, CMS is exploring how to incorporate additional aspects of coding completeness and 

quality. The result of these efforts would inform how to weigh the future model design to predict 

costs and to capture conditions that are present in clinical conditions.8

 

Commenters did not present evidence that the risk adjustment model systematically 

 

7

See RTI, ``Evaluation of the CMS-HCC Risk Adjustment Methodology,'' (March 2011), available at: 

https://www.cms.gov/MedicareAdvtgSpecRateStats/downloads/Evaluation_Risk_Adj_

Model_2011.pdf. 8

 See “Advance Notice of Methodological Changes for Calendar Year (CY) 2013 for Medicare Advantage (MA) 

Capitation Rates, Part C and Part D Payment Policies and 2013 Call Letter.” 
1178 

disadvantages physicians or groups that see certain patient types, nor did they present reliable 

data sources we could use in our risk adjustment model to account for recommended factors such 

as socioeconomic status, education, literacy, English proficiency, homelessness, and religion. 

We agree with commenters that patient compliance could be a relevant issue, but commenters 

did not present a method about how to incorporate such compliance into the risk adjustment 

model using existing beneficiary data. 

After consideration of the comments and for the reasons discussed above, we are 

finalizing our proposed approach to risk adjustment of the cost measures included in the valuebased payment modifier. 

e. Attribution of Quality and Cost Measures 

Calculation of administrative claims-based quality and cost measure performance rates 

requires us to attribute Medicare beneficiaries to groups of physicians. We proposed to use a 

plurality of care method to attribute beneficiaries to a group of physicians (77 FR 45005). In this 

method, we attributed Medicare FFS beneficiaries to the group practice that billed a larger share 

of office and other outpatient Evaluation and Management (E/M) services (based on dollars) than 

any other group of physician practice (that is, the plurality). In addition, beneficiaries had to 

have at least two E/M services furnished by the group of physicians. 

We sought comments on two possible alternative attribution approaches for the valuebased payment modifier (77 FR 45005). First, we sought comment on whether we should use an 

attribution approach based on the methodology used in the Medicare Shared Savings Program to 

assign a beneficiary to an Accountable Care Organization (ACO). As discussed in the CY 2013 

proposed FFS rule (77 FR 44819), this attribution approach would involve a two-step process 

that emphasizes primary care services furnished by a physician or group of physicians. Second, 

we sought comment on whether we instead should apply the “degree of involvement” attribution 
1179 

method. We used the “degree of involvement” method to attribute beneficiaries for cost 

purposes to individual physicians in the CY 2010 Physician Feedback reports. Under this 

attribution method, we classified the patients for which a physician submitted at least one 

Medicare FFS Part B claim into three categories (directed, influenced, and contributed) based on 

the amount of physician involvement with the patient.9

 For directed and influenced patients, the 

physician billed for 35 percent or more of the patient’s office or other outpatient evaluation and 

management (E/M) visits or for 20 percent or more of the patient’s total professional costs, 

whereas for contributed patients, the physician billed for fewer than 35 percent of the patient’s 

outpatient E&M visits and for less than 20 percent of the patient’s total professional costs. 

The following is a summary of the comments we received regarding the attribution 

proposal. 

 Comment: We received several comments on attribution. Of the many commenters who 

expressed a preference for one of the attribution methods, the majority expressed support for the 

plurality of care method or the plurality of primary care services method used in the Medicare 

Shared Savings Program (Shared Savings Program). Arguments in favor of a plurality of care 

attribution method include consistency with 2010 group feedback reports, administrative 

simplicity, transparency, credibility, understandability, and its emphasis on role of treatment of 

chronic conditions. One commenter supported using a plurality of care method, but stated that 

CMS should encourage beneficiaries to choose a primary care physician and adopt an attribution 

method that includes greater consideration of annual wellness visits. Another commenter 

suggested that CMS adopt either a plurality of care or plurality of primary care services as 

included in the Shared Savings Program, as it would provide a better transition to episodes of 

 

9

 CMS, “Detailed Methodology for Individual Physician Reports” (2012), available at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Downloads/QRURs_for_Individual_Physicians.pdf 
1180 

care than the degree of involvement method. 

Although commenters were more favorable of the plurality of care or plurality of primary 

care method than the degree of involvement attribution method, some commenters expressed 

concerns about using an attribution method based on plurality of care. Some commenters agreed 

with CMS that the plurality of care method, which depends on E/M frequency, would not work 

for certain specialists, with one commenter stating that plurality unfairly attributes costs to 

certain specialties over others and other commenters agreeing with CMS that plurality will not be 

applicable to single specialty groups. One commenter expressed concern that the plurality 

method may be too restrictive for some practices. Another commenter noted that plurality of 

care attribution in the performance year is a problem when used with risk adjustment that is 

based on claims that are submitted in years prior to the performance year, and noted that multiple 

attribution or degree of involvement may alleviate some, but not all, of the issues. One 

commenter asked how the plurality of care method accommodates specialists who do not furnish 

the plurality of a patient’s care. 

CMS asked for comment on the plurality of primary care attribution approach that is 

similar to what is used in the Shared Savings Program. Although fewer commenters discussed 

this method than the plurality of care method, most who did discuss this method expressed 

general support for this approach, either as their preferred attribution method or one that was at 

least at the same level of acceptability as the plurality of care method. Some commenters stated 

that, while the plurality of care method would be consistent with the attribution method proposed 

for the PQRS GPRO web-interface, the plurality of primary care attribution method is 

comparable to that used in the Shared Savings Program and would create consistency across 

these programs. One specialist group indicated that a patient that sees a specialist for 

management of chronic conditions and receives a plurality of primary care services from the 
1181 

specialist would be appropriately attributed under this method. One medical center supported the 

Shared Savings Program-like approach over the plurality of care method because most group 

reporting measures are primary care based, so attribution under this method would be to the 

primary care physician whereas, under plurality of care attribution, the beneficiaries could be 

assigned incorrectly to higher cost specialists. 

Response: We are persuaded by the comments that we should not finalize the plurality of 

care method, but should instead align the attribution methodology with the methodology used for 

the Shared Savings Program. Given that we are applying the value-based payment modifier to 

groups of physicians of 100 or more eligible professionals, we believe it is important to align 

attribution methods with the one being used for the Shared Savings Program and the PQRS. 

Because the cost measures we are using for the value-based payment modifier focus on total per 

capita costs, we believe it is reasonable to attribute beneficiaries to those groups of physicians 

that are most responsible for the delivery of primary care services and have the ability to furnish 

it in a cost-effective manner. 

We recognize that certain large single specialty groups – such as those limited to 

emergency medicine, diagnostic radiology, pathology, and anesthesiology – will not be attributed 

beneficiaries under this attribution methodology. Indeed, neither the plurality of care attribution 

methodology nor the Shared Savings Program methodology would attribute beneficiaries to 

certain single specialty groups. However, after we have had the opportunity to examine the issue 

further and gain more experience with the value-based payment modifier we anticipate 

addressing this issue in future rulemaking. We believe that as we continue to phase in the valuebased payment modifier, we will refine our attribution methods to assign beneficiaries to these 

physicians and groups of physicians within these specialties. 

Comment: Support for the degree of involvement method was mixed, with a high 
1182 

percentage of commenters of this method suggesting that it needed to be studied further and 

explained to physicians. Some commenters argued that the degree of involvement method was 

more comprehensive and a better alternative in the long run; allows physicians who contribute to 

the care of a patient to be recognized for their services; and is preferable for attribution for 

individual physicians (rather than groups). One commenter supported the degree of involvement 

method, but disagreed with the idea of combining the directed and influenced categories because 

of the differences in accountability between the two categories. Similarly, another commenter 

indicated that if CMS selected the degree of involvement method over its preferred method of 

plurality of care, only the directed category should be used, since influenced patients are not 

sufficiently under the physicians’ care. Another commenter suggested that CMS study the 

effects of the degree of involvement method and consider whether to exclude certain specialists 

from attribution because they should not be treating patients with certain conditions. 

A number of commenters expressed either concern or confusion about the degree of 

involvement attribution method. Several commenters suggested that CMS use data from the 

Physician Feedback reports to examine the impact of different methods on groups’ cost and 

quality scores. Some commenters questioned how the degree of involvement classification 

would translate into how much would be attributed to a physician or a group. One commenter 

indicated that the degree of involvement method would be problematic in many cases and would 

need to evolve over time, with consideration for physicians who see patients at multiple 

facilities. Emergency physicians expressed concern about their ability to influence overall costs 

through coordination, although they might be attributed the costs under this method. 

Response: We thank commenters for their views on the degree of involvement 

attribution methodology, but as discussed above, we are finalizing the attribution methodology 

used in the Medicare Shared Savings Program. We will continue to study this methodology for 
1183 

it may continue to have applicability when we make proposals to apply the value-based payment 

modifier to individual physicians. 

Comment: Some commenters expressed concerns about attribution methods in general, 

stating that the current models do not address attribution appropriately when a patient sees 

multiple physicians, with some costs within a physician’s control and other costs not within the 

physician’s control. Another commenter suggested that CMS explore the option of a set of 

billing codes to make explicit the scope and nature of responsibility between the physician and 

patient. Another commenter indicated that attribution methods for specialists must account for 

care furnished because the original physician did not take sufficient preventive steps or because 

the patient was referred to a specialist. One commenter stated that attribution of the entire cost 

of surgeries should be attributed to the performing surgeon. 

Response: We thank commenters for their views and will consider them when 

developing future proposals to design an attribution methodology for those groups of physicians 

that will not have beneficiaries attributed to them under the finalized attribution methodology 

discussed above for the 2013 performance period. 

Comment: Many commenters indicated that CMS should study the impact of different 

attribution methods on physicians/physician groups’ costs and share the results to solicit 

stakeholder feedback, possibly through future rulemaking. A number of commenters expressed a 

willingness to work with CMS on attribution. Commenters wanted to understand how the results 

change when the attribution methodology changes, and some suggested that CMS delay the 

value-based payment modifier until CMS has tested and implemented a meaningful system for 

attribution to specialists. Some commenters discussed the RAND study to prove their point that 

the attribution methodology can affect how physicians and groups of physicians are 

characterized for cost and quality purposes. This study, which used claims on adults age 18-65 
1184 

that were continuously enrolled in four Massachusetts commercial plans in the years 2004 and 

2005, created 12 attribution rules and found that about 22 percent of physicians would be 

assigned to the wrong cost category given a change in attribution rules.10

Response: We agree with commenters that it would be informative to study the results of 

different attribution methods using the same data and share the results with physicians. We do 

not agree with the commenters’ suggestion to delay implementation of the value-based payment 

modifier. We believe it is critical for physicians and groups of physicians to report data for 

quality measures through the PQRS. A delay of the value-based payment modifier would 

undermine this objective. Moreover, because the quality-tiering calculation methodology is 

optional, we believe we have provided a reasonable way to implement the value-based payment 

modifier so that groups of physicians can obtain information on how their payment could be 

modified in the future and take appropriate action. 

 As a result of the comments, we are not finalizing the proposed plurality of care method, 

but instead, as described above, we will apply the same attribution rule as that used for the 

Medicare Shared Savings Program and the PQRS GPRO web interface. This methodology is 

described at http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27461.pdf. See also 45 

CFR 425.400 through 425.402. 

f. Composite Scores for the Value-Based Payment Modifier 

 Section 1848(p)(2) of the Act requires that quality of care be evaluated, to the extent 

practicable, based on a composite of measures of the quality of care furnished. Likewise, section 

1848(p)(3) of the Act requires that costs in the value-based payment modifier be evaluated, to the 

extent practicable, based on a composite of appropriate measures of costs. 

(1) Quality of Care and Cost Domains 

 

10 See RAND, Is Physician Cost Profiling Ready for Prime Time? Available at: 

http://www.rand.org/pubs/research_briefs/RB9523-1/index1.html 
1185 

 We proposed to align the quality measures used in the value-based payment modifier 

with the national priorities established in the National Quality Strategy (77 FR 45006). The 

National Quality Strategy outlined six priorities including: 

● Make care safer by reducing harm caused in the delivery of care (patient safety). 

● Ensure that care engages each person and family as partners (patient experience). 

● Promote effective communication and coordination of care (care coordination). 

● Promote the most effective prevention and treatment practices for leading causes of 

mortality (clinical care). 

● Work with communities to promote wide use of best practice to enable healthy living 

(population/community health). 

● Make quality care more affordable for individuals, families, employers, and 

governments by developing and spreading new health care delivery models (efficiency).11

We proposed to classify each of the quality measures that we proposed for the valuebased payment modifier into one of these six domains. We proposed to weight each domain 

equally to form a quality of care composite. We believe this is a straightforward approach that 

recognizes the importance of each domain. Within each domain, we proposed to weight each 

measure equally so that groups of physicians have equal incentives to improve care delivery on 

all measures. To the extent that a domain does not contain quality measures, the remaining 

domains would be equally weighted to form the quality of care composite. For example, if only 

three domains contain quality information, each domain would be weighted at 33.3 percent to 

form the quality composite while the remaining three domains would not be included. 

In terms of the cost composite, we finalized in the CY 2012 PFS final rule (76 FR 73434) 

five per capita cost measures: total per capita costs (Parts A and B) and total per capita costs for 

 

11 National Quality Strategy, http://www.healthcare.gov/law/resources/reports/nationalqualitystrategy032011.pdf. 
1186 

beneficiaries with four chronic diseases (diabetes, CAD, COPD, heart failure). We proposed to 

group these five per capita cost measures into two separate domains: total overall costs (one 

measure) and total costs for beneficiaries with specific conditions (four measures). A separate 

domain for costs for beneficiaries with specific conditions highlights our desire to incentivize 

efficient care for beneficiaries with these conditions. 

Similar to the quality of care composite, we proposed to weight each cost domain equally 

to form the cost composite and within the cost domains we proposed to weight each measure 

equally. In those instances in which we cannot calculate a particular cost measure, for example, 

due to too few cases, we proposed to weight the remaining cost measures in the domain equally. 

 Comment: We received comments both in support of and in opposition to our proposed 

composite score methodology. Some commenters expressed support for quality of care and cost 

composites, with one noting their view that composite scores are more meaningful for purchasers 

than are other measures. Some commenters expressed concerns with the proposed composite 

measures. For example, one commenter observed that quality of care and cost composites might 

mask significant variation in performance across disease categories. That is, a physician could 

demonstrate high quality and low costs for one disease category, but lower quality and higher 

costs for others; however, this would not be detected within a composite measure. This 

commenter also recommended that the internal validity of measures should be demonstrated 

before multiple measures are combined into a single composite. Another commenter expressed 

concern that few measures within the composites were applicable to their particular specialty. 

Comments on our proposed domains and weighting methodology were also mixed. One 

commenter expressed support for our proposal to equally weight domains, but recommended that 

attention be given to the number of measures in each domain so that they were weighted to 

support our policy goals. Another commenter expressed concern about establishing separate 
1187 

domains when some of these had no measures in place (for example, population/community 

health) while others had only a handful of measures, which could cause differential weighting 

among measures. 

We also received varying views on how to weight various measures. One commenter 

suggested that quality outcome measures should receive more weight than other measure types; 

another comment suggested that outcome measures be weighted lower than the PQRS measures 

as the latter are likely to be more direct indicators of a physician’s performance, particularly for 

specialty physicians. Alternatively, one commenter suggested that CMS weight existing PQRS 

measures within the efficiency domain for those who successfully report or assess costs on a 

measure-by-measure basis. 

 Response: We appreciate the comments in support of, and suggestions to improve upon, 

our proposals. We believe that forming each group of physicians’ quality and cost composites 

by equally weighting quality measures in equally weighted domains makes the most sense when 

groups of physicians have flexibility to choose which measures they will report. It also is a 

transparent method and easily understood by physicians. We recognize that some groups may 

not report measures in certain proposed domains, such as community/population health, 

efficiency, and patient experience. We wish to clarify that our proposal intended to establish an 

overall framework for how we would weight measures, and that as more measures are included 

in this and the PQRS programs, they would be incorporated into our framework. As we stated in 

the proposed rule (77 FR 45006), in cases where a group does not report measures in one or two 

of the domains the remaining domains will be weighted equally. If the group only reports 

measures in a single domain, the domain would be weighted 100 percent. Moreover, all 

measures in a domain would be equally weighted. 

We agree with the commenters’ recommendation that we continue to monitor and 
1188 

examine our policy to form the quality and cost composites. We believe this monitoring will be 

facilitated with the data reported by those participating in value-based payment modifier and the 

PQRS programs. As part of this monitoring, we will be able to examine whether the quality and 

cost composites are masking performance variation within a group as suggested by the 

commenters. 

Accordingly, we are finalizing our proposal to construct the quality composite by 

classifying each group’s quality measures into one of the six National Quality Strategy domains, 

to weight each measure equally within each domain, and to weight the domains equally to form 

the quality composite. Likewise, we are finalizing our proposals to construct the cost composite 

by classifying each group’s per capita cost measures into two domains – all patients and all 

patients with four specific chronic conditions, to weight each measure equally within each 

domain, and to weight the domains equally to form the cost composite. 

(2) Value-Based Payment Modifier Scoring Methods 

We proposed a scoring approach that focuses on how the group of physicians’ 

performance differs from the benchmark on a measure-by-measure basis because we proposed to 

provide flexibility to groups of physicians as to the quality measures they report (77 FR 45007). 

We explained that the scoring methodology needs to be able to compare “apples to apples.” For 

each quality and cost measure, we proposed to divide the difference between a group of 

physicians’ performance rate and the benchmark by the measure’s standard deviation. The 

benchmarks, as further described below, are the national means of the quality or cost measure. 

This step produces a score for each measure that is expressed in standardized units. 

Comment: The comments we received on this issue supported our proposal to establish 

standardized scores for performance measures to ensure fair comparisons among groups of 

physicians. 
1189 

 Response: After consideration of the comments, we are finalizing our proposal to 

establish standardized scores for the value-based modifier performance measures. We believe 

that this approach achieves our policy objective to distinguish clearly between high and low 

performance and to allow us to create composites of quality of care for groups of physicians that 

report different quality measures. We will be considering the effects of our methodology over 

the next several years as we implement this program and may consider changes to the policy 

through future rulemaking. 

(3) Benchmarks and Peer Groups for Quality Measures 

We proposed that the benchmark for each quality measure be the national mean of each 

measure’s performance rate during the performance period (77 FR 45008). We proposed to 

unify the calculation of the benchmark by weighting the performance rate of each physician and 

group of physicians submitting data on the quality measure by the number of beneficiaries used 

to calculate the performance rate so that group performance is weighted appropriately. 

In addition, we proposed that the benchmarks for quality measures in the PQRS 

administrative claims-based reporting option be the national mean of each quality measure’s 

performance rate calculated at the TIN level. We proposed to calculate the national mean by 

including all TINs of groups of physicians with 25 or more eligible professionals. We proposed 

to weight the TIN’s performance rate by the number of beneficiaries used to calculate the quality 

measure. 

To help groups of physicians understand how their quality measure performance affects 

their quality of care composite score, we proposed to publish the previous years’ performance 

rates (and standardized scores) on each quality measure. 

 Comment: We received several comments supporting our proposed national benchmark. 

Some commenters highlighted their view that national benchmarks were a fair way to both (1) 
1190 

reward high-quality, low-cost groups of physicians while (2) providing targets for improvement 

to underperforming groups of physicians. Although generally supporting our proposal, one 

commenter expressed the concern that benchmarks might be skewed and inconsistent across 

years because physicians could choose the measures on which they reported rather than requiring 

that they report on the full distribution of performance. Accordingly, this commenter 

recommended that all groups of physicians should report on a common set of measures. 

Other commenters reported concerns about the proposed national benchmark and, as an 

alternative, suggested that comparisons should be within regions, physician or to some other 

appropriate peer group, for example, considering patient risk. One commenter encouraged CMS 

to set performance standards higher in subsequent years. 

Some commenters suggested that CMS explore and conduct analyses on a variety of 

benchmarking options. For example, one suggested that CMS examine the advantages of 

initially using a regional or blended benchmark that gradually moves to a national benchmark. 

In their view, this could be a means to encourage physician buy-in while not disadvantaging 

certain regions based on their historical performance levels. 

One commenter suggested that for a pay-for-performance system to be effective, it must 

have clarity and credibility with front-line practitioners. This commenter observed that under 

our proposals, physicians receiving a payment adjustment are unlikely to understand why their 

payments are getting adjusted and what they need to do to improve their value modifier. 

 Response: We appreciate the comments we received in support of our proposed national 

benchmarks as well as suggested alternatives. Given that Medicare is a national program, we 

concur with comments that a national benchmark is most appropriate. Medicare beneficiaries 

should receive high quality and low cost care regardless of their location. Moreover, we use 

national benchmarks for other Medicare programs aimed at improving the quality and cost of 
1191 

care, for example, the Medicare Shared Savings program. 

Because we are allowing flexibility on the quality measures that groups of physicians can 

report, we believe the most appropriate peer group consists of other physicians and physician 

groups reporting the same measure regardless of specialty. Under this approach, we expect 

physicians and physician groups will report data on the quality measures that best reflect the care 

they furnish. 

We also believe that the optional nature of the quality-tiering approach to calculating the 

value-based payment modifier will encourage physician buy-in while not disadvantaging certain 

regions based on their historical performance levels, thus we will not develop regional 

benchmarks for each quality measure. 

Further, we believe transparency is a key component to establish credibility among 

physicians, namely, physicians need to understand why their payments are being adjusted in 

order to improve their performance. Thus, we are modifying our proposal to establish 

benchmarks based on the year prior to the performance year so that groups of physicians have 

information on national benchmarks prior to the end of the performance year. For example, the 

benchmark for the 2013 performance year will be based on 2012. We intend that these 

benchmarks would be available publicly to inform a group of physicians’ choice of PQRS 

reporting method for the applicable performance year. 

Accordingly, we are finalizing our proposal for national benchmarks and we will unify 

the calculation of the benchmark by weighting the performance rate of each physician and group 

of physicians submitting data (through any PQRS reporting method) on the quality measure by 

the number of beneficiaries used to calculate the performance rate. In addition, the benchmarks 

for quality measures in the PQRS administrative claims-based reporting option are the national 

mean of each quality measure’s performance rate calculated at the TIN level. We will weight the 
1192 

TIN’s performance rate by the number of beneficiaries used to calculate the quality measure. 

We also will use the year prior to the performance year as the year for calculating the 

benchmark. If a measure is new to the PQRS, we will be unable to calculate a benchmark, and 

hence, performance on that measure will not be included in the quality composite. We will be 

considering the effects of our policies over the next several years as we implement this program 

and may consider changes and refinements through future rulemaking. 

(4) Benchmarks and Peer Groups for Cost Measures 

To ensure fair cost comparisons that identify groups of physicians that are outliers (both 

high and low), we proposed that the methodology used to attribute beneficiaries to a group of 

physicians be the same as the methodology used to attribute beneficiaries in the peer group (77 

FR 45008). We explained that we seek to compare like groups of physicians that use the same 

cost attribution methodology to ensure we are making “apples to apples” comparisons among 

groups of physicians. As discussed above, we are finalizing a cost attribution methodology that 

we use in the Medicare Shared Savings Program and that relies on a two-step process. We 

sought comment, however, on whether the cost measure peer groups should change if we 

adopted the “degree of involvement” methodology for groups of physicians other than groups of 

physicians using the PQRS GPRO web-interface to submit data on quality measures. We also 

solicited comments on establishing cost benchmarks on a quality measure-by-quality measure 

basis. 

 Comment: As discussed above, we received comments in support of our proposal for a 

national benchmark. We also received several suggestions that we implement regional cost 

benchmarks rather than national ones to account for regional variations in spending. 

 Response: Consistent with our discussion above regarding the national basis of this 

program, we are finalizing our proposal to establish national benchmarks for the five cost 
1193 

measures based on data from the current performance year. Given that we are standardizing 

Medicare payments to eliminate regional payment differences to ensure fair national 

comparisons, we do not believe it is appropriate to establish regional benchmarks for the valuebased payment modifier. We will be considering the effects of this policy over the next several 

years as we implement this program and may consider changes to these policies through future 

rulemaking. 

 (5) Reliability Standard 

 We believe it is crucial that the value-based payment modifier be based on quality of care 

and cost composites that reliably measure performance. Statistical reliability is defined as the 

extent to which variation in the measure’s performance rate is due to variation in the quality (or 

cost) furnished by the physicians (or group of physicians) rather than random variation due to the 

sample of cases observed. Potential reliability values range from zero to one, where one (highest 

possible reliability) signifies that all variation in the measure’s rates is the result of variation in 

differences in performance across physicians (or groups of physicians). Generally, reliabilities in 

the 0.40-0.70 range are often considered moderate and values greater than 0.70 high. 

 Therefore, we proposed to establish a minimum number of cases in order for a quality or 

cost measure to be included in the quality of care or cost composite (77 FR 45009). To the 

extent that a group of physicians fails to meet the minimum number of cases for a particular 

measure, the measure would not be counted and the remaining measures in the domain would be 

given equal weight. To the extent that we cannot develop either a reliable quality of care 

composite or cost composite because we do not have reliable domain information, we proposed 

that we would not calculate a value-based payment modifier and payment would not be affected. 

Based on an analysis of the individual CY 2010 Physician Feedback reports and on recent 

literature, we proposed a minimum case size of 20 for both quality and cost measures to ensure 
1194 

high statistical reliability. We explained that the average reliability of the total per capita cost 

measure assessed at the individual level for physicians in all specialties was high (greater than 

0.70) when the minimum case size was 20 or more. We also stated that reliability was high for 

nine of the 15 administrative claims based quality measures that we are proposing for purposes 

of the value-based payment modifier for the PQRS administrative claims-based reporting option 

when the minimum case size was 20 or greater. We anticipate that statistical reliability of the 

quality and cost measures will increase when we assess physicians at the TIN level rather than 

NPI level, because, on average, a TIN will be attributed more beneficiaries than an NPI. 

 Comment: We received a few comments on this proposal expressing support for strong 

reliability standards or a minimum case size threshold. We received a couple of comments 

recommending a higher minimum case size, for example, 30 rather than 20. One commenter 

sought clarification of our analysis of the reliability of the administrative claims based quality 

measures from the 2010 Individual Physician Feedback reports. 

 Response: We appreciate the comments we received in support of strong reliability 

standards. Based upon our statistical analysis that we discussed in the proposed rule (77 FR 

45009), we believe a minimum case size of 20 is sufficient for this purpose. As we stated in our 

proposal, nine of the 15 administrative claims quality measures were highly reliable at the 

individual level. The other six were either moderately reliable at the individual level or assessed 

clinical care in high priority areas. We anticipate that reliability will not be an issue given that 

our analysis was at the individual level and not for groups of 100 or more eligible professionals. 

Accordingly, we are finalizing our proposal for 20 cases as the minimum case size; however, we 

will monitor and examine this issue as we implement this program and may consider changes to 

this policy through future rulemaking as we broaden the value-based payment modifier to reach 

all physicians and groups of physicians in 2017. 
1195 

g. Payment Adjustment Amount 

 Section 1848(p) of the Act does not specify the amount of physician payment that should 

be subject to the adjustment for the value-based payment modifier; however, section 

1848(p)(4)(C) of the Act requires the payment modifier be implemented in a budget neutral 

manner. Budget neutrality means that payments will increase for some groups of physicians 

based on high performance and decrease for others based on low performance, but the aggregate 

amount of Medicare spending in any given year for physicians’ services will not change as a 

result of application of the value-based payment modifier. 

 In making proposals about the amount of Medicare payment made under the PFS at risk 

for the value-based payment modifier, we considered that there are two other payment 

adjustments affecting physicians’ Medicare payment in 2015 that could further decrease 

physician payments in 2016. Specifically, under the PQRS, a physician who does not submit 

data on quality measures to meet the satisfactory reporting criteria for the PQRS payment 

adjustment during the applicable reporting period in 2013 will have his or her fee schedule 

amount reduced by 1.5 percent for services furnished in 2015. This PQRS downward payment 

adjustment to the fee schedule will increase to 2 percent in 2016 (and thereafter) based on 

reporting periods that fall in CY 2014 (and thereafter, reporting period or periods that fall two 

years prior to the year in which the PQRS payment adjustment is assessed). The second payment 

adjustment is for physicians who do not achieve meaningful EHR use under the EHR Incentive 

program. Section 1848(a)(7) of the Act provides for a downward payment adjustment of 1 

percent in 2015 , 2 percent in 2016, and 3 percent in 2017 . We note that the adjustment in 2015 

for not achieving meaningful use is increased by 1 percentage point (to -2 percent) if the 

physician was subject to the eRx Incentive Program payment adjustment for 2014. 

As discussed above, we have finalized our policy to allow groups of physicians of 100 or 
1196 

more eligible professionals to elect whether to have their value-based payment modifier based on 

the quality-tiering methodology. For those groups that elect quality-tiering, we proposed that the 

maximum payment adjustment be -1.0 percent for poor performance (75 FR 45010). We stated 

that due to the budget neutrality requirement, we did not propose the exact amount of the upward 

payment adjustments for high performance under the quality-tiering approach because the 

upward payment adjustments (in the aggregate) will have to balance the downward payment 

adjustments in order to achieve budget neutrality. Thus, we proposed to determine the projected 

aggregate amount of downward payment adjustments and then calculate the upward payment 

adjustment factor based on the amount of the projected aggregate upward payment adjustments. 

For groups of physicians subject to the value-based payment modifier that have not met 

the PQRS criteria for satisfactory reporting as described above (including those groups that have 

not participated in any of the PQRS reporting mechanisms), we proposed to set their value-based 

payment modifier at -1.0 percent (77 FR 45010). We arrived at our proposal for a -1.0 percent 

downward adjustment using the following rationale: Section 1848(p)(1) of the Act requires us to 

differentiate payment based on a comparison of quality of care furnished compared to cost. 

Because we do not have performance rates on which to assess the quality of care furnished by 

these groups, we can differentiate payment based on costs only rather than quality and cost as 

required by statute. Due to the fact that the value-based payment modifier is just starting in 

2015, we do not wish to apply a greater downward payment adjustment for non-satisfactory 

reporters than we are proposing for the low quality/high cost groups that request that their valuebased payment modifier be calculated using a quality-tiering approach. 

 Comment: Commenters expressed general support for our proposal to limit the downside 

risk to -1.0 percent for groups not participating in the PQRS and to ensure that those groups that 

elected quality-tiering would not be penalized more than those who did not participate in the 
1197 

PQRS. For example, one commenter noted that absent a specified maximum penalty, practices 

would be unwilling to risk having their payments significantly cut under a voluntary program. 

Another commenter expressed appreciation for our proposal to limit payment reductions to 1 

percent, but also noted that with the potential for additional reductions for PQRS, e-Rx, and a 2 

percent sequester-related reduction, the proposed 1 percent reduction still poses some risk. 

Similarly, some commenters requested a higher floor on downward payment adjustments, for 

example, -0.5 percent rather than -1.0 percent or even no negative adjustment for practices that 

opt into quality-tiering. One commenter raised a question as to whether participants in qualitytiering should be penalized at all given they had taken the minimum step of reporting PQRS data. 

As an alternative, this commenter recommended that CMS consider upward adjustments for 

groups that perform well with no adjustment for the remainder. Another commenter offered the 

view that with the possibility of a downward payment adjustment, only high quality/low cost 

physicians will participate in the program, which would result in a narrow range of comparisons 

that could be made and high performers being classified as being low. In their view, this would 

limit the ability to learn from the program. 

In contrast, however, we received many comments suggesting that the proposed payment 

adjustments were insufficient to motivate change at the physician level. Hence, one commenter 

recommended that quality-tiered scoring be mandatory for groups that report PQRS measures in 

2013 as not doing so effectively creates a one-year opt out. Further, they recommended that the 

maximum downward adjustment be increased to -3.0 percent as it would both motivate change 

among lower performing physicians while better making available a sufficiently meaningful 

reward for good performance. Some commenters recommended that CMS apply higher payment 

differentials, some as high as +/- 10 percent or more either in 2015 or subsequent years. 

Related to this, some commenters expressed concern that since the upward payment 
1198 

adjustment was yet unspecified, there was little incentive or clarity in terms of the advantages 

and risks for participating in the program. One commenter sought clarity on whether budget 

neutrality meant that groups that elect quality-tiering would be “vying to receive an upward 

modifier adjustment from a pool of funds derived from groups that received the -1.0 percent 

adjustment or would be competing against one another. 

 Response: While we appreciate comments suggesting larger payment adjustments to 

more strongly encourage quality improvements, we are finalizing our proposed adjustments as 

we believe they better align with our goal to gradually phase in the value-based payment 

modifier. We anticipate that as we gain more experience with our value-based payment modifier 

methodologies, we will consider ways to increase the amount of payment at risk. 

 We also appreciate concerns expressed about the uncertain of the amount of the upward 

payment adjustment; however, given statutory requirements for budget neutrality, we have not 

identified a way to specify an upward amount until all downward adjustments have been 

determined. We are open to comments on how we might be able to provide an upward payment 

amount for future rulemaking. We also wish to clarify that the total amount of upward payment 

adjustments is a fixed amount that is equal the amount made available through downward 

payment adjustments. 

 In summary, we are finalizing our proposal to establish a -1.0 value-based payment 

modifier adjustment for those groups of physicians of 100 or more eligible professionals that fall 

into category 2, which are those that neither (a) self-nominate for the PQRS as a group and report 

at least one measure nor (b) elect the PQRS administrative claims option for CY 2013. We also 

are finalizing our proposal to limit the downside payment adjustment for groups of physicians 

that elect the quality-tiering option at -1.0 percent. 

h. Value-Based Payment Modifier Scoring Methodology 
1199 

 Section 1848(p)(1) of the Act requires the Secretary to establish a payment modifier that 

provides for differential payment to a physician or group of physicians under the fee schedule 

based upon the quality of care furnished compared to cost during a performance period. As 

noted previously, the statute requires that quality of care furnished and cost shall be evaluated, to 

the extent practicable, based on composites of quality of care furnished and cost. 

 In making our proposals, we developed two models that compare the quality of care 

furnished to costs: a quality-tiering model and a total performance score model. We proposed 

the quality-tiering model for the value-based payment modifier, and solicited comments on the 

total performance score model (77 FR 44010-12). 

(1) Quality-Tiering Model 

 The quality-tiering model compares the quality of care composite with the cost composite 

to determine the value-based payment modifier. To make this comparison, we proposed to 

classify the quality of care composites scores into high, average, and low quality of care 

categories based on whether they are statistically above, not different from, or below the mean 

quality composite score. We seek to ensure that those groups of physicians classified as high or 

low performers have performance that is meaningfully different from average performance (to be 

sure that no group of physicians is disadvantaged for performance only slightly different from 

the benchmark) and is precisely measured (to ensure that no group of physicians is 

disadvantaged by an inaccurate performance assessment). We proposed to assess meaningful 

differences as those performance scores that are at least one standard deviation from the mean. 

We proposed to assess precision by requiring a group of physicians’ score to be statistically 

different from the mean at the 5.0 percent level of significance (that is, a 95 percent confidence 

interval). 

Likewise, we proposed to identify those groups of physicians that have cost composite 
1200 

scores that are statistically different from the mean cost composite score of all groups of 

physicians. We proposed to classify these groups of physicians into high, average, and low cost 

categories based on whether they are significantly above, not different from, or below the mean 

cost composite score as described above with reference to quality composite. We proposed to 

assess meaningful differences as those performance scores that are at least one standard 

deviation from the mean and we proposed to assess precision at the 5.0 percent level of 

significance. 

We proposed to compare quality of care composite classification with the cost composite 

classification to determine the value-based payment modifier adjustment according to the 

amounts in Table 126. 

TABLE 126: Value-Based Payment Modifier Amounts for the Quality-Tiering Approach 

Quality/cost Low cost Average cost High cost 

High quality +2.0x* +1.0x* +0.0% 

Average quality +1.0x* +0.0% -0.5% 

Low quality +0.0% -0.5% -1.0% 

* Groups of physicians eligible for an additional +1.0x if reporting measures and average beneficiary risk score in 

the top 25 percent of all risk scores. 

We proposed to establish the upward payment adjustment factor (“x”) after the 

performance period has ended based on the aggregate amount of downward payment 

adjustments. We also proposed to aggregate the downward payment adjustments in Table 126 

with the downward adjustment for groups of physicians subject to the value-based payment 

modifier that are not satisfactory PQRS reporters and then to solve for the upward payment 

adjustment factor (“x”). For example, after determining the aggregate projected amount of the 

downward payment adjustments, CMS could calculate that the payment adjustment factor (“x”) 

would be 0.75 percent such that high quality/low cost groups of physicians would receive a 1.5 

percent (2 x 0.75) upward payment adjustment during the payment adjustment period. 
1201 

We also proposed that the scoring methodology provide a greater upward payment 

adjustment (+1.0x) for groups of physicians that care for high-risk patients (as evidenced by the 

average HCC risk score of the attributed beneficiary population) and submit data on PQRS 

quality measures through PQRS via the GPRO using the web-interface, claims, registries, or 

EHRs. We proposed to increase the upward payment adjustment to +3x (rather than +2x) for 

groups of physicians classified as high quality/low cost and to +2x (rather than +1x) for groups 

of physicians that are either high quality/average cost or average quality/low cost if the group of 

physicians’ attributed patient population has an average risk score that is in the top 25 percent of 

all beneficiary risk scores. In other words, we did not propose this additional upward payment 

adjustment (+1.0x) for groups of physicians that select the PQRS administrative claims-based 

reporting option. 

A second approach to scoring the value-based payment modifier is a total performance 

score approach. We sought comment on this approach. This approach allows us to develop a 

unique value-based payment modifier for each group of physicians. This approach results in a 

range of continuous payment adjustments rather than the thresholds proposed in the quality tier 

approach. This method would be similar to the approach we use in the Hospital Value-Based 

Purchasing program where we use a linear exchange function to develop a unique payment for 

each hospital. This approach results in a continuous array of unique value-based payment 

modifiers such that there are no longer cut-off points between high and low performing groups of 

physicians. 

 Comment: We received several comments in support of the quality-tiering model. In 

some cases, commenters noted their support for quality-tiering as it was readily understandable 

or could provide an incentive to care for difficult-to-treat beneficiaries. MedPAC indicated 

support for CMS’ proposal to apply the value modifier bonus or penalty only when a physician 
1202 

group’s performance is significantly different from the national mean. Further, MedPAC 

indicated that it has supported an “outlier” approach for cost measures as a reasonable way to 

identify physicians or groups with extraordinarily higher or lower costs than average. In some 

cases, commenters suggested that we apply the quality-tiering model initially, but consider 

moving to the total performance score model over time. One commenter noted they had general 

concerns with quality-tiering, but would take a wait-and-see approach as long as it was voluntary 

rather than mandatory. 

 We also received many comments supporting the total performance score methodology. 

Several commenters expressed their view that this methodology better aligned with the hospital 

value-based purchasing methodology than did quality-tiering or that it would be most appropriate 

for hospital-based physicians. 

Many of these commenters suggested that the total performance score methodology: (1) 

offered greater incentives for groups to participate in the program or to improve their 

performance because they could be rewarded for either achievement or improvement; and (2) 

avoided “cut off problems” where groups are placed in high and low performing categories that 

occur under the quality-tiering approach. One commenter offered their view that applying a 

cutoff such as one standard deviation is crude in that a physician performing at 0.99 standard 

deviations below the mean would be considered average while another performing at 1.01 

standard deviations below the mean would be considered low. Another commenter observed that 

since quality-tiering applies to only physician groups above or below one standard deviation, the 

methodology effectively removes two-thirds of practices from its effects. Another suggested that 

a focus on outliers does little to improve care as variation in performance within groups is 

hidden. 

Commenters also noted that CMS might not have sufficient historical data on all 
1203 

physicians to implement this methodology, and suggested that it could evolve from qualitytiering over time. 

Response: We appreciate the comments in support of the quality-tiering model, and are 

finalizing our proposal to adopt this model. We agree with the commenters that this approach is 

a reasonable way to phase in the value-based payment modifier, especially as more groups of 

physicians report quality data and we can fine tune our methodology to identify high and low 

performers. Although we recognize the beneficial aspects of the total performance score model 

mentioned by the commenters (for example, incentives for continuous improvement and no cutoff issues), we believe that model may be inappropriate when groups of physicians have the 

ability to select the quality measures on which they report such that there is not a uniform 

yardstick by which to assess performance improvement. Moreover, at this initial stage of the 

value-based payment modifier, we believe a more reasonable approach is to focus on outliers 

rather than trying to adjust the payment of every group of physicians, despite the fact that a focus 

on outliers may mask performance variation within a group of physicians. 

Comment: Also, assuming adoption of the quality-tiering model, some commenters 

suggested a more stringent criterion than one standard deviation from the mean to differential 

outliers. For example, some commenters suggested that two or three standard deviations be used 

as a threshold for distinguishing groups. In particular, one commenter noted that a more 

stringent threshold should be used if and when the risk for downward adjustments increases. 

 In other cases, commenters suggested alternatives to distinguishing groups by statistical 

comparison. For example, one commenter suggested that CMS explore a concept of 

“meaningful clinical difference” that is used in the domain of patient self-reported health status. 

 Response: We thank this commenter for their suggestions on how to distinguish outliers, 

that is high and low performers, but are finalizing our proposal to use one standard deviation 
1204 

with a 5 percent level of confidence. We believe distinguishing outliers in this way provides 

substantial confidence to physicians that we will not misclassify groups as high or low 

performers when they actually are not. Allowing groups of physicians the option to elect 

quality-tiering also addresses the issues that we are being too stringent in identifying high and 

low performers. We will be considering the effects of this policy over the next several years as 

we implement this program and may consider changes to these policies through future 

rulemaking. 

Comment: Commenters were generally supportive of our proposal to offer additional 

incentives for groups caring for high-risk beneficiaries. Some commenters suggested that the 

high-risk incentives be expanded to include additional physician groups, for example, to those 

groups with average or high costs who also have average or above average quality scores. 

Another commenter recommended that we apply the high-risk beneficiary upward adjustment to 

all practices participating in quality-tiering—not just those categorized as high quality/low-cost, 

high quality/average cost, or average quality/low cost tiers—particularly, if a penalty is assessed 

for the lowest performing tier. Another comment suggested that in a budget neutrality system, 

however, it was impossible to provide an upward bump-up in the payment adjustment for all 

groups caring for high-risk beneficiaries, because there would be fewer funds to distribute to 

high performing groups. 

Response: We thank commenters for their support and, for the reasons noted above, are 

finalizing our proposal to provide an upward payment adjustment for groups electing qualitytiering that are high performers and care for high-risk beneficiaries. 

i. Proposed Informal Review and Inquiry Process 

 Section 1848(p)(10) of the Act provides that there shall be no administrative or judicial 

review under section 1869 of the Act, section 1878 of the Act, or otherwise of the following: 
1205 

● The establishment of the value-based payment modifier; 

● The evaluation of the quality of care composite, including the establishment of 

appropriate measure of the quality of care; 

● The evaluation of costs composite, including establishment of appropriate measures of 

costs; 

● The dates of implementation of the value-based payment modifier; 

● The specification of the initial performance period and any other performance period; 

● The application of the value-based payment modifier; and 

● The determination of costs. 

 Despite the preclusion of administrative and judicial review, we believe it is useful for 

groups of physicians to understand how their payment under the PFS could be changed by the 

value-based payment modifier. We also believe that an informal mechanism is needed for 

groups of physicians to review and to identify any possible errors prior to application of the 

value-based payment modifier. 

 Therefore, we intend to disseminate Physician Feedback reports containing calendar year 

2013 data in the fall of 2014 to groups of physicians subject to these policies; these reports 

would be the basis of the value-based payment modifier in 2015. We proposed that these reports 

would contain, among other things, the quality and cost measures and measure performance and 

benchmarks used to score the composites, and quality of care and cost composite scores, and the 

value-based payment modifier amount (77 FR 45012). 

 After the dissemination of the Physician Feedback reports in the fall of 2014, we 

proposed that physicians would be able to e-mail or call a technical help desk to inquire about 

their report and the calculation of the value-based payment modifier. We envisioned this process 

to help educate and inform physicians about the value-based payment modifier, especially for 
1206 

those groups of physicians that have elected that their value-based payment modifier be 

calculated using a quality-tiering approach. 

 In anticipation of the reports that we would produce in 2014, in the fall of 2013 we plan 

to produce and disseminate Physician Feedback reports at the TIN level to all groups of 

physicians with 25 or more eligible professionals based on 2012 data. These reports will 

include a “first look” at the methodologies we proposed in this rule for the value-based payment 

modifier. We view these reports as a way to help educate groups of physicians about how the 

value-based payment modifier could affect their payment under the PFS. 

 Comment: We received comments in support of making feedback available to 

participating physician groups and the opportunity to discuss this feedback with CMS. One 

commenter noted that the dissemination of physician feedback reports should be the first step in 

a large scale educational campaign on the implementation of the value-based modifier. Further, 

in their view, the success of the program depends on physician practices believing in the data and 

acting on it to improve their performance. Some commenters recommended that data be shared 

with all satisfactory PQRS reporters. One commenter asked that CMS share or post sample data 

so that physician groups could model what the value-based modifier might mean for them 

financially as they decide whether or not to participate. Another commenter requested that 

patient-specific information should be available to assist practices in verifying the data. In 

contrast, another commenter offered the view that while these reports could be relevant to 

primary care physicians or large multi-specialty practices, they might be less so to single 

specialty practices such as podiatrists. 

A number of commenters noted the importance of making feedback reports available in a 

timely manner, and expressed concerns about the usefulness of data that are not current. For 

example, commenters reported that untimely data are not actionable and assessing payments on 
1207 

such data offer little incentive for change. One commenter suggested that data need to be timely 

or penalties should otherwise be waived. 

We also received comments expressing support for the availability of technical 

assistance, for example, through a technical help desk as well as an appeals or review process. 

One commenter suggested that CMS establish corrective action plans or some means to assist 

poorer performers before applying a payment adjustment. One commenter disagreed with the 

“limited distribution of physician feedback reports prior to implementation of the value based 

modifier” and suggested we provide feedback reports to all physicians in advance of payment 

adjustments.” In addition, some commenters urged CMS to consider adopting a Corrective 

Action Plan, or similar program, for outliers/poor performers prior to applying the value-based 

payment modifier. 

 Response: We thank commenters for their support. We will provide physician feedback 

reports during the fall of 2014 for all groups of physicians affected by the value-based payment 

modifier in 2015 and, as discussed below, we will make a help desk available to address 

questions related to the reports. We also are planning on many enhancements and features 

suggested by the commenters so that the feedback reports provide meaningful and actionable 

information to physicians to improve the quality of care they furnish to Medicare beneficiaries. 

(4) Physician Feedback Program 

 Section 1848(n) of the Act requires us to provide confidential reports to physicians that 

measure the resources involved in furnishing care to Medicare FFS beneficiaries. Section 

1848(n)(1)(A)(iii) of the Act also authorizes us to include information on the quality of care 

furnished to Medicare FFS beneficiaries. In September 2011, we produced and disseminated 

confidential feedback reports to physician groups that participated in the PQRS Group Practice 

Reporting Option (GPRO) in 2010, and in March 2012 we produced and disseminated reports to 
1208 

physicians practicing in the following states: Iowa, Kansas, Missouri, and Nebraska. 

 In the CY 2013 PFS proposed rule, we discussed that, in the fall of 2012, we plan to 

disseminate Physician Feedback reports to physicians in nine states (California, Iowa, Illinois, 

Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin) based on 2011 data. These 

reports will contain the PQRS measures that physicians in these states submitted via any of the 

PQRS reporting methods, as well as information on 28 administrative claims measures included 

in the 2010 reports. We also will produce and disseminate Physician Feedback reports to the 

groups of physicians that reported measures through the PQRS GPRO web interface in 2011. 

We adjusted and improved the content and organization of the Physician Feedback reports that 

we plan to produce later this year based on the comments we received from the Program Year 

2010 report recipients. We plan to increase our outreach efforts to encourage physicians to 

view their reports, to begin to understand the methodologies we have adopted in this final rule 

for the value-based payment modifier and that are included in the 2011 reports, and to provide 

suggestions on how we can make these reports more meaningful and actionable in the future. 

 In the fall of 2013, we plan to produce and disseminate Physician Feedback reports at 

the TIN level to all groups of physicians with 25 or more eligible professionals. These reports 

will include a “first look” at the methodologies that we have adopted in this final rule for the 

value-based payment modifier. 

In addition, section 1848(n) of the Act requires that we use the episode-based costs in 

the Physician Feedback reports beginning in 2013 for the reports based on 2012 data. As 

discussed above in relation to the value-based payment modifier, we plan to include episodebased cost measures for several episode types in future Physician Feedback reports. In addition, 

we plan to consider adjusting the format and organization of the reports, to the extent 

practicable, to address the best practices outlined in the American Medical Association’s 
1209 

Guidelines for Reporting Physician Data. We believe that this dissemination plan satisfies our 

obligations under the section 1848(p)(4)(B)(ii)(II) of the Act to provide information to 

physicians and groups of physicians about the quality of care furnished to Medicare FFS 

beneficiaries. 

 In the fall of 2014, we plan to disseminate Physician Feedback reports based on 2013 

data that show the amount of the value-based payment modifier and the basis for its 

determination. We plan to provide these reports to all groups of physicians (at the TIN level) 

with 25 or more eligible professionals even though groups of physicians with 25 to 99 eligible 

professionals will not be subject to the value-based payment modifier in 2015. We are 

examining whether we can provide reports to groups of physicians with fewer than 25 eligible 

professionals and individual level reports as well. These reports will contain, among other 

things, performance on the quality and cost measures used to score the composites and the valuebased payment modifier amount. As discussed above, we anticipate providing an opportunity for 

review and correction as outlined in our value-based payment modifier proposals above. 

 We received many comments on our future plans for the Physician Feedback reports. A 

summary of the comments and our responses to those comments are provided below. 

Comment: We received many suggestions from commenters on ways to improve the 

content, format, and distribution of the Physician Feedback reports (also termed the “Quality and 

Resource Use Reports” (QRURs)), with a focus on making the content more actionable for 

quality improvement. 

Response: We appreciate all of the suggestions on how to improve the Physician 

Feedback reports. We are working with the American Medical Association, state medical 

societies, specialty societies, and other stakeholders to address these issues in future feedback 

reports. 
1210 

Comment: A commenter stated that it was unclear whether the physician feedback 

reports will replace the PQRS reports that are released when incentive payments are distributed 

and would support the integration of the two reports. 

 Response: We are looking at ways to streamline the reports supporting the PQRS and the 

physician value-based payment modifier programs in order to create one unified format for 

quality assessment. 

Comment: Commenters appreciated CMS’ planned physician outreach activities to 

garner physician reaction to the information contained in the Physician Feedback reports and 

elicit physician input on ways to increase their utility in future years. Additionally, they 

suggested that CMS should: 

● Work with national and state medical specialty societies to ensure that physicians 

understand these reports. 

● Work with medical specialty societies to improve the Physician Feedback reports. 

● Further increase physician awareness of and education for the value-based payment 

modifier and Physician Feedback Program. 

● Provide a mechanism for interpretation of feedback reports and meaningful dialogue 

between physicians, specialty society staff, and CMS. 

 Response: We appreciate the commenters’ support of our outreach activities and are 

already undertaking the activities recommended by commenters. 

Comment: Several commenters stated that many practices did not receive reports for 

individual physicians within their practice or they received reports for physicians who are no 

longer in the practice due to inaccuracies. In addition, the commenters stated that some practices 

had a difficult time obtaining the reports. The commenters recommended that CMS should work 

to ensure that it is not difficult for physicians to obtain these reports – particularly if the 
1211 

information on the report is tied to penalties. 

 Response: We are already aware of the concerns raised by these commenters. 

Accordingly, we have adjusted our procedures for disseminating the 2011 physician feedback 

reports later in 2012, in order to minimize the difficulties physicians may have in obtaining their 

reports and to ensure reports go to their intended recipients. 

 Comment: A commenter expressed concern about possible unintended consequences that 

physician feedback reports may have for clinical practice. The commenter stated a belief that 

aspects of the program will lead physicians to avoid sicker, more complicated patients and 

expressed concern about the potential of the program to move physician attention toward 

program compliance and away from evaluating and addressing the concerns of patients during 

visits. The commenter states that this has the potential to reduce quality of care and patient 

satisfaction. 

 Response: We do not agree that the Physician Feedback reports will have negative 

consequences on clinical practice. We believe that the Physician Feedback reports provide 

useful information to physicians about the quality of care furnished to Medicare beneficiaries 

and should be used by physicians to determine the areas where they need to make improvements 

in their clinical practice. Moreover, the cost measures in the Physician Feedback reports are risk 

adjusted so that we are controlling for preexisting health conditions and other patient factors 

when making comparisons in the reports. 

 Comment: A number of commenters were concerned that the Physician Feedback reports 

would not be provided in time to inform physicians about their 2015 utilization, which is the 

basis for the 2017 payment adjustment period. 

 Response: As we stated above, in the fall of 2013, we plan to produce and disseminate 

Physician Feedback reports at the TIN level to all groups of physicians with 25 or more eligible 
1212 

professionals These reports will provide a “first look” at the methodologies that will be used to 

develop the value-based payment modifier. We view these reports as a way to help educate 

physicians about how the value-based payment modifier could affect their payment under the 

PFS. Even though we are applying the value-based payment modifier to groups of physicians 

of 100 or more eligible professionals, we believe it is important to provide the Physician 

Feedback reports to a wider audience in anticipation of making proposals in future rulemaking 

on applying the value-based payment modifier to all physicians and groups of physicians 

starting January 1, 2017. 

Comment: Several commenters stated that CMS should make the Physician Feedback 

reports available to all physicians in 2014. 

 Response: We will take the commenters’ recommendation under consideration as we 

develop the policy for disseminating the 2014 Physician Feedback reports. However, we 

believe it is important to prioritize our efforts on groups of physicians that would be subject to 

the value-based payment modifier in the near future first. 

 Comment: A number of commenters stated that CMS should provide a mechanism for 

physicians to request the list of patients for which cost and quality measures are attributed in 

their Physician Feedback reports. 

Response: We agree that it would be useful for physicians to have a list of the patients 

who were attributed in the calculation of their cost and quality measures and are working to 

include this information as part of future Physician Feedback reports, recognizing that we seek 

to ensure that the data provided is used for quality improvement purposes and is consistent with 

privacy regulations. 

 Comment: A commenter recommended that future Physician Feedback reports focus on 

the cost of the care provided by the physician receiving the report instead of the total cost of all 
1213 

care received by the beneficiary. The commenter indicated that this would be both more 

informative and more actionable for individual physicians than the current per capita cost 

measures. 

 Response: As we stated earlier, one of the principles governing the implementation of 

the value-based payment modifier is a “focus on shared accountability.” Under this principle, we 

believe that the value-based payment modifier can facilitate shared accountability by assessing 

performance at the practice group level and by focusing on the total costs of care, not just the 

costs of care furnished by an individual physician. Physicians reporting measures at the group 

level are encouraged to seek innovative ways to furnish high-quality, patient-centered, and 

efficient care to the Medicare FFS beneficiaries they treat. 

L. Medicare Coverage of Hepatitis B Vaccine

1. Modification of high risk groups eligible for Medicare Part B coverage of Hepatitis B 

vaccine. 

a. Background and Statutory Authority – Medicare Part B Coverage of Hepatitis B Vaccine 

Section 1861(s)(10)(B) of the Act authorizes Medicare Part B coverage of hepatitis B 

vaccine and its administration if furnished to an individual who is at high or intermediate risk of 

contracting hepatitis B. High and intermediate risk groups are defined in regulations at §410.63. 

 On December 23, 2011, the United States Centers for Disease Control and Prevention 

(CDC) published a Morbidity and Mortality Weekly Report (MMWR), which included an article 

entitled “Use of Hepatitis B Vaccination for Adults with Diabetes Mellitus: Recommendations 

of the Advisory Committee on Immunization Practices (ACIP).” The article stated that “In the 

United States, since 1996, a total of 29 outbreaks of HBV [Hepatitis B virus] infection in one or 

multiple long-term care (LTC) facilities, including nursing homes and assisted-living facilities, 

were reported to CDC; of these, 25 involved adults with diabetes receiving assisted blood 
1214 

glucose monitoring. These outbreaks prompted the Hepatitis Vaccines Work Group of the 

Advisory Committee on Immunization Practices (ACIP) to evaluate the risk for HBV infection 

among all adults with diagnosed diabetes.” 

“HBV is highly infectious and environmentally stable; HBV can be transmitted by 

medical equipment that is contaminated with blood that is not visible to the unaided eye. 

Percutaneous exposures to HBV occur as a result of assisted monitoring of blood glucose and 

other procedures involving instruments or parenteral treatments shared between persons. Lapses 

in infection control during assisted blood glucose monitoring that have led to HBV transmission 

include multipatient use of finger stick devices designed for single-patient use and inadequate 

disinfection and cleaning of blood glucose monitors between patients. Breaches have been 

documented in various settings, including LTC facilities, hospitals, community health centers, 

ambulatory surgical centers, private offices, homes, and health fairs.” Additionally, in analyses 

of persons without hepatitis B-related risk behaviors (that is, injection-drug use, male sex with a 

male, and sex with multiple partners), persons aged 23 through 59 years with diabetes had 2.1 

times the odds of developing acute hepatitis B as those without diabetes; and the odds for 

hepatitis B infection were 1.5 times as likely for persons aged 60 and older. (MMWR, 

December 23, 2011). 

Based on the Hepatitis Vaccines Work Group findings, ACIP recommended that: 

● Hepatitis B vaccination should be administered to unvaccinated adults with diabetes 

mellitus who are aged 19 through 59 years. 

● Hepatitis B vaccination may be administered at the discretion of the treating clinician 

to unvaccinated adults with diabetes mellitus who are aged 60 years and older. 

b. Implementation 
1215 

Based on the ACIP recommendations, we proposed to modify §410.63(a)(1), High Risk Groups, 

by adding new paragraph “(viii) Persons diagnosed with diabetes mellitus.” Since HBV can be 

transmitted by medical equipment (that is, finger stick devices and blood glucose monitors) that 

is contaminated with blood that is not visible to the unaided eye, we believe that persons 

diagnosed with diabetes mellitus should be added to the high risk group. Since lapses in 

infection control have been reported in both community and facility settings, the increased risk 

of contracting HBV is not limited to the facility setting. We believe that expanding coverage of 

Hepatitis B vaccinations and administration to those diagnosed with diabetes mellitus is 

supported by the findings and evidence reviewed by the Hepatitis Vaccines Work Group and the 

ACIP recommendations. Hepatitis B vaccination is a preventive measure that needs to occur 

before exposure. It is difficult to predict which diabetics will eventually be exposed in the 

circumstances that we discussed above. Therefore, we proposed to expand coverage for hepatitis 

B vaccine and its administration to all individuals diagnosed with diabetes mellitus, not just 

those individuals with diabetes that are receiving glucose monitoring in facilities, for example, in 

nursing homes. 

c. Summary of Public Comments 

We received 15 public comments that supported the proposed rule to expand coverage of 

hepatitis B vaccination and its administration to individuals diagnosed with diabetes mellitus. 

We did not receive any public comments that opposed our proposed expansion. In addition to 

their support of our proposal, below is a summary of additional comments received and our 

responses. 

Comment: One commenter suggested that coverage should be limited to individuals with 

diabetes when the treating physician recommends to the individual that he or she receive a 

hepatitis B vaccination, rather than having the vaccination be mandatory for all individuals 
1216 

diagnosed with diabetes mellitus. 

Response: We believe that our proposal provides the physician with flexibility to 

determine whether provision of hepatitis B vaccination to a patient is appropriate based on the 

individual patient’s risk factors. Nothing in the proposed rule or this final rule mandates 

vaccination for individuals diagnosed with diabetes mellitus. Accordingly, we are not making 

the suggested changes in this final rule. 

Comment: Some commenters requested that we provide coverage under Medicare Part B 

for all ACIP-recommended immunizations, the herpes zoster vaccine, and hepatitis C virus 

screening, as Medicare preventive benefits. 

Response: These comments are outside the scope of this rulemaking, as our proposed 

rule specifically addressed Medicare coverage of Hepatitis B vaccine and its administration 

under a specific statute, §1861(s)(10)(B) of the Act. The commenters’ requested expansions 

would not be based on this statute. 

Based on the overwhelming support of the public comments received, we are 

implementing this rule as proposed. 

M. Updating Existing Standards for E-prescribing under Medicare Part D and Lifting the LTC 

exemption.

1. Background 

a. Legislative History 

Section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 

2003 (MMA) (Pub. L. 108-173) amended title XVIII of the Act to establish a voluntary 

prescription drug benefit program at section 1860D-4(e) of the Act. Among other things, these 

provisions required the adoption of Part D e-prescribing standards. Prescription Drug Plan 

(PDP) sponsors and Medicare Advantage (MA) organizations offering Medicare Advantage-
1217 

Prescription Drug Plans (MA-PD) are required to establish electronic prescription drug programs 

that comply with the e-prescribing standards that are adopted under this authority. There is no 

requirement that prescribers or dispensers implement e-prescribing. However, prescribers and 

dispensers who electronically transmit prescription and certain other information for covered 

drugs prescribed for Medicare Part D eligible beneficiaries, directly or through an intermediary, 

are required to comply with any applicable standards that are in effect. The Medicare Part –D eprescribing Program adopts standards that allow Eligible Professionals (EP) to participate in 

the eRx Incentive Payment program and Other CMS programs that require the reporting of 

electronic prescribing transactions. 

For a further discussion of the statutory basis for this final rule and the statutory 

requirements at section 1860D-4(e) of the Act, please refer to section I. (Background) of the EPrescribing and the Prescription Drug Program proposed rule, published February 4, 2005 (70 

FR 6256). 

b. Regulatory History 

(1) Foundation and Final Standards 

(a) Adopting and updating: 

CMS utilized several rounds of rulemaking to adopt standards for the Part D eprescribing program. Its first rule, which was published on November 7, 2005 (70 FR 67568), 

adopted three standards that were collectively referred to as the “foundation” standards. One of 

these standards, the National Council for Prescription Drug Programs (NCPDP) SCRIPT 

Standard, Implementation Guide, Version 5, Release 0 (Version 5.0), May 12, 2004 (excluding 

the Prescription Fill Status Notification Transaction and its three business cases; Prescription Fill 

Status Notification Transaction--Filled, Prescription Fill Status Notification Transaction--Not 
1218 

Filled, and Prescription Fill Status Notification Transaction--Partial Fill), hereafter referred to as 

the NCPDP SCRIPT 5.0, is the subject of several of the changes effectuated by this and prior 

final rules. We issued a subsequent rule on April 7, 2008 (73 FR 18918) that adopted additional 

standards which are referred to as “final” standards. One of these standards, Version 1.0 of the 

NCPDP Formulary and Benefit standard, Implementation Guide, Version 1, Release 0, hereafter 

referred to as the NCPDP Formulary and Benefit 1.0) is also the subject of another of the 

changes effectuated by this final rule. Please see the “Initial Standards Versus Final Standards” 

discussion at 70 FR 67568 in the November 7, 2005 rule for a more detailed discussion about 

“foundation” and “final” standards. 

(b) Exemption from the NCPDP SCRIPT standard in long term care settings (LTC) 

 While prescribers and dispensers who electronically transmit prescription and certain 

other information for covered drugs prescribed for Medicare Part D eligible beneficiaries, 

directly or through an intermediary, are generally required to comply with any applicable Part D 

e-prescribing standards that are in effect at the time of their transmission, the early versions of 

the NCPDP SCRIPT standard did not support the complexities of the prescribing process for 

patients in long term care facilities where the prescribing process involves not only a prescriber 

and a pharmacy, but also a facility and its staff. As such, we exempted such entities from use of 

the NCPDP SCRIPT standard. That exemption, currently found at §423.160(a)(3)(iv), provides 

an exemption for entities transmitting prescriptions or prescription-related information where the 

prescriber is required by law to issue a prescription for a patient to a non-prescribing provider 

(such as a nursing facility) that in turn forwards the prescription to a dispenser. 

For a more detailed discussion, see the November 7, 2005 final rule (70 FR 67583). 

(2) Updating e-Prescribing Standards 

 Transaction standards are periodically updated to take new knowledge, technology and 
1219 

other considerations into account. As CMS adopted specific versions of the standards when it 

adopted the foundation and final e-prescribing standards, there was a need to establish a process 

by which the standards could be updated or replaced over time to ensure that the standards did 

not hold back progress in the industry. CMS discussed these processes in its November 7, 2005 

final rule (70 FR 67579). 

The discussion noted that the rulemaking process will generally be used to retire, replace 

or adopt a new e-prescribing standard, but it also provided for a simplified “updating process” 

when a standard could be updated with a newer “backward-compatible” version of the adopted 

standard. In instances in which the user of the later version can accommodate users of the earlier 

version of the adopted standard without modification, it noted that notice and comment 

rulemaking could be waived, in which case the use of either the new or old version of the 

adopted standard would be considered compliant upon the effective date of the newer version’s 

incorporation by reference in the Federal Register. We utilized this streamlined updating 

process when we published an interim final rule with comment on June 23, 2006 (71 FR 36020). 

That rule recognized NCPDP SCRIPT 8.1 as a backward compatible update to the NCPDP 

SCRIPT 5.0, thereby allowing for use of either of the two versions in the Part D program. Then, 

on April 7, 2008, CMS used notice and comment rulemaking (73 FR 18918) to finalize the 

identification of the NCPDP SCRIPT 8.1 as a backward compatible update of the NCPDP 

SCRIPT 5.0, and, effective April 1, 2009, retire NCPDP SCRIPT 5.0 and adopt NCPDP SCRIPT 

8.1 as the official Part D e-prescribing standard. Finally, on July 1, 2010, CMS utilized the 

streamlined process to recognize NCPDP SCRIPT 10.6 as a backward compatible update of 

NCPDP SCRIPT 8.1 in an interim final rule (75 FR 38026). 

In contrast to the extensive updating that was done to the NCPDP SCRIPT standard in 

the Part D e-prescribing program, the original NCPDP Formulary and Benefit 1.0 is still in place 
1220 

as the official Part D e-prescribing standard. 

2. Proposals for Calendar Year 2013 

 a. Proposed Finalization of NCPDP SCRIPT 10.6 as a Backward Compatible Version 

of NCPDP SCRIPT 8.1, Retirement of NCPDP SCRIPT 8.1 and Adoption of NCPDP SCRIPT 

10.6 as the official Part D E-Prescribing Standard 

 As described in the CY 2013 Physician Fee Schedule proposed rule (77 FR 45022-

45023) we proposed to finalize our recognition of NCPDP SCRIPT 10.6 as a backward 

compatible version of the official Part D e-prescribing standard NCPDP SCRIPT 8.1, effective 

from the effective date of the final rule through October 31, 2013, but, in response to the 

comments that were received to the interim final rule with comment, we also proposed to retire 

NCPDP SCRIPT 8.1 effective October 31, 2013, and we proposed to adopt NCPDP SCRIPT 

10.6 as the official Part D e-prescribing standard effective November 1, 2013. For further 

discussion on our NCPDP SCRIPT updating proposals please see CY 2013 Physician Fee 

Schedule proposed rule (77 FR 45022 through 45025). 

 As such, we proposed to revise §423.160(b)(2)(ii) so as to limit its application to 

transactions on or before October 31, 2013 and add a new §423.160(b)(2)(iii) to require that, as 

of November 1, 2013, providers and dispensers would use NCPDP SCRIPT 10.6 for the 

following electronic transactions that convey prescription or prescription related information: 

• Get message transaction. 

• Status response transaction. 

• Error response transaction. 

• New prescription transaction. 

• Prescription change request transaction. 

• Prescription change response transaction. 
1221 

• Refill prescription request transaction. 

• Refill prescription response transaction. 

• Verification transaction. 

• Password change transaction. 

• Cancel prescription request transaction. 

• Cancel prescription response transaction 

• Fill status notification. 

 Furthermore, we proposed to amend §423.160(b)(1) by adding a new 423.160(b)(1)(iii) 

to amend the information about which subsequent requirements in the section are applicable to 

which timeframes and amend §423.160(b)(1)(ii) to limit its application to transactions on or 

before October 31, 2013. 

The following is a summary of the comments we received regarding the finalization of 

NCPDP SCRIPT 10.6 as a backward compatible version of NCPDP SCRIPT 8.1, the proposed 

retirement of NCPDP SCRIPT 8.1, and the proposed adoption of NCPDP SCRIPT 10.6 as the 

official Part D E-Prescribing standard. We received comments on all three proposals. 

Comment: All commenters agreed with our proposals to finalize NCPDP SCRIPT 10.6 

as a backward compatible version of NCPDP SCRIPT 8.1 and to retire NCPDP SCRIPT 8.1. 

They also agreed that CMS should move forward with the adoption of NCPDP SCRIPT 10.6 as 

the official Part D e-prescribing standard. 

Response: We appreciate the favorable feedback that we received on this proposal and 

are in agreement with the commenters who responded. 

Comment: Most commenters agreed on our timeline to retire NCPDP SCRIPT Version 

8.1 on October 31, 2013 and adopt NCPDP SCRIPT Version 10.6 as the official Part D eprescribing standard on November 1, 2013. 
1222 

Response: We appreciate the feedback we received on the proposed timeline to retire 

NCPDP SCRIPT 8.1 on October 31, 2013 and finalize the adoption of NCPDP SCRIPT 10.6 on 

November 1, 2013 as the official Part D e-prescribing standard. We are in agreement with those 

commenters that responded to finalize NCPDP SCRIPT 10.6 as proposed. 

Comment: One commenter suggested that CMS finalize the adoption of the NCPDP 

SCRIPT Version 10.6 Part D e-prescribing standard effective January 1, 2014, which would 

coincide with the Office of the National Coordinator for Health IT (ONC) requirement for use of 

NCPDP SCRIPT 10.6 for certification of electronic health record (EHR) technology. The 

commenter did not, however, note any harm that would result if we were to stick with the 

proposed effective date of November 1, 2013. 

 Response: We appreciate the comment, but we do not believe that there is a compelling 

reason to change the proposed (November 1, 2013) effective date. As proposed, Part D eprescribers will be free to use either version 8.1 or version 10.6 through October 31, 2013, after 

which time they will need to use version 10.6 when e-prescribing Part D covered drugs for Part 

D eligible individuals. As such, ONC’s 2011 Edition EHR certification criteria (which permit 

the certification of EHR technology to versions 8.1 or 10.6 and subsequently enable an eligible 

professional (EP)/eligible hospital (EH) to use either standard through the calendar year 

(CY)/fiscal year (FY) 2013 meaningful use reporting period) and 2014 Edition EHR certification 

criteria (which requires EHR technology to be certified to only version 10.6 and subsequently 

enables EPs/EHs to use EHR technology certified to such standard when they start their CY/FY 

2014 meaningful use reporting) will never require use of a version of NCPDP SCRIPT that is not 

also an option under the Part D e-prescribing standards. Furthermore, NCPDP SCRIPT 10.6 is 

backwards compatible with version 8.1, so version 10.6 EHR users will always be able to 

communicate with version 8.1 users, and vice versa. 
1223 

 In light of the overwhelmingly positive comments that we received in response to our 

proposals to finalize the NCPDP SCRIPT 10.6 as a Backward Compatible Version of NCPDP 

SCRIPT 8.1 as of the effective date of this final rule, and retire NCPDP SCRIPT 8.1 and adopt 

NCPDP SCRIPT 10.6 as the official Part D e-Prescribing Standard effective November 1, 2013, 

we are finalizing our proposals. To effectuate this, we revised §423.160(b)(1)(ii) to limit its 

applicability to transactions taking place between April 1, 2009 and October 31, 2013, added a 

new §423.160(b)(1)(iii) to cover transactions on or after November 1, 2013, and added a new 

§423.160(b)(2)(iii) to cover the communication of a prescription or prescription-related 

information between prescribers and dispensers on or after November 1, 2013. 

b. Proposed Recognition of NCPDP Formulary and Benefit Standard 3.0 as a Backward 

Compatible Version of the NCPDP Formulary and Benefit Standard 1.0, Proposed Retirement of 

NCPDP Formulary and Benefit Standard 1.0 and Proposed Adoption of NCPDP Formulary and 

Benefit Standard 3.0

Formulary and Benefits standards provide a uniform means for pharmacy benefit payers 

(including health plans and PBMs) to communicate a range of formulary and benefit information 

to prescribers via point-of-care (POC) systems. These include: 

• General formulary data (for example, therapeutic classes and subclasses); 

• Formulary status of individual drugs (that is, which drugs are covered); 

• Preferred alternatives (including any coverage restrictions, such as quantity limits and 

need for prior authorization); and 

• Copayment (the copayments for one drug option versus another). 

 The NCPDP Formulary and Benefits Standard 1.0 enables the prescriber to consider this 

information during the prescribing process, and make the most appropriate drug choice without 

extensive back-and-forth administrative activities with the pharmacy or the health plan. 
1224 

 As discussed above, the November 7, 2005 final rule (70 FR 67579) established the 

process of updating an official Part D e-prescribing standard with the recognition of ‘‘backwardcompatible’’ versions of the official standard in instances in which the user of the later version 

can accommodate users of the earlier version of the adopted standard without modification. In 

these instances, notice and comment rulemaking could be waived, and use of either the new or 

old version of the adopted standard would be considered compliant with the adopted standard 

upon the effective date of the newer version’s incorporation by reference in the Federal 

Register. This backward compatible version updating process allows for the standards’ 

updating/maintenance to correct technical errors, eliminate technical inconsistencies, and add 

optional functions that provide optional enhancements to the specified e-prescribing transaction 

standard. Since the adoption of the NCPDP Formulary and Benefits 1.0 standard in the Part D eprescribing program, NCPDP has updated its Formulary and Benefits standard. Changes were 

based upon industry feedback and business needs and ranged in complexity from creating whole 

new fields or lists within the standard to simply changing a particular field designation from 

mandatory to optional. Each time a change is made to a standard it is given a new version 

number. The current version of the Formulary and Benefits standard is Version 3.0. 

One of the major improvements between Version 1.0 and 3.0 involved the addition of 

Text message support for “Coverage and Copay Information,” the addition of the “Text Message 

Type (A46-1S)” field and the addition of “Optional Prior Authorization Lists.” Theses list were 

added for use in conveying prior authorization requirements. 

Other improvements included conversion of certain elements from optional to mandatory. 

Version 3.0 also provides for “Formulary Status List Headers,” which are fields that allow the 

sender to specify a default formulary status for non-listed drugs. Subsequent versions also 

allowed for the omission of “Formulary Status Detail” records when the non-listed formulary 
1225 

policies are used exclusively to convey the status of a drug on a formulary.

Changes to a standard may also involve removing fields that are not widely used in industry. 

The removed fields are often replaced by new fields that better serve the business needs of the 

industry. For example, the following items have been removed through the various updates that 

led up to Version 3.0: “Classification List” and references to it (such as Drug Classification 

Information), “Coverage Information Detail – Medical Necessity (MN),” “Coverage Information 

Detail–Resource Link–Summary Level (RS),” and the Classification ID in the Cross Reference 

Detail. 

In place of these deleted fields, the following fields were added or amended to ultimately 

result in Version 3.0: The “Formulary Status existing value 2” field was changed to “On 

Formulary/Non-Preferred,” and “The file load also enables payers to specify a single coveragerelated text message for each drug” field was changed to “A payer may send multiple quantity 

limits, step medications, text messages and resource links for the same drug.” 

 We reviewed Version 3.0, and based on our findings, we have determined that NCPDP 

Formulary and Benefits 3.0 maintains full functionality of the official adopted Part D eprescribing standard NCPDP Formulary and Benefits 1.0, and would permit the successful 

communication of the applicable transaction with entities that continue to use Version 1.0. 

 While we would usually use the “backward compatible” waiver of notice and comment 

procedures that are described above to recognize Version 3.0 as a backward compatible version 

of the officially adopted Version 1.0, this would have to be done in an interim final rule with 

comment. As we cannot combine proposals and elements of a final rule in one rule, we elected 

this one time to formally propose recognizing a subsequent standard as a backward compatible 

version of an adopted standard through full notice and comment rulemaking to avoid having to 

publish two rules contemporaneously. We therefore proposed to recognize the use of either 
1226 

Version 1.0 or 3.0 as compliant with the adopted Version 1.0 effective 60 days after the 

publication of a final rule. 

 As noted above, according to the November 7, 2005 final rule (70 FR 67580), entities 

that voluntarily adopt later versions of standards that are recognized as backward compatible 

versions of the official Part D e-prescribing standard must still accommodate the earlier official 

Part D e-prescribing standard without modification. Therefore, as we used full notice and 

comment in place of the backward compatible methodology in this one instance, we also 

proposed to require users of 3.0 to support users who are still using Version 1.0 until such time 

as Version 1.0 is officially retired as a Part D e-prescribing standard and Version 3.0 is adopted 

as the official Part D e-prescribing standard. 

 To effectuate these proposals, we proposed to revise §423.160(b)(5) by placing the 

existing material in a new subsection (b)(5)(i), and creating a second new subsection (b)(5)(ii) to 

reflect the use of Version 3.0. as a backward compatible version of the official Part D eprescribing standard, effective 60 days after the publication of the final rule through October 31, 

2013. We further proposed revising §423.160(b)(5) by adding a new section §423.160(b)(5)(iii) 

to cover Formulary and Benefit transactions on or after November 1, 2013 We also needed to 

add an end date of [OFR—Insert date 60 days after publication in the Federal Register] to 

§423.160(b)(5)(i). We solicited comments on our proposals, the timing for these proposals, and 

when we ought to retire Version 1.0 as the official Part D e-prescribing standard, and adopt the 

NCPDP Formulary and Benefit Version 3.0. as the official Part D e-prescribing standard. 

The following is a summary of the comments we received regarding our proposal to 

recognize NCPDP Formulary and Benefit Standard 3.0 as a backward compatible version of the 

NCPDP Formulary and Benefit Standard 1.0, the proposed retirement of NCPDP Formulary and 

Benefit Standard 1.0 and the proposed adoption of NCPDP Formulary and Benefit Standard 3.0. 
1227 

Comment: Commenters generally supported our proposals for effective dates for the use 

of NCPDP Formulary and Benefit Standard 3.0 as a backward compatible version of the adopted 

NCPDP Formulary and Benefit 1.0 (60 days after the publication of the final rule), and the 

retirement of Version 1.0 as an official Part D e-prescribing standard as of November 1, 2013. 

However, one commenter suggested a Version 1.0 sunset date of July 1, 2014 to coordinate the 

Part D e-prescribing standards with the date upon which NCPDP will cease to support Version 

1.0 . 

Response: We appreciate the overwhelming support from the commenters who agreed 

witt us in recognizing Version 3.0 as a backward compatible version of Version 1.0 and the 

retirement of Version 1.0 and the adoption of Version 3.0 as the official Part D e-prescribing 

standard effective November 1, 2013.We also appreciate the suggestion to alter the proposed 

retirement date for Version 1.0 to coincide with the date upon which NCPDP will cease to 

support that version of the standard. While maintaining Version 1.0 as a Part D e-prescribing 

standard would delay the industry’s fully benefiting from the improvements found in Version 

3.0, as Version 3.0 is a backward compatible version of Version 1.0, we would not anticipate 

significant added burden on the industry if we were to allow the continued use of Version 1.0 

until it is no longer supported by NCPDP. As we aim to ensure that our regulations impose the 

minimum burden possible on the industry, we therefore believe that it would be appropriate to 

not finalize the adoption of Version 3.0 at this time. Although the commententer have shown 

support for our proposal we believe that there is ample time to finalize NCPDP Formulary and 

Benefits Version 3.0 at a later date in future rulemaking. We believe that allowing the use of 

Version 3.0 as a backward compatible verion of Version 1.0 would create some confusion 

because of the extended timeframe to adopt Version 3.0 and the retirement of Version 1.0 as 

proposed by the commenters. 
1228 

As a result of the comments, It is our intention to keep NCPDP Formulary and Benefits Version 

1.0 as the official standard for the Medicare Part D eprescribing program and hold off on 

finalizing Verison 3.0 until future rulemaking. 

c. Proposed Elimination of the Exemption for Non-Prescribing Providers (Long Term Care) 

 In our November 16, 2007 proposed rule (72 FR 64902 - 64906), we discussed the 

inability of NCPDP SCRIPT versions 5.0 and 8.1 to support the workflows and legal 

responsibilities in the long-term care setting, that is, entities transmitting prescriptions or 

prescription-related information where the prescriber is required by law to issue a prescription 

for a patient to a non-prescribing provider (such as a nursing facility) that in turn forwards the 

prescription to a dispenser (‘‘three-way prescribing communications’’ between facility, 

physician, and pharmacy). As such, such entities were provided with an exemption from the 

requirement to use the NCPDP SCRIPT standard in transmitting such prescriptions or 

prescription-related information. On July 1, 2010 we published an IFC (75 FR 38029) in which 

we conveyed that we would consider removing the LTC exemption when there was an NCPDP 

SCRIPT standard that could address the unique needs of long-term care settings. We noted that 

NCPDP SCRIPT Version 10.6 was available, and that we believed that it addressed the concerns 

of the LTC industry regarding their ability to successfully support their workflows when eprescribing. We solicited comments on the impact and timing of adopting version 10.6 as the 

official Part D e-prescribing standard and the removal of the long-term care facility exemption 

from the NCPDP SCIPT standard. For further background discussion on our proposal to lift the 

LTC exemption please refer to the proposed rule (77 FR 45024-45025). 

 We proposed to eliminate the current exemption at §423.160(a)(3)(iv) upon adoption of 

NCPDP SCRIPT 10.6 as the official Part D e-prescribing standard, which, as described above, 

was proposed to take place on November 1, 2013. 
1229 

We solicited comments on lifting the Long Term Care exemption, effective November 1, 

2013 in conjunction with the effective date of NCPDP SCRIPT 10.6. We also solicited 

comments regarding the impact of these proposed effective dates on industry and other interested 

stakeholders, and whether an earlier or later effective date should be adopted. 

The following is summary of the comments we received regarding the proposal. 

Comment: The commenters agreed with our proposal to lift the current exemption for 

entities transmitting prescriptions or prescription-related information in the LTL setting. The 

commenters, however, did not agree with our proposed timeline for the lifting the current 

exemption. They suggested that CMS push the effective date until November 1, 2014 instead of 

the proposed November 1, 2013 proposal. 

 They stated that while they are supportive of moving to NCPDP SCRIPT 10.6 and 

encourage LTC providers to move toward a single standard, they fully expect that those entities 

currently using HL7or propriety messaging will need additional time to make the transition. 

They also recommend an extended transition period to ensure that both vendors and providers 

are ready for the new requirements. 

 Response: Upon review, we believe the commenters have made valid arguments in 

regards to moving the effective to November 1, 2014. We realize that many in the LTC 

community may need extra time to transition their IT systems to accommodate and support the 

current Part D e-prescribing standards. Based on industry comments we will lift the LTC 

exemption based on November 1, 2014 date as suggested by the commenters to give them more 

time to make the transition to a single standard for e-prescribing. Therefore, we will amend 

§423.160(a)(3)(iv) to insert November 1, 2014 as the expiration of the exemption. We would 

note, however, that if a member of the LTC industry and their trading partner are ready to use 

this standard to prescribe electronically before the exemption is lifted on November 1, 2014, they 
1230 

are certainly free to use the standard, but they will not be required to do so under the Part D eprescribing program. 

Comment: One commenter called on CMS to encourage state Boards of Pharmacy to 

reexamine the medication management process in the LTPAC settings and develop and allow 

more effective and efficient mechanisms for e-prescribing in LTPAC. The commenter stated 

that if the e-prescribing system could be suitably, sufficiently and appropriately modified, such 

that the various state Boards of Pharmacy were to consider a physicians’ order from a facility as 

a valid prescription, the conditions would be in place for electronic medication management and 

e-prescribing to be more widely adopted in LTPAC settings. They also asked CMS to facilitate, 

encourage and work with regulators, industry and other stakeholders to resolve these issues. 

 Response: We have prescribed legislative authority under the MMA to adopt Part D eprescribing standards. The MMA outlines out the process through which we can adopt Part D eprescribing standards to facilitate e-prescribing. We do not have the authority to facilitate, 

encourage, or work with the various state Boards of Pharmacy to change how they define the 

transaction from the LTC facility to the dispensing pharmacy. As a result of these comments, we 

are eliminating the exemption at §423.160(a)(3)(iv) effective November 1, 2014. 

IV. Additional Provisions 

A. Waiver of Deductible for Surgical Services Furnished on the Same Date as a Planned 

Screening Colorectal Cancer Test and Colorectal Cancer Screening Test Definition—Technical 

Correction.

Section 4104(c) of the Affordable Care Act amended section 1833(b) of the Act to waive 

the Part B deductible for colorectal cancer screening tests that become diagnostic in the course of 

the procedure or visit. Specifically, section 1833(b) of the Act waives the deductible for 
1231 

“colorectal screening tests regardless of the code that is billed for the establishment of a 

diagnosis as a result of the test, or 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 note that in the proposed rule, we referred in this discussion to section 1833(b)(1) of 

the Act; however, the relevant amendment was a new sentence added at the end of section 

1833(b). We have corrected the reference in this final rule with comment period. To implement 

this statutory provision, we proposed in the PFS proposed rule for CY 2011 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.” After receiving public comment, this 

proposal was finalized in the CY 2011 final rule with comment period (75 FR 73431) and the 

policy was implemented, effective January 1, 2011. However, we neglected to amend our 

regulations to reflect this policy. 

When a screening test becomes a diagnostic service, we instruct the practitioner to bill 

the procedure that is actually furnished and to append the PT modifier to the diagnostic 

procedure code that is reported. By use of this modifier, the practitioner signals that the 

procedure meets the criteria for the deductible to be waived. 

In the CY 2013 PFS proposed rule, we proposed to amend our regulations at §410.160, 

Part B annual deductible, to include colorectal screening tests that become diagnostic services in 

the list of services for which the deductible does not apply. Specifically, we proposed to add a 

new §410.160(b)(8) to read, “Beginning January 1, 2011, a surgical service furnished on the 

same date as a planned colorectal cancer screening test as described in §410.37.” 

The following is summary of the comments we received regarding the proposal to amend 

our regulations to the policy we adopted for CY 2011 to implement the statutory amendment that 
1232 

waives the Part B deductible for a colorectal cancer screening test that becomes diagnostic. 

Comment: We received two comments on this proposal. One commenter was 

appreciative and supportive of the proposal. The other commenter stated that we had “violated 

the intent of the Affordable Care Act” and not implemented this provision consistent with the 

statute at section 1833(b) of the Act. The commenter stated that by using “surgical service” in 

the proposed regulation when the statute referred to “other procedure,” we were inappropriately 

applying the deductible to pathology and anesthesia services when they are furnished in 

connection with a colorectal screening test that becomes a diagnostic procedure. The commenter 

also expressed concern with our covering procedures “on the same date” when the Act covers 

procedures “in the same clinical encounter.” 

Response: We thank the commenter who supported our proposal. We note that we did 

not propose to modify the policy we adopted as final in the CY 2011 PFS final rule with 

comment period, and which we have been applying in accordance with section 1833(b) of the 

statute since January 1, 2011. Rather, we proposed to codify our current policy in our 

regulations. Our current policy, as stated in the CY 2011 PFS final rule with comment period, is 

to waive the deductible for all surgical services furnished on the same date as a planned 

screening colonoscopy, planned flexible sigmoidoscopy, or barium enema (because these 

services are considered to be “furnished in connection with, as a result of, and in the same 

clinical encounter as the screening test.”) We received and responded to comments similar to the 

second one noted above in the course of rulemaking for CY 2011. However, because the 

commenter questioned the language we used in the proposed text of the regulation, we discuss 

the issue in this final rule. After evaluating the comment regarding whether the deductible is 

appropriately applied to payments for anesthesia and biopsy services, we conclude that it is. We 

believe that the intent of section 1833(b) of the statute, as amended by section 4104(c) of the 
1233 

Affordable Care Act, is to waive the deductible for tests that are scheduled and begin as 

colorectal screening tests, but that become diagnostic in the course of the treatment, so that even 

though the test is no longer considered and billed as a screening test, the deductible is 

nonetheless waived as it would have been if the test had remained a screening test. Thus, we 

believe Congress intended to insure that we apply the deductible for these “screening turned 

diagnostic” tests consistently with the way it is applied to colorectal screening tests. When a 

colorectal screening test is furnished, the payment for moderate sedation is included in the 

payment for the procedure, and there would be no associated pathology service. The deductible 

is waived for these tests under section 1833(b) of the Act. As a result, the deductible would be 

waived for the typical sedation furnished in connection with a colorectal screening test (since it 

is included within the code); and there would be no need to waive any deductible for a pathology 

service. The proposed regulation applies the same policy to colorectal screening tests that 

become diagnostic. To the extent that moderate sedation is included in a procedure that is billed 

with the PT modifier, the beneficiary pays no deductible. When a beneficiary receives anesthesia 

other than moderate sedation with a colorectal screening test, a separate charge is incurred to 

which the deductible applies. The proposed regulation would specify that same policy for 

screening tests that become diagnostic. 

We also believe that the language of the Act is consistent with applying the deductible to 

pathology services. By the use of the term a “colorectal screening test regardless of the code that 

is billed,” the statute waives the deductible for procedures that, in and of themselves, begin as 

colorectal screening tests. As noted above, pathology services would not be part of a colorectal 

screening test. 

In regard to the commenter’s concern about using “same day,” instead of “same clinical 

encounter,” this too is the policy we established through notice and comment rulemaking for CY 
1234 

2011. We believe it would be exceedingly rare for a beneficiary to have additional procedures 

on the same date as a screening colorectal cancer test or a “screening turned diagnostic” 

colorectal procedure that are not in the same clinical encounter. Therefore, we believe “same 

day” is the practical equivalent of “same clinical encounter.” To the extent there is a difference 

between these two terms, the language we proposed would provide broader rather than more 

limited waiver of the deductible as the commenter asserted. Given the practical equivalence 

between the language in the statute and in the proposed regulation, and the fact that our claims 

processing system can easily distinguish “same day” but not “same clinical encounter,” we will 

not modify our policy or the proposed regulation language as the commenter suggests. 

Based upon the comments we received, and further review of the policy we established to 

implement the statute, we are finalizing the proposed amendment to the regulation as initially 

proposed. Specifically, we will amend the regulation at §410.160, Part B annual deductible, to 

include colorectal screening tests that become diagnostic services in the list of services for which 

the Part B deductible does not apply and will add a new §410.160(b)(8), which will read, 

“Beginning January 1, 2011, a surgical service furnished on the same date as a planned 

colorectal cancer screening test as described in §410.37.” 

Section 103 of the BIPA amended section 1861(pp)(1)(C) of the Act to permit coverage 

of screening colonoscopies for individuals not at high risk for colorectal cancer who meet certain 

requirements. To conform our regulations to section 1861(pp)(1)(C) of the Act, we proposed to 

modify §410.37(a)(1)(iii) of our regulations to define “Screening colonoscopies” by removing 

the phrase “In the case of an individual at high risk for colorectal cancer” from this paragraph. 

We also proposed to delete paragraph (g)(1) from this section since Medicare no longer 

receives claims for dates of service between January 1, 1998 and June 30, 2001, making this 

paragraph obsolete. We also proposed to redesignate paragraphs (g)(2) through (g)(4) and make 
1235 

technical changes to newly redesignated paragraph (g)(1) by replacing the reference to paragraph 

(g)(4) with a reference to newly redesignated paragraph (g)(3). 

Comment: We received no comments addressing the proposed modifications to §410.37. 

Response: We are finalizing the proposed regulation as initially proposed for §410.37. 

Specifically, Section 103 of the BIPA amended section 1861(pp)(1)(C) of the Act to permit 

coverage of screening colonoscopies for individuals not at high risk for colorectal cancer who 

meet certain requirements. To conform our regulations to section 1861(pp)(1)(C) of the Act, we 

will modify §410.37(a)(1)(iii) to define “Screening colonoscopies” by removing the phrase “In 

the case of an individual at high risk for colorectal cancer” from this paragraph. 

Finally, we will delete paragraph (g)(1) from this section since Medicare no longer 

receives claims for dates of service between January 1, 1998 and June 30, 2001, making this 

paragraph obsolete, will redesignate paragraphs (g)(2) through (g)(4) and make technical 

changes to newly redesignated paragraph (g)(1) by replacing the reference to paragraph (g)(4) 

with a reference to newly redesignated paragraph (g)(3). 

B. Physician Self-Referral Prohibition: Annual Update to the List of CPT/HCPCS Codes 

1. General 

Section 1877 of the Act prohibits a physician from referring a Medicare beneficiary for 

certain designated health services (DHS) to an entity with which the physician (or a member of 

the physician's immediate family) has a financial relationship, unless an exception applies. 

Section 1877 of the Act also prohibits the DHS entity from submitting claims to Medicare or 

billing the beneficiary or any other entity for Medicare DHS that are furnished as a result of a 

prohibited referral. 

Section 1877(h)(6) of the Act and §411.351 of our regulations specify that the following 

services are DHS: 
1236 

● Clinical laboratory services. 

● Physical therapy services. 

● Occupational therapy services. 

● Outpatient speech-language pathology services. 

● Radiology services. 

● Radiation therapy services and supplies. 

● Durable medical equipment and supplies. 

● Parenteral and enteral nutrients, equipment, and supplies. 

● Prosthetics, orthotics, and prosthetic devices and supplies. 

● Home health services. 

● Outpatient prescription drugs. 

● Inpatient and outpatient hospital services. 

2. Annual Update to the Code List 

a. Background 

In §411.351, we specify that the entire scope of four DHS categories is defined in a list of 

CPT/HCPCS codes (the Code List), which is updated annually to account for changes in the 

most recent CPT and HCPCS Level II publications. The DHS categories defined and updated in 

this manner are: 

● Clinical laboratory services. 

● Physical therapy, occupational therapy, and outpatient speech-language pathology 

services. 

● Radiology and certain other imaging services. 

● Radiation therapy services and supplies. 
1237 

The Code List also identifies those items and services that may qualify for either of the 

following two exceptions to the physician self-referral prohibition: 

● Dialysis-related drugs furnished in or by an ESRD facility (§ 411.355(g)). 

● Preventive screening tests, immunizations, or vaccines (§ 411.355(h)). 

 The definition of DHS at § 411.351 excludes services that are reimbursed by Medicare as 

part of a composite rate (unless the services are specifically identified as DHS and are 

themselves payable through a composite rate, such as home health and inpatient and outpatient 

hospital services). 

 EPO and other dialysis-related drugs furnished by an ESRD facility (except drugs for 

which there are no injectable equivalents or other forms of administration) are currently being 

paid under the ESRD PPS (effective January 1, 2011) promulgated in the final rule published on 

August 12, 2010 in the Federal Register (75 FR 49030). Drugs for which there are no 

injectable equivalents or other forms of administration will be payable under the ESRD PPS 

beginning January 1, 2014. 

 The Code List was last updated in Addendum J of the CY 2012 PFS final rule with 

comment period.

b. Response to Comments 

 We received no public comments relating to the Code List that became effective 

January 1, 2012. 
1238 

c. Revisions Effective for 2013 

 The updated, comprehensive Code List effective January 1, 2013, appears on our website 

at http://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/List_of_Codes.html. 

 Additions and deletions to the Code List conform it to the most recent publications of 

CPT and HCPCS Level II and to changes in Medicare coverage policy and payment status. 

 Tables 127 and 128 identify the additions and deletions, respectively, to the 

comprehensive Code List that become effective January 1, 2013. Tables 127 and 128 also 

identify the additions and deletions to the list of codes used to identify the items and services that 

may qualify for the exception in § 411.355(g) (regarding dialysis–related outpatient prescription 

drugs furnished in or by an ESRD facility) and in § 411.355(h) (regarding preventive screening 

tests, immunizations, and vaccines). 

 In Table 127, we specify additions that reflect new CPT and HCPCS codes that become 

effective January 1, 2013, or that became effective since our last update, including those 

additions that reflect changes in Medicare coverage policy or payment status. Table 128 reflects 

the deletions necessary to conform the Code List to the most recent publications of the CPT and 

HCPCS, and to changes in Medicare coverage policy and payment status. 

 We will consider comments regarding the codes listed in Tables 127 and 128. Comments 

will be considered if we receive them by the date specified in the "DATES" section of this final 

rule with comment period. We will not consider any comment that advocates a substantive 

change to any of the DHS defined in § 411.351. 

TABLE 127: Additions to the Physician Self-Referral List of CPT1/HCPCS Codes 

CLINICAL LABORATORY SERVICES 

86152 Cell enumeration & id 

86153 Cell enumeration phys interp 

PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND 

OUTPATIENT SPEECH-LANGUAGE PATHOLOGY SERVICES 
1239 

{No additions} 

RADIOLOGY AND CERTAIN OTHER IMAGING SERVICES 

78012 Thyroid uptake measurement 

78013 Thyroid imaging w/blood flow 

78014 Thyroid imaging w/blood flow 

78071 Parathyrd planar w/wo subtrj 

78072 Parathyrd planar w/spect&ct 

RADIATION THERAPY SERVICES AND SUPPLIES 

32701 Thorax stereo rad targetw/tx 

DRUGS USED BY PATIENTS UNDERGOING DIALYSIS 

{No additions} 

PREVENTIVE SCREENING TESTS, IMMUNIZATIONS AND 

VACCINES 

G0106 Colon CA screen;barium enema 

G0120 Colon ca scrn; barium enema 

G0118 Glaucoma scrn hgh risk direc 

Q2034 Agriflu vaccine 

90672 Flu vaccine 4 valent nasal 1

CPT codes and descriptions only are copyright 2012 AMA. All rights are reserved and applicable FARS/DFARS 

clauses apply. 

TABLE 128: Deletions from the Physician Self-Referral List of CPT1/HCPCS Codes 

CLINICAL LABORATORY SERVICES 

0030T Antiprothrombin antibody

0279T Ctc test 

0280T Ctc test w/i&r 

PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND 

OUTPATIENT SPEECH-LANGUAGE PATHOLOGY SERVICES 

{No deletions} 

RADIOLOGY AND CERTAIN OTHER IMAGING SERVICES 

78006 Thyroid imaging with uptake 

78007 Thyroid image mult uptakes 

78010 Thyroid imaging 

78011 Thyroid imaging with flow 

RADIATION THERAPY SERVICES AND SUPPLIES 

{No deletions} 
1240 

DRUGS USED BY PATIENTS UNDERGOING DIALYSIS 

{No deletions}

PREVENTIVE SCREENING TESTS, IMMUNIZATIONS AND 

VACCINES 

{No deletions} 1 CPT codes and descriptions only are copyright 2012 AMA. All rights are reserved and applicable FARS/DFARS 

clauses apply. 

V. 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: 

● The need for the information collection and its usefulness in carrying out the proper 

functions of our agency. 

● The accuracy of our estimate of the information collection burden. 

● The quality, utility, and clarity of the information to be collected. 

● Recommendations to minimize the information collection burden on the affected 

public, including automated collection techniques. 

In the CY 2013 PFS proposed rule, we solicited public comment on each of the section 

3506(c)(2)(A)-required issues for the following information collection requirements (ICRs). No 

PRA-related comments were received.

A. ICRs Regarding Durable Medical Equipment Scope and Conditions (§410.38(g))
1241 

 As a condition of payment for certain covered items of DME, §410.38(g) specifies that a 

physician must have documented and communicated to the DME supplier that the physician or 

physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) has had a 

face-to-face encounter with the beneficiary no more than 6 months before the order is written. 

 In the proposed rule, we proposed that when the face-to-face encounter is performed by a 

physician, the submission of the pertinent portion(s) of the beneficiary’s medical record (portions 

containing sufficient information to document that the face-to-face encounter meets our 

requirements) would be considered sufficient and valid documentation of the face-to-face 

encounter when submitted to the supplier and made available to CMS or its agents upon request. 

While we believe that many of the practitioners addressed in this final rule with comment period 

are already conducting a needs assessment and evaluating or treating the beneficiary for 

conditions relevant to the covered item of DME, this final rule with comment period may require 

some changes in their procedures to ensure that their documentation fulfills Medicare's 

regulatory requirements. Suppliers should already be receiving written orders and 

documentation to support the appropriateness of certain items of DME. 

To promote the authenticity and comprehensiveness of the written order and as part of 

our efforts to reduce the risk of waste, fraud, and abuse, as a condition of payment, a written 

order must include the following: (1) the beneficiaries’ name; (2) the item of DME ordered; (3) 

the signature of the prescribing practitioner; (4) the prescribing practitioner NPI; and (5) the date 

of the order. 

To determine costs, we utilized the Bureau of Labor Statistics mean hourly rates for the 

professional, analyzed for the year that the original data was received. The hourly rate for a 

physician, including fringe benefits and overhead is estimated at $118 per hour. The hourly rate, 

including fringe benefits and overhead, for a NP, PA, or CNS is estimated at $55 per hour. The 
1242 

hourly rate for administrative assistant, including fringe benefits and overhead, is estimated at 

$23 per hour. 

Physicians are now required to document the face-to-face encounter if it was performed 

by a PA, NP, or CNS. To allow payment for this documentation, a G code is established for this 

service. Since the effective date for this regulation is July 1, 2013, only 6 months of year 1 are 

included in calendar year 2013. Likewise, it was assumed that about 500,000 of these 

documentation services would be billed in year 1. We estimate the time for a physician to review 

each one of these encounters that results in an order is 10 minutes. Therefore, we estimate that 

the physician documentation burden to review and document when a PA, NP or CNS performed 

the face-to-face encounter in year 1 would be nearly 83,333 hours and a total of 483,333 hours 

over 5 years. The associated cost in year 1 is nearly $9.8 million and over 5 years has associated 

costs of nearly $57.03 million based on the growth rate of the Medicare population. The increase 

is slightly more than five-fold because the number of Medicare beneficiaries would increase over 

time. The average annual burden over 5-years for 580,000 claims (2,900,000/5) is 96,667 hours 

at a cost of $11,406,667. 

TABLE 129: PHYSICIAN TIME TO DOCUMENT OCCURRENCE OF A 

FACE-TO-FACE ENCOUNTER 

 Year 1 5 Years 

Number of claims affected 500,000 2,900,000

Time for physician review of each claim 10 min 10 min 

Total Time 83,333 hours 483,333 hours 

Estimated Total Cost (Hours times $118) $ 9,833,333 $57,033,333 

We assume it will take 3 minutes for a PA, NP, or CNS to prepare the medical record for 

the review of the face-to-face encounter. For the 500,000 orders used in the previous estimate, 

this creates a total of 25,000 hours at a cost of about $1.4 million in year 1 and nearly 145,000 

hours over 5 years at a cost of nearly $8 million based on the growth rate of the Medicare 

population. Though consistent with previous estimates, we believe that using a PA, NP, or CNS 
1243 

hourly rate creates a high burden impact estimate since most of these tasks would more than 

likely be completed by administrative personnel. We invited but received no public comments 

on our estimates related to the appropriateness of these estimates. The average annual burden 

over 5-years for 580,000 claims (2,900,000/5) is 29,000 hours at a cost of $1,595,000. 

TABLE 130: Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Time 

 Year 1 5 Years 

Number of claims affected 500,000 2,900,000

Time for PAs, NPs, or CNSs to gather and provide each claim 3 min 3 min

Total Time 25,000 hours 145,000 hours 

Estimated Total Cost (Hours times $55) $ 1,375,000 $ 7,975,000

This final rule with comment period creates only a minimal change in the normal course 

of business activities in regards to recordkeeping. Although we believe the documentation of a 

needs assessment, evaluation, and/or treatment of a beneficiary for a condition relevant to an 

item of DME is a common practice, it is possible that some practitioners may not be 

documenting the results of all encounters so there may be additional impact for some 

practitioners. 

This regulation requires that the supplier have access to the documentation of the face-toface encounter (required when CMS conducts an audit), CMS already accounts for the audit 

burden associated with the exchange of documentation for claims subject to prepayment review 

(approved under OCN 0938-0969). As a business practice we recognize that some suppliers may 

receive the documentation of the face-to-face for all applicable claims, voluntarily. 

 We believe that the requirements that are set out in this final rule with comment period 

meet the utility and clarity standards. We invited but received no public comments on this 

assumption and on ways to minimize the burden on affected parties. The recordkeeping 

requirement in §410.38(g)(5) and the requirement to maintain and make the supplier’s 

order/additional documentation available to CMS upon request is subject to the PRA, but we 
1244 

believe that these requirements are usual and customary business practices as defined in 5 CFR 

1320.3(b)(2) and, therefore, the associated burden is exempt from the PRA. 

B. ICRs Regarding the Physician Quality Reporting System (§414.90)

We are making several program revisions to the Physician Quality Reporting System for 

reporting periods that occur in 2013 and 2014, and, therefore, we are making several revisions to 

§414.90. All of the requirements and burden estimates are currently approved by OMB under 

OCN 0938-1059, and are not subject to additional OMB review under the authority of the 

Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

First, we are revising §414.90(e) – Use of Consensus-based Quality Measures. We are 

redesignating §414.90(e) as §414.90(f) and then revising newly designated §414.90(f) to broadly 

define our use of consensus-based quality measures. The current regulation at §414.90(e) (now 

redesignated as §414.90(f)) states that we will publish a final list of measures every year. 

However, we finalized measures for 2013 and beyond this year. While §414.90(e) (now 

redesignated as §414.90(f)) contains information collection requirements regarding the input 

process and the endorsement of consensus-based quality measures, this rule would not revise any 

of the information collection requirements or burden estimates that are associated with those 

provisions. 

Second, we are revising §414.90(b) – Definitions under the Physician Quality Reporting 

System. Specifically, we are revising the definition of “group practice” to include groups of 2-

24 eligible professionals in the definition. We are revising the definition of “qualified registry” 

to indicate CMS’ authority to disqualify registries. We are also eliminating the definition of 

“qualified electronic health record product” to more specifically address the EHR-based 

reporting mechanisms available under PQRS as “direct electronic health record (EHR) product” 

and “electronic health record (EHR) data submission vendor.” We are also adding the definition 
1245 

of “administrative claims,” which is a newly-established reporting mechanism available under 

PQRS for the purpose of reporting quality measures for the 2015 and 2016 PQRS payment 

adjustments. In addition, we are adding the definition of “group practice reporting option 

(GPRO) web-interface.” While the GPRO web-interface was available as a reporting 

mechanism in CY 2012, we had not previously included a definition for the GPRO webinterface. While §414.90(b) contains information collection requirements regarding the input 

process and the endorsement of consensus-based quality measures, this rule would not revise any 

of the information collection requirements or burden estimates that are associated with 

§414.90(b). 

Third, we are revising §414.90(g) (formerly designated as 414.90(f)) – Requirements for 

the Incentive Payments. In this final rule, we are redesignating 414.90(f) as 414.90(g) and 

making changes to newly designated §414.90(g) to indicate the applicable incentive amounts and 

requirements for the 2013 and 2014 PQRS incentives. While §414.90(e) (newly designated in 

this final rule as §414.90(f)) contains information collection requirements regarding the input 

process and the endorsement of consensus-based quality measures, this rule would not revise any 

of the information collection requirements or burden estimates that are associated with those 

provisions. 

Fourth, we are adding §414.90(e) – Requirements for the Payment Adjustments. We are 

adding §414.90(e) to indicate the applicable adjustment amounts and requirements for the 2015 

and 2016 PQRS payment adjustments. While §414.90(e) contains information collection 

requirements regarding the input process and the endorsement of consensus-based quality 

measures, this rule would not revise any of the information collection requirements or burden 

estimates that are associated with those provisions. The impact of this revision to the current 

information collection requirements or burden estimates that are associated with those provisions 
1246 

are described here: 

The preamble of this final rule with comment period discusses the background of the 

PQRS, provides information about the measures and reporting mechanisms that will be available 

to eligible professionals and group practices who choose to participate in the 2013 and 2014 

PQRS, and provides the criteria for satisfactory reporting in CYs 2013 and 2014 (for the 2013 

and 2014 PQRS incentives and the 2015 and 2016 PQRS payment adjustments). 

a. Participation in the 2013 and 2014 PQRS 

 According to the 2010 Reporting Experience Report, a total of $391,635,495 in PQRS 

incentives was paid by CMS for the 2010 program year, which encompassed 168,843 individual 

eligible professionals. In 2010, eligible professionals earned a 2.0 percent incentive (that is, a 

bonus payment equal to 2.0 percent of the total allowed part B charges for covered professional 

services under the PFS furnished by the eligible professional in the reporting period) for 

satisfactory reporting under PQRS. For 2013 and 2014, eligible professionals can earn a 0.5 

percent incentive for satisfactory reporting, a reduction of 1.5 percent from 2010. Therefore, 

based on 2010, we would expect that approximately $97 million (approximately 1⁄4 of 

$391,635,495) in incentive payments would be distributed to eligible professionals who 

satisfactorily report. However, we estimate that, due to the implementation of payment 

adjustments beginning in 2015, participation in PQRS would rise to approximately 300,000 

eligible professionals and 400,000 eligible professionals in 2013 and 2014 respectively. 

 The average incentive distributed to each eligible professional in 2010 was $2,157. 

Taking into account the 1.5 percent incentive reduction from 2.0 percent in 2010 to 0.5 percent 

in 2013 and 2014, we estimate that the average amount per eligible professional earning an 

incentive in 2013 and 2014 would be $539. Therefore, we estimated that we would distribute 

approximately $162 million ($539 x 300,000 eligible professionals) and $216 million ($539 x 
1247 

400,000 eligible professionals) in incentive payments in 2013 and 2014, respectively. We 

believe these incentive payments will help offset the cost to eligible professionals participating in 

PQRS for the applicable year. Please note that, beginning 2015, incentive payments for 

satisfactory reporting in PQRS will cease and payment adjustments for not satisfactorily 

reporting will commence. 

 We noted that the total burden associated with participating in PQRS is the time and 

effort associated with indicating intent to participate in PQRS, if applicable, and submitting 

PQRS quality measures data. When establishing these burden estimates, we assumed the 

following: 

● The requirements for reporting for the PQRS 2013 and 2014 incentives and payment 

adjustments for 2015 and beyond would be established as proposed in this 2013 Medicare PFS 

final rule with comment period. 

● For an eligible professional using the claims, registry, or EHR-based reporting 

mechanisms and group practices using the registry or EHR-based reporting mechanisms, that the 

eligible professional or group practice would report on 3 measures. 

● With respect to labor costs, we believe that a billing clerk would handle the 

administrative duties associated with participating, while a computer analyst would handle duties 

related to reporting PQRS quality measures. According to the Bureau of Labor Statistics, the 

mean hourly wage for a billing clerk is approximately $16/hour whereas the mean hourly wage 

for a computer analyst is approximately $40/hour. 

b. Burden Estimate on Participation in 2013 and 2014 – New Individual Eligible Professionals: 

Preparation 

 For an eligible professional who wishes to participate in PQRS as an individual using the 

traditional reporting mechanisms, the eligible professional need not indicate his/her intent to 
1248 

participate. Instead, the eligible professional may simply begin reporting quality measures data. 

Therefore, these burden estimates for individual eligible professionals participating in PQRS are 

based on the reporting mechanism the individual eligible professional chooses. However, we 

believe a new eligible professional or group practice would spend 5 hours—which includes 2 

hours to review the PQRS measures list, review the various reporting options, and select a 

reporting option and measures on which to report and 3 hours to review the measure 

specifications and develop a mechanism for incorporating reporting of the selected measures into 

their office work flows. Therefore, we believe that the initial administrative costs associated 

with participating in PQRS would be approximately $80 ($16/hour x 5 hours). 

c. Burden Estimate on Participation in 2013 and 2014 via the Claims Reporting Mechanism – 

Individual Eligible Professionals 

(1) The Traditional Claims-based Reporting Mechanism 

In 2010, approximately 200,000 of the roughly 245,000 eligible professionals (or 84 

percent) of eligible professionals used the claims-based reporting mechanism. We believe that 

although the number of eligible professionals or group practices using the claims-based reporting 

mechanism will increase in 2013 and 2014, we anticipated that the percentage of eligible 

professionals or group practices using the claims-based reporting mechanism will decrease 

slightly as eligible professionals and group practices transition towards using the EHR-based 

reporting mechanism. Therefore, we estimated that the percentage of PQRS participants using 

the claims-based reporting mechanism will decrease as we anticipate that more eligible 

professionals would use the registry and EHR-based reporting mechanisms. For these reasons, 

we estimated that approximately 320,000 eligible professionals would participate in PQRS using 

the traditional claims-based reporting mechanism by 2014. 
1249 

With respect to an eligible professional who participated in PQRS via claims, the eligible 

professional must gather the required information, select the appropriate quality data codes 

(QDCs), and include the appropriate QDCs on the claims they submitted for payment. PQRS 

will collect QDCs as additional (optional) line items on the existing HIPAA transaction 837-P 

and/or CMS Form 1500 (OCN 0938-0999). Based on our experience with the Physician 

Voluntary Reporting Program (PVRP), we continue to estimate that the time needed to perform 

all the steps necessary to report each measure via claims would range from 0.25 minutes to 12 

minutes, depending on the complexity of the measure. Therefore, the time spent reporting 3 

measures would range from 0.75 minutes to 36 minutes. Using an average labor cost of 

$40/hour, we estimated that the time cost of reporting for an eligible professional via claims 

would range from $0.50 (0.75 minutes x $40/hour) to $24.00 (36 minutes x $40/hour) per 

reported case. With respect to how many cases an eligible professional would report when using 

the claims-based reporting mechanism, we established that an eligible professional would need 

to report on 50 percent of the eligible professional’s applicable cases. The actual number of 

cases on which an eligible professional reports would vary depending on the number of the 

eligible professional’s applicable cases. However, in prior years, when the reporting threshold 

was 80 percent, we found that the median number of reporting cases for each measure was 9. 

Since we reduced the reporting threshold to 50 percent, we estimated that the average number of 

reporting cases for each measure would be reduced to 6. Based on these estimates, we estimated 

that the total cost of reporting for an eligible professional choosing the claims-based reporting 

mechanism would range from ($0.50/per reported case x 6 reported cases) $3.00 to 

($24.00/reported case x 6 reported cases) $144. 

(2) The Administrative Claims Reporting Mechanism. 
1250 

We note that, for the 2015 PQRS payment adjustments, we are finalizing an 

administrative claims reporting option for eligible professionals and group practices. The burden 

associated with reporting using the administrative claims reporting option is the time and effort 

associated with using this option. To submit quality measures data for PQRS using the 

administrative claims reporting option, an eligible professional or group practice would need to 

(1) register as an administrative claims reporter for the applicable payment adjustment and (2) 

report quality measures data. With respect to registration, we believe it would take 

approximately 2 hours to register to participate in PQRS as an administrative claims reporter. 

Therefore, we estimated that the cost of undergoing the administrative claims selection process 

would be ($16/hour x 2 hours) $32. 

 With respect to reporting, we noted that any burden associated with reporting would be 

negligible, as an eligible professional or group practice would not be required to attach reporting 

G-codes on the claims they submitted. Rather, CMS would bear the burden of calculating the 

measures rates from claims data submitted by the eligible professional or group practice. We 

note that there would be no additional burden on the eligible professional or group practice to 

submit these claims, as the eligible professional or group practice would have already submitted 

these claims for reimbursement purposes. 

d. Burden Estimate on Participation in the CYs 2013 and 2014 PQRS via the Registry-based or 

EHR-based Reporting Mechanism 

 In 2010, approximately 40,000 of the roughly 245,000 eligible professionals (or 16 

percent) of eligible professionals used the registry-based reporting mechanism. We believe the 

number of eligible professionals and group practices using the registry based reporting 

mechanism would remain the same, as we believe the decision for an eligible professional or 

group practice to purchase a registry would not likely be solely to report PQRS quality measures 
1251 

data to CMS. Rather, we believe that eligible professionals use registries for functions other than 

PQRS and therefore would obtain a registry solely for PQRS reporting by CY 2014. 

 In 2010, only 14 of the roughly 245,000 eligible professionals (or <1 percent) of eligible 

professionals used the EHR-based reporting mechanism. We believe the number of eligible 

professionals and group practices using the EHR-based reporting mechanism would increase as 

eligible professionals become more familiar with EHR products. In particular, we believe 

eligible professionals and group practices would transition from using the claims-based to the 

EHR-based reporting mechanisms. We estimated that approximately 40,000 eligible 

professionals (4 percent), whether participating as an individual or part of a group practice, 

would use the EHR-based reporting mechanism in CY 2014. 

 With respect to an eligible professional or group practice who participated in PQRS via a 

qualified registry, direct EHR product, or EHR data submission vendor product, we believe there 

would be little to no burden associated for an eligible professional to report PQRS quality 

measures data to CMS, because the selected reporting mechanism would submit the quality 

measures data for the eligible professional. While we noted that there may be start-up costs 

associated with purchasing a qualified registry, direct EHR product, or EHR data submission 

vendor, we believe that an eligible professional or group practice would not purchase a qualified 

registry, direct EHR product, or EHR data submission vendor product solely for the purpose of 

reporting PQRS quality measures. Therefore, we have not included the cost of purchasing a 

qualified registry, direct EHR, or EHR data submission vendor product in our burden estimates. 

e. Burden Estimate on Participation in the CYs 2013 and 2014 PQRS – Group Practices 

 Unlike eligible professionals who choose to report individually, we noted that we 

proposed that eligible professionals choosing to participate as part of a group practice under the 

GPRO would need to indicate their intent to participate in PQRS as a group practice. The total 
1252 

burden for group practices who submit PQRS quality measures data via the GPRO web-interface 

would be the time and effort associated with submitting this data. To submit quality measures 

data for PQRS, a group practice would need to (1) be selected to participate in the PQRS GPRO 

and (2) report quality measures data. With respect to the administrative duties for being selected 

to participate in PQRS as a GPRO, we believe it would take approximately 6 hours – including 2 

hours to decide to participate in PQRS as a GPRO; 2 hours to self-nominate, and 2 hours to 

undergo the vetting process with CMS officials – for a group practice to be selected to participate 

in PQRS GPRO for the applicable year. Therefore, we estimated that the cost of undergoing the 

GPRO selection process would be ($16/hour x 6 hours) $96. 

 With respect to reporting PQRS quality measures using the GPRO web-interface, the 

total reporting burden is the time and effort associated with the group practice submitting the 

quality measures data (that is, completing the data collection interface). Based on burden 

estimates for the PGP demonstration, which uses the same data submission methods, we 

estimated the burden associated with a group practice completing the data collection interface 

would be approximately 79 hours. Therefore, we estimated that the report cost for a group 

practice to submit PQRS quality measures data for an applicable year would be ($40/hour x 79 

hours) $3,160. 

f. Maintenance of Certification Program Incentive 

 Eligible professionals who wish to qualify for an additional 0.5 percent Maintenance of 

Certification Program incentive would need to “more frequently” than is required to qualify for 

or maintain board certification status participate in a qualified Maintenance of Certification 

Program for the year in which the eligible professionals seek to qualify for this additional 

incentive and successfully complete a qualified Maintenance of Certification Program practice 

assessment for the applicable year. Although we understand that there is a cost associated with 
1253 

participating in a Maintenance of Certification Board, we believe that most of the eligible 

professionals attempting to earn this additional incentive would already be enrolled in a 

Maintenance of Certification Board for reasons other than earning the additional Maintenance of 

Certification Program incentive. Therefore, the burden to earn this additional incentive would 

depend on what a certification board establishes as “more frequently” and the time needed to 

complete the practice assessment component. We expect that the amount of time needed to 

complete a qualified Maintenance of Certification Program practice assessment would be spread 

out over time since a quality improvement component is often required. With respect to the 

practice assessment component, according to an informal poll conducted by ABMS in 2012, the 

time an individual spent to complete the practice assessment component of the Maintenance of 

Certification ranged from 8-12 hours. 

g. Burden Estimate on Vendor Participation in the 2013 and 2014 

Aside from the burden of eligible professionals and group practices participating in 

PQRS, we believe that registry and EHR vendor products incur costs associated with 

participating in PQRS. 

 Based on the number of registries that have self-nominated to become a qualified PQRS 

registry in prior program years, we estimated that approximately 50 additional registries would 

self-nominate to be considered a qualified registry for PQRS. With respect to qualified 

registries, the total burden for qualified registries who submitted PQRS quality measures data 

would be the time and effort associated with submitting this data. To submit quality measures 

data for the proposed PQRS program years, a registry would need to (1) become qualified for the 

applicable year and (2) report quality measures data on behalf of its eligible professionals. With 

respect to administrative duties related to the qualification process, we estimated that it would 

take a total of 10 hours – including 1 hour to complete the self-nomination statement, 2 hours to 
1254 

interview with CMS, 2 hours to calculate numerators, denominators, and measure results for 

each measure the registry wished to report using a CMS-provided measure flow, and 5 hours to 

complete an XML submission – to become qualified to report PQRS quality measures data. 

Therefore, we estimated that it would cost a registry approximately ($16.00/hour x 10 hours) 

$160 to become qualified to submit PQRS quality measures data on behalf of its eligible 

professionals. 

With respect to the reporting of quality measures data, the burden associated with 

reporting is the time and effort associated with the registry calculating quality measures results 

from the data submitted to the registry by its eligible professionals, submitting numerator and 

denominator data on quality measures, and calculating these measure results. We believe, 

however, that registries already perform these functions for its eligible professionals irrespective 

of participating in PQRS. Therefore, we believe there is little to no additional burden associated 

with reporting PQRS quality measures data. Whether there is any additional reporting burden 

would vary with each registry, depending on the registry’s level of knowledge with submitting 

quality measures data for PQRS. 

 With respect to EHR products, the total burden for direct EHR products and EHR data 

submission vendors who submit PQRS quality measures data would be the time and effort 

associated with submitting this data. To submit quality measures data for PQRS, a direct EHR 

product or EHR data submission vendor would need to report quality measures data on behalf of 

its eligible professionals. Please note that since we are not continuing to require direct EHR 

products and EHR data submission vendors to become qualified to submit PQRS quality 

measures data, there is no burden associated with a qualification process for direct EHR products 

and EHR data submission vendor products. With respect to reporting quality measures data, we 

believe the burden associated with the EHR vendor programming its EHR product(s) to extract 
1255 

the clinical data that the eligible professional would need to submit to CMS will depend on the 

vendor’s familiarity with PQRS and the vendor’s system and programming capabilities. Since 

we believe that an EHR vendor would be submitting data for reasons other than reporting under 

PQRS, we believe there would be no additional burden for an EHR vendor to submit quality 

measures data for PQRS reporting. 

g. Summary of Burden Estimates on Participation in the 2013 and 2014 PQRS - Eligible 

Professionals and Vendors 

TABLE 131: ESTIMATED COSTS FOR REPORTING PQRS QUALITY MEASURES 

DATA FOR ELIGIBLE PROFESSIONALS 

 Estimated 

Hours 

Estimated 

Cases 

Number of 

Measures 

Hourly 

Rate 

Total 

Cost 

Individual Eligible Professional 

(EP): Preparation 

5.0 1 N/A $16 $80 

Individual EP: Claims 0.2 6 3 $40 $144 

Individual EP: Administrative 

Claims 

2 1 N/A $16 $32 

Individual EP: Registry N/A 1 N/A N/A Minimal

Individual EP: HER N/A 1 N/A N/A Minimal

Group Practice: Self-Nomination 6.0 1 N/A $16 $96 

Group Practice: Reporting 79 1 N/A $40 $3,160 

TABLE 132: ESTIMATED COSTS TO VENDORS TO PARTICIPATE IN PQRS 

 Estimated Hours Hourly Rate Total Cost 

Registry: Self-Nomination 10 $160 $160 

EHR: Programming 0 $0 0 

We invited but received no public comments on our estimates related to the impact of the 

collection of information requirements related to PQRS. However, we believe that the estimated 

changes from the requirements and burden estimates currently approved by OMB under OCN 

0938-1059 are due to a combination of all revisions being made at §414.90(b), newly designated 

§414.90(f), and newly created§414.90(e), rather than just one outstanding provision. Therefore, 

please note that we have combined all impacts of the collection of information requirements 
1256 

related to PQRS in this section, in lieu of separating these impacts as it was proposed. 

Otherwise, our burden estimates remain unchanged. 

C. ICRs Regarding Physician Quality Reporting System – Requirements for the Payment 

Adjustments (§414.90)

While §414.90 contains information collection requirements regarding the PQRS 

payment adjustments, this rule will not revise any of the information collection requirements or 

burden estimates that are associated with those provisions, except for the provisions that would 

allow the administrative claims reporting option. Otherwise, all of the requirements and burden 

estimates are currently approved by OMB under OCN 0938-1083 and are not subject to 

additional OMB review under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 

3501 et seq.). 

 Specifically, although we are finalizing the criteria to report 1 measure or measures group 

for the 2015 PQRS payment adjustment, we do not expect eligible professional and group 

practices to stop reporting when they have met this threshold. Rather, since the reporting period 

for the 2013 PQRS incentive and 2015 PQRS payment adjustment coincide, we expect that all 

eligible professionals and group practices who use the traditional PQRS reporting mechanisms – 

claims, registry, EHR, and GPRO web interface – will attempt to report PQRS quality measures 

to meet the criteria for the 2013 PQRS Incentive. Therefore, the burden estimates for the 2013 

PQRS incentive apply to the 2015 PQRS payment adjustment. 

 With respect to the 2016 PQRS payment adjustment, we did not finalize the criteria to 

report 1 measure or measures group. Therefore, at this time, eligible professionals and group 

practices using the traditional PQRS reporting mechanisms – claims, registry, EHR, and GPRO 

web interface must meet the criteria for the 2014 PQRS incentive for the 2016 PQRS payment 

adjustment. Therefore, the burden estimates for the 2014 PQRS incentive apply to the 2016 
1257 

PQRS payment adjustment. 

(2) The Administrative Claims Reporting Mechanism. 

We note that, for the 2015 PQRS payment adjustment, we are finalizing an administrative 

claims reporting option for eligible professionals and group practices. The burden associated 

with reporting using the administrative claims reporting option is the time and effort associated 

with using this option. To submit quality measures data for PQRS using the administrative 

claims reporting option, an eligible professional or group practice would need to (1) elect to use 

the administrative claims-based reporting mechanism for the applicable payment adjustment and 

(2) be analyzed under the administrative claims-based reporting mechanism. With respect to 

election, we believe it would take approximately 2 hours to register to participate in PQRS as an 

administrative claims reporter. Therefore, we estimated that the cost of undergoing the 

administrative claims selection process would be ($16/hour x 2 hours) $32. 

 With respect to reporting, we noted that any burden associated with reporting would be 

negligible, as an eligible professional or group practice would not be required to attach reporting 

G-codes on the claims they submitted. Rather, CMS would calculate the administrative claims 

measures rates from claims submitted by group practices and eligible professionals. We note 

that there would be no additional burden on the eligible professional or group practice to submit 

these claims, as the eligible professional or group practice would have already submitted these 

claims for reimbursement purposes. 

D. Summary of Annual Burden Estimates for Codified Requirements

The requirements for the eRx Incentive Program for 2012—2014 were established in the 

CY 2012 Medicare PFS final rule. Although we made proposals related to the eRx Incentive 

Program in the CY 2013 Medicare PFS, these proposals have no additional burden or impact on 

the public. Therefore, this rule does not revise the requirements or burden estimates approved by 
1258 

OMB under OCN 0938-1059. We invited but received no public comment on our proposed 

impact analysis and are therefore finalizing the analysis for the collection of information 

requirements associated with the Electronic Prescribing (eRx) Incentive Program. 

TABLE 133: Summary of Annual Burden Estimates 

Regulation 

section(s) 

OCN Respondents Responses Burden per 

response (hr) 

Total 

burden 

(hr) 

§410.38(g) 

re: Physician 

10 min 96,667 

§410.38(g) 

re: PA, NP, or 

CNS 

0938-New 580,000 580,000 3 min 29,000 

§414.90 0938-1059 400,000 400,000 

(400,000 

responses 

x 3 

measures) 

0.5 (31.5 

minutes – the 

median) 

200,000 

E. Additional Information Collection Requirements

While this final rule with comment period will impose collection of information 

requirements that are set out in the regulatory text (see above), this rule also sets out information 

collection requirements that are set out only in the preamble. Following is a discussion of the 

preamble-specific information collections, all of which have already received OMB approval. 

1. Part B Drug Payment 

The discussion of average sales price (ASP) issues in section III.B.1 of this final rule with 

comment period 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 

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. All of the requirements 

and burden estimates are currently approved by OMB under OCN 0938-0921, and are not 
1259 

subject to additional OMB review under the authority of the Paperwork Reduction Act of 1995 

(44 U.S.C. 3501 et seq.). 

2. CAHPS Survey for the Physician Quality Reporting System and Physician Compare 

As explained previously, the burden estimates related to PQRS are under OCN 0938-

1083. However, we note that, to meet the criteria for the 2013 and 2014 PQRS incentives, we 

are requiring that group practices using the GPRO web interface complete a CAHPS survey. 

This would require the collection of information to obtain the patient experience data that will be 

included in the quality information reported by eligible professionals. The data collected in the 

survey will be scored and reported via Physician Compare on the cms.gov website. The 

information collection – a survey – will be targeted to Fee-for-service Medicare beneficiaries 

who have received care in the prior 12 months from the physician group practices participating 

in Physician Quality Reporting. The survey will be administered in English and Spanish, and 

beneficiaries may have assistance to complete the survey or designate a proxy respond on their 

behalf. 

Administering the CAHPS survey is different from the estimates provided from reporting 

measures, as beneficiaries must actively participate in the reporting of data by completing these 

surveys. According to estimates we have performed with respect to administering this survey, 

we anticipate that it will take approximately 39.53 hours to administer the CAHPS survey. We 

estimate that the cost per response will be $7,673.50. We understand the estimated cost is high. 

However, as we indicate in Section G in this final rule, CMS will assume the expense of 

administering the CAHPS survey. A summary of the burden estimates for administering the 

CAHPS survey is provided below: 

 Time Per 

Response 

Hour Per 

Response 

Annual Hour 

Burden 

Cost Per 

Response 

Annual Cost 

Burden 

Reporting 20.24 

minutes 

0.337 39,530 $7.6735 $900,100 
1260 

Record Keeping 0 0 0 0 0 

Third Party 

Disclosure 

0 0 0 0 0 

Total 20.24 

minutes 

0.337 39,530 $7.6735 $900,100 

F. Submission of PRA-Related Comments

If you comment on these information collection and recordkeeping requirements, please 

submit your comments to the Office of Information and Regulatory Affairs, Office of 

Management and Budget, 

 Attention: CMS Desk Officer, [CMS-1590-FC] 

 Fax: (202) 395-6974; or 

 Email: OIRA_submission@omb.eop.gov. 

VI. Waiver of Proposed Rulemaking 

We ordinarily publish a notice of proposed rulemaking in the Federal Register and 

invite public comment on the proposed rule. The notice of proposed rulemaking includes a 

reference to the legal authority under which the rule is proposed, and the terms and substance of 

the proposed rule or a description of the subjects and issues involved. This procedure can be 

waived, however, if an agency finds good cause that a notice-and-comment procedure is 

impracticable, unnecessary, or contrary to the public interest and incorporates a statement of the 

finding and its reasons in the rule issued. 

We utilize HCPCS codes for Medicare payment purposes. The HCPCS is a national drug 

coding system comprised of Level I (CPT) codes and Level II (HCPCS National Codes) that are 

intended to provide uniformity to coding procedures, services, and supplies across all types of 

medical providers and suppliers. Level I (CPT) codes are copyrighted by the AMA and consist 

of several categories, including Category I codes which are 5-digit numeric codes, and Category 

III codes which are temporary codes to track emerging technology, services, and procedures. 
1261 

The AMA issues an annual update of the CPT code set each Fall, with January 1 as the effective 

date for implementing the updated CPT codes. The HCPCS, including both Level I and Level II 

codes, is similarly updated annually on a CY basis. Annual coding changes are not available to 

the public until the Fall immediately preceding the annual January update of the PFS. Because 

of the timing of the release of these new codes, it is impracticable for us to provide prior notice 

and solicit comment on these codes and the RVUs assigned to them in advance of publication of 

the final rule that implements the PFS. Yet, it is imperative that these coding changes be 

accounted for and recognized timely under the PFS for payment because services represented by 

these codes will be provided to Medicare beneficiaries by physicians during the CY in which 

they become effective. Moreover, regulations implementing HIPAA (42 CFR parts 160 and 

162) require that the HCPCS be used to report health care services, including services paid under 

the PFS. We assign interim RVUs to any new codes based on a review of the AMA RUC 

recommendations for valuing these services. We also assign interim RVUs to certain codes for 

which we did not receive specific AMA RUC recommendations, but that are components of new 

combined codes. We set interim RVUs for the component codes in order to conform them to the 

value of the combined code. Finally, we assign interim RVUs to certain codes for which we 

received AMA RUC recommendations for only one component (work or PE) but not both. By 

reviewing these AMA RUC recommendations for the new codes, we are able to assign RVUs to 

services based on input from the medical community and to establish payment for them, on an 

interim basis, that corresponds to the relative resources associated with furnishing the services. 

We are also able to determine, on an interim final basis, whether the codes will be subject other 

payment policies. If we did not assign RVUs to new codes on an interim basis, the alternative 

would be to either not pay for these services during the initial CY or have each Medicare 

contractor establish a payment rate for these new codes. We believe both of these alternatives 
1262 

are contrary to the public interest, particularly since the AMA RUC process allows for an 

assessment of the valuation of these services by the medical community prior to our establishing 

payment for these codes on an interim basis. Therefore, we believe it would be contrary to the 

public interest to delay establishment of fee schedule payment amounts for these codes. 

For the reasons previously outlined in this section, we find good cause to waive the notice 

of proposed rulemaking for the interim RVUs for selected procedure codes identified in 

Addendum C and to establish RVUs for these codes on an interim final basis. We are providing 

a 60-day public comment period. 

Section II.C. of this final rule with comment period discusses the identification and 

review of potentially misvalued codes by the AMA RUC, as well as our review and decisions 

regarding the AMA RUC recommendations. Similar to the AMA RUC recommendations for 

new and revised codes previously discussed, due to the timing of the AMA RUC 

recommendations for the potentially misvalued codes, it was impracticable for CMS to solicit 

public comment regarding specific proposals for revision prior to this final rule with comment 

period. We believe it is in the public interest to implement the revised RVUs for the codes that 

were identified as misvalued, and that have been reviewed and re-evaluated by the AMA RUC, 

on an interim final basis for CY 2013. The revisions of RVUs for these codes will establish a 

more appropriate payment that better corresponds to the relative resources associated with 

furnishing these services. A delay in implementing revised values for these misvalued codes 

would not only perpetuate the known misvaluation for these services, it would also perpetuate a 

distortion in the payment for other services under the PFS. Implementing the changes now 

allows for a more equitable distribution of payments across all PFS services. We believe a delay 

in implementation of these revisions would be contrary to the public interest, particularly since 

the AMA RUC process allows for an assessment of the valuation of these services by the 
1263 

medical community prior to the AMA RUC’s recommendation to CMS. For the reasons 

previously described, we find good cause to waive notice and comment procedures with respect 

to the misvalued codes and to revise RVUs for these codes on an interim final basis. We are 

providing a 60-day public comment period. 

We ordinarily provide a 60-day delay in the effective date of the provisions of a rule in 

accordance with the Administrative Procedure Act (APA) (5 U.S.C. 553(d)), which requires a 

30-day delayed effective date, and the Congressional Review Act (5 U.S.C. 801(a)(3)), which 

requires a 60-day delayed effective date for major rules. However, we can waive the delay in the 

effective date if the Secretary finds, for good cause, that the delay is impracticable, unnecessary, 

or contrary to the public interest, and incorporates a statement of the finding and the reasons in 

the rule issued (5 U.S.C. 553(d)(3); 5 U.S.C. 808(2)). 

VII. 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 

considered all comments we received by the date and time specified in the “DATES” section of 

this preamble, and, when we proceeded with a subsequent document, we responded to the 

comments in the preamble to that document. 

VIII. Regulatory Impact Analysis 

A. Statement of Need

 This final rule with comment period is necessary in order to make payment and policy 

changes under the Medicare PFS and to make required statutory changes under the Middle Class 

Tax Relief and Job Creation Act of 2012 (MCTRJCA), the Affordable Care Act, and other 

statutory changes. This final rule with comment period also is necessary to make changes to Part 
1264 

B drug payment policy and other related Part B related policies. 

B. Overall Impact

We have examined the impact of this rule as required by Executive Order 12866 on 

Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving 

Regulation and Regulatory Review (February 2, 2012), 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 (March 22, 1995; Pub. L. 104-4), Executive Order 

13132 on Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2)). 

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of 

available regulatory alternatives and, if regulation is necessary, to select regulatory approaches 

that maximize net benefits (including potential economic, environmental, public health and 

safety effects, distributive impacts, and equity). A regulatory impact analysis (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 the Congressional Review Act. Accordingly, we have prepared a RIA 

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 entities. For purposes of the 

RFA, small entities include small businesses, nonprofit organizations, and small governmental 

jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by 

nonprofit status or by having revenues of $7.0 million to $34.5 million in any 1 year (for details 

see the SBA’s website at www.sba.gov/content/table-small-business-size-standards (refer to the 

620000 series)). Individuals and states are not included in the definition of a small entity. 
1265 

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 that 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. 

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. This analysis must conform to the provisions of section 604 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 for Medicare payment regulations and has fewer than 100 

beds. We are not preparing an analysis for section 1102(b) of the Act because we have 

determined, and the Secretary certifies, that this proposed rule would 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 also requires that agencies 

assess anticipated costs and benefits on State, local, or tribal governments or on the private sector 
1266 

before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 

dollars, updated annually for inflation. In 2012, that threshold is approximately $139 million. 

This final rule with comment period would have no consequential spending effect on state, local, 

or tribal governments or on the private sector. 

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. Since this regulation does not impose any costs on state or local 

governments, the requirements of Executive Order 13132 are not applicable. 

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 final rule with comment period; details the costs and benefits of 

the rule; analyzes alternatives; and presents the measures we would use to minimize the burden 

on small entities. As indicated elsewhere in this final rule with comment period, we proposed to 

implement 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, and to 

implement statutory provisions. We provided information for each of the policy changes in the 

relevant sections of this final rule with comment period. We are unaware of any relevant federal 

rules that duplicate, overlap, or conflict with this final rule with comment period. The relevant 

sections of this final rule with comment period contain a description of significant alternatives if 

applicable. 

C. Relative Value Unit (RVU) Impacts 

1. Resource-Based Work, PE, and Malpractice RVUs 

Section 1848(c)(2)(B)(ii)(II) of the Act requires that increases or decreases in RVUs may 
1267 

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 BN. 

Our estimates of changes in Medicare revenues for PFS services compare payment rates 

for CY 2012 with final payment rates for CY 2013 using CY 2011 Medicare utilization as the 

basis for the comparison. To the extent that there are year-to-year changes in the volume and 

mix of services furnished by physicians, the actual impact on total Medicare revenues would be 

different from those shown in Tables 134 (CY 2013 PFS Final Rule with Comment Period 

Estimated Impact on Total Allowed Charges by Specialty) and 135 (CY 2013 PFS Final Rule 

with Comment Period Estimated Impact on Total Allowed Charges by Specialty by Selected 

Policy). 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 and would 

depend 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. 

Tables 134 and 135 show the payment impact on PFS services. We note that these 

impacts do not include the effect of the January 2013 conversion factor changes under current 

law. The annual update to the PFS conversion factor is calculated based on a statutory formula 

that measures actual versus allowed or “target” expenditures, and applies a sustainable growth 

rate (SGR) calculation intended to control growth in aggregate Medicare expenditures for 

physicians’ services. This update methodology is typically referred to as the “SGR” 
1268 

methodology, although the SGR is only one component of the formula. Medicare PFS payments 

for services are not withheld if the percentage increase in actual expenditures exceeds the SGR. 

Rather, the PFS update, as specified in section 1848(d)(4) of the Act, is adjusted to eventually 

bring actual expenditures back in line with targets. If actual expenditures exceed allowed 

expenditures, the update is reduced. If actual expenditures are less than allowed expenditures, 

the update is increased. By law, we are required to apply these updates in accordance with 

section 1848(d) and (f) of the Act, and any negative updates can only be averted by an Act of the 

Congress. While the Congress has provided temporary relief from negative updates for every 

year since 2003, a long-term solution is critical. We are committed to working with the 

Congress to permanently reform the SGR methodology for Medicare PFS updates. We provide 

our most recent estimate of the SGR and physician update for CY 2013 in section III.N. of this 

final rule with comment period. 

The following is an explanation of the information represented in Table 134: 

● 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 2011 utilization and CY 2012 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, and 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 2013 impact on total allowed charges of the changes in the work and 

malpractice RVUs, including the impact of changes due to potentially misvalued codes. 
1269 

● Column D (Impact of PE RVU Changes): This column shows the estimated CY 2013 

impact on total allowed charges of the changes in the PE RVUs. 

● Column E (Combined Impact): This column shows the estimated CY 2013 combined 

impact on total allowed charges of all the changes in the previous columns. 

TABLE 134: CY 2013 PFS Final Rule with Comment Period 

Estimated Impact on Total Allowed Charges by Specialty* 

(A) (B) (C) (D) (E) 

 Specialty Allowed 

Charges 

(mil) 

Impact of 

Work and 

MP RVU 

Changes 

Impact of 

PE RVU 

Changes 

Combined 

Impact 

TOTAL $ 86,588 0% 0% 0%

01-ALLERGY/ IMMUNOLOGY $ 200 0% 3% 3%

02-ANESTHESIOLOGY ** $ 1,923 0% 1% 1%

03-CARDIAC SURGERY $ 369 0% -1% -1%

04-CARDIOLOGY $ 6,733 -1% -2% -2%

05-COLON AND RECTAL SURGERY $ 153 0% 2% 2%

06-CRITICAL CARE $ 263 0% 1% 1%

07-DERMATOLOGY $ 3,024 0% 0% 0%

08-EMERGENCY MEDICINE $ 2,839 0% 0% 0%

09-ENDOCRINOLOGY $ 437 0% 1% 1%

10-FAMILY PRACTICE $ 5,943 2% 4% 7%

11-GASTROENTEROLOGY $ 1,896 0% 0% 0%

12-GENERAL PRACTICE $ 587 0% 1% 1%

13-GENERAL SURGERY $ 2,283 0% 1% 0%

14-GERIATRICS $ 220 1% 3% 5%

15-HAND SURGERY $ 135 0% 1% 1%

16-HEMATOLOGY/ ONCOLOGY $ 1,909 0% 2% 2%

17-INFECTIOUS DISEASE $ 629 0% 1% 1%

18-INTERNAL MEDICINE $ 11,163 2% 3% 4%

19-INTERVENTIONAL PAIN MGMT $ 539 0% 1% 1%

20-INTERVENTIONAL RADIOLOGY $ 204 0% -2% -3%

21-MULTISPECIALTY CLINIC/OTHER PHY $ 81 0% 0% -1%

22-NEPHROLOGY $ 2,080 0% 0% 0%

23-NEUROLOGY $ 1,604 -2% -5% -7%

24-NEUROSURGERY $ 687 0% 0% 0%

25-NUCLEAR MEDICINE $ 49 0% -2% -3%

27-OBSTETRICS/ GYNECOLOGY $ 704 0% 0% 0%

28-OPHTHALMOLOGY $ 5,645 -3% 0% -3%

29-ORTHOPEDIC SURGERY $ 3,643 0% 0% 0%

30-OTOLARNGOLOGY $ 1,076 0% 2% 2%

31-PATHOLOGY $ 1,210 0% -6% -6%
1270 

(A) (B) (C) (D) (E) 

 Specialty Allowed 

Charges 

(mil) 

Impact of 

Work and 

MP RVU 

Changes 

Impact of 

PE RVU 

Changes 

Combined 

Impact 

32-PEDIATRICS $ 65 1% 3% 3%

33-PHYSICAL MEDICINE $ 999 -1% -3% -4%

34-PLASTIC SURGERY $ 356 -1% 1% 1%

35-PSYCHIATRY $ 1,170 -1% 3% 2%

36-PULMONARY DISEASE $ 1,703 0% 1% 1%

37-RADIATION ONCOLOGY $ 1,988 0% -7% -7%

38-RADIOLOGY $ 4,818 0% -3% -3%

39-RHEUMATOLOGY $ 548 0% 0% 0%

40-THORACIC SURGERY $ 343 0% -1% -1%

41-UROLOGY $ 1,918 0% -1% -1%

42-VASCULAR SURGERY $ 888 0% -2% -2%

43-AUDIOLOGIST $ 57 0% -4% -4%

44-CHIROPRACTOR $ 746 0% 1% 1%

45-CLINICAL PSYCHOLOGIST $ 575 1% -3% -2%

46-CLINICAL SOCIAL WORKER $ 406 1% -3% -2%

47-DIAGNOSTIC TESTING FACILITY $ 888 0% -7% -7%

48-INDEPENDENT LABORATORY $ 1,073 0% -14% -14%

49-NURSE ANES / ANES ASST ** $ 1,104 0% 1% 1%

50-NURSE PRACTITIONER $ 1,623 1% 3% 4%

51-OPTOMETRY $ 1,061 -1% 1% 1%

52-ORAL/MAXILLOFACIAL SURGERY $ 45 0% 1% 1%

53-PHYSICAL/OCCUPATIONAL THERAPY $ 2,636 0% 4% 4%

54-PHYSICIAN ASSISTANT $ 1,229 1% 2% 3%

55-PODIATRY $ 1,925 0% 2% 2%

56-PORTABLE X-RAY SUPPLIER $ 106 0% 5% 5%

57-RADIATION THERAPY CENTERS $ 72 0% -9% -9%

98-OTHER $ 19 0% 1% 1%

* Table 83 shows only the proposed payment policy impact on PFS services. We note that these impacts do not 

include the effects of the negative January 2013 conversion factor change under current law. 

**These figures have been revised to correct errors in the calculations presented in the CY 2013 PFS 

proposed rule. 

Table 135 shows the estimated impact of selected policies in this final rule with comment 

period on total allowed charges, by specialty. The following is an explanation of the information 

represented in Table 135: 

● 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 
1271 

specialty based on CY 2011 utilization and CY 2012 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, and suppliers within a specialty to arrive at the total 

allowed charges for the specialty. 

●Column (C) (Impact of End of PPIS Transition): This column shows the estimated CY 

2013 impact on total allowed charges of the changes in the RVUs due to the final year of the 

PPIS transition. 

Column D (Impact of New and Revised Codes, Updated Claims Data, MPPR on the TC 

of ophthalmology and cardiovascular diagnostic tests, and Other Factors): This column shows 

the estimated CY 2013 impact on total allowed charges of the changes in the RVUs, due to new 

and revised codes, proposed multiple procedure payment reduction for the TC of cardiovascular 

and ophthalmology diagnostic tests furnished on the same day (section III.B.4. of this final rule 

with comment period), and other final policies that resulted in minimal redistribution of 

payments under the PFS, the use of CY 2011 claims data to model payment rates, and other 

factors. 

● Column E (Impact of Updated Equipment Interest Rate Assumption): This column 

shows the estimated CY 2013 impact on total allowed charges of the changes in the RVUs 

resulting from our update to the equipment interest rate assumption as discussed in section 

III.A.2.f. of this final rule with comment period. 

● Column F (Impact of Discharge Transitional Care Management Services): This 

column shows the estimated CY 2013 combined impact on total allowed charges of the changes 

in the RVUs resulting from our policy to recognize new CPT codes that pay for post-discharge 

transitional care management services in the 30 days following an inpatient hospital, outpatient 
1272 

observation or partial hospitalization, skilled nursing facility (SNF), or community mental health 

center (CMHC) discharge as discussed in section III.H.1. of this final rule with comment period. 

● Column G (Impact of Input and Price Changes for Certain Radiation Therapy 

Procedures): This column shows the estimated CY 2013 combined impact on total allowed 

charges of the changes in the RVUs resulting from our policy to adjust inputs on certain radiation 

therapy procedures. 

● Column H (Cumulative Impact): This column shows the estimated CY 2013 

combined impact on total allowed charges of all changes from the policies in this final rule with 

comment period in the previous columns. 

TABLE 135: CY 2013 PFS Final Rule with Comment Period Estimated Impact on Total 

Allowed Charges by Specialty by Selected Policy* 

 (A) (B) (C) (D) (E) (F) (G) (H) 

 Specialty Allowed 

Charges 

(mil) 

 Impact of End of 

PPIS Transition 

 New and Revised 

Codes, MPPR, New 

Utilization and 

Other Factors 

Updated Equipment 

Interest Rate 

Assumption 

Transitional Care 

Management 

 Input Changes for 

Certain Radiation 

Therapy Procedures 

Total (Cumulative 

Impact) 

TOTAL $ 86,588 0% 0% 0% 0% 0% 0% 

01-ALLERGY/ 

IMMUNOLOGY 

 $ 200 

0% 1% 2% 0% 0% 3% 

02-ANESTHESIOLOGY ** $ 1,923 1% -1% 0% 0% 0% 1% 

03-CARDIAC SURGERY $ 369 -1% 0% 0% 0% 0% -1% 

04-CARDIOLOGY $ 6,733 -2% 0% 0% -1% 0% -2% 

05-COLON AND RECTAL 

SURGERY 

 $ 153 

1% 0% 0% 0% 0% 2% 

06-CRITICAL CARE $ 263 0% 0% 0% 0% 0% 1% 

07-DERMATOLOGY $ 3,024 0% 0% 1% -1% 0% 0% 

08-EMERGENCY 

MEDICINE 

 $ 2,839 0% 0% 0% 0% 0% 0% 

09-ENDOCRINOLOGY $ 437 1% 1% 0% -1% 0% 1% 

10-FAMILY PRACTICE $ 5,943 1% 1% 0% 4% 0% 7% 

11-

GASTROENTEROLOGY 

 $ 1,896 0% 0% 0% 0% 0% 0% 

12-GENERAL PRACTICE $ 587 1% 0% 0% -1% 0% 1% 

13-GENERAL SURGERY $ 2,283 1% 0% 0% 0% 0% 0% 

14-GERIATRICS $ 220 1% 1% 0% 2% 0% 5% 
1273 

15-HAND SURGERY $ 135 1% 0% 0% -1% 0% 1% 

16-HEMATOLOGY/ 

ONCOLOGY 

 $ 1,909 

-1% 3% 1% -1% 0% 2% 

17-INFECTIOUS DISEASE $ 629 1% 1% 0% 0% 0% 1% 

18-INTERNAL MEDICINE $ 11,163 1% 1% 0% 3% 0% 4% 

19-INTERVENTIONAL 

PAIN MGMT 

 $ 539 

1% 0% 0% -1% 0% 1% 

20-INTERVENTIONAL 

RADIOLOGY 

 $ 204 

-2% 0% 0% 0% 0% -3% 

21-MULTISPECIALTY 

CLINIC/OTHER PHY 

 $ 81 

0% 0% 0% -1% 0% -1% 

22-NEPHROLOGY $ 2,080 0% 0% 0% 0% 0% 0% 

23-NEUROLOGY $ 1,604 1% -8% 0% 0% 0% -7% 

24-NEUROSURGERY $ 687 0% 0% 0% 0% 0% 0% 

25-NUCLEAR MEDICINE $ 49 -2% 0% -1% 0% 0% -3% 

27-OBSTETRICS/ 

GYNECOLOGY 

 $ 704 

0% 0% 0% -1% 0% 0% 

28-OPHTHALMOLOGY $ 5,645 2% -4% 0% 0% 0% -3% 

29-ORTHOPEDIC 

SURGERY 

 $ 3,643 

1% 0% 0% 0% 0% 0% 

30-OTOLARNGOLOGY $ 1,076 1% 1% 1% -1% 0% 2% 

31-PATHOLOGY $ 1,210 -1% -5% 0% 0% 0% -6% 

32-PEDIATRICS $ 65 1% 0% 0% 3% 0% 3% 

33-PHYSICAL MEDICINE $ 999 1% -5% 0% -1% 0% -4% 

34-PLASTIC SURGERY $ 356 1% 0% 0% 0% 0% 1% 

35-PSYCHIATRY $ 1,170 0% 2% 0% -1% 0% 2% 

36-PULMONARY 

DISEASE 

 $ 1,703 0% 1% 0% -1% 0% 1% 

37-RADIATION 

ONCOLOGY 

 $ 1,988 

-4% 2% -3% -1% -1% -7% 

38-RADIOLOGY $ 4,818 -2% 0% -1% 0% 0% -3% 

39-RHEUMATOLOGY $ 548 0% 1% 0% -1% 0% 0% 

40-THORACIC SURGERY $ 343 -1% 0% 0% 0% 0% -1% 

41-UROLOGY $ 1,918 -2% 1% 0% -1% 0% -1% 

42-VASCULAR SURGERY $ 888 -1% -1% 0% 0% 0% -2% 

43-AUDIOLOGIST $ 57 -3% 0% 0% 0% 0% -4% 

44-CHIROPRACTOR $ 746 1% 0% 0% 0% 0% 1% 

45-CLINICAL 

PSYCHOLOGIST 

 $ 575 

-2% 1% 0% 0% 0% -2% 

46-CLINICAL SOCIAL 

WORKER 

 $ 406 

-2% 0% 0% 0% 0% -2% 

47-DIAGNOSTIC TESTING 

FACILITY 

 $ 888 

-5% 0% -2% -1% 0% -7% 
1274 

48-INDEPENDENT 

LABORATORY 

 $ 1,073 

-2% -12% 1% -1% 0% -14% 

49-NURSE ANES / ANES 

ASST ** 

 $ 1,104 

2% -1% 0% 0% 0% 1% 

50-NURSE 

PRACTITIONER 

 $ 1,623 1% 1% 0% 2% 0% 4% 

51-OPTOMETRY $ 1,061 2% -1% 0% 0% 0% 1% 

52-

ORAL/MAXILLOFACIAL 

SURGERY 

 $ 45 

1% 0% 1% -1% 0% 1% 

53-

PHYSICAL/OCCUPATION

AL THERAPY 

 $ 2,636 

2% 2% 0% 0% 0% 4% 

54-PHYSICIAN 

ASSISTANT 

 $ 1,229 1% 0% 0% 2% 0% 3% 

55-PODIATRY $ 1,925 2% 0% 1% -1% 0% 2% 

56-POR X-RAY SUPPLIER $ 106 

1% 4% 1% -1% 0% 5% 

57-RADIATION THERAPY 

CENTERS 

 $ 72 

-5% 4% -5% -1% -1% -9% 

98-OTHER $ 19 1% 0% 0% 0% 0% 1% 

*Table 135 shows only the proposed payment policy impact on PFS services. We note that these impacts do not 

include the effects of the negative January 2013 conversion factor change under current law. 

** These figures have been revised to correct errors in the calculations presented in the CY 2013 PFS 

proposed rule. 

2. CY 2013 PFS Impact Discussion 

a. Changes in RVUs 

The most widespread specialty impacts of the RVU changes are generally related to 

several factors. First, as discussed in section III.A.2. of this final rule with comment period, we 

are currently implementing the final year of the 4-year transition to new PE RVUs using the 

PPIS data that were adopted in the CY 2010 PFS final rule with comment period. This impact 

appears in column C of Table 135. The impacts of the final year of the transition are generally 

consistent with the impacts that would be expected based on the impacts displayed in the 

CY 2012 final rule with comment period. The second factor is the post-discharge transitional 

care management policy, under which we will pay for care coordination in the 30 days following 

an inpatient hospital, outpatient hospital observation services or partial hospitalization, SNF, or 
1275 

CMHC discharge from the treating physician in the hospital to the beneficiary’s primary 

physician in the community. We estimate that CPT codes 99495 and 99496 for TCM will 

redistribute approximately $0.6 billion in allowed charges to primary care specialties under the 

physician fee schedule (estimated using the CY 2012 CF), with approximately 20 percent of that 

representing redistributed beneficiary coinsurance. The redistributive effect of this policy 

appears on column F of Table 135. 

Column E in Table 135 also reflects updates to the proposed interest rate assumption used 

in the medical equipment calculation in the PE RVU methodology. Other final rule policies, 

including the multiple procedure payment reduction policy for the technical component of 

diagnostic cardiovascular and ophthalmological procedures, as well as new values for new and 

revised codes are included in Column D. Column G in Table 135 isolates the impact of revisions 

to equipment inputs and prices for certain radiation therapy services. Table 135 shows the same 

information as provided in Table 134, but rather than isolating the policy impact on physician 

work, PE, and malpractice separately, Table 135 shows the impact of varied final policies on 

total RVUs. 

b. Combined Impact 

 Column E of Table 134 and column H of Table 135 display the estimated CY 2013 

combined impact on total allowed charges by specialty of all the RVU and MPPR changes. 

These impacts range from an increase of 7 percent for family practice to a decrease of 14 percent 

for independent laboratory. We have received numerous new codes with new values and revised 

codes with new values for CY 2013 as a result of our ongoing misvalued codes initiative. Many 

of the new and revised codes that we valued on an interim basis for CY 2013 originated with the 

potentially misvalued codes initiative. Reductions for pathology, neurology, and independent 

laboratories are a result of the potentially misvalued code initiative. In the case of independent 
1276 

laboratories, we note that independent laboratories receive the majority of the Medicare revenue 

from the Clinical Lab Fee Schedule, which is unaffected by the potentially misvalued code 

initiative. Again, these impacts are estimated prior to the application of the negative CY 2013 

Conversion Factor (CF) update applicable under the current statute. 

Table136 (Impact of Final Rule with Comment Period on CY 2013 Payment for Selected 

Procedures) shows the estimated impact on total payments for selected high volume procedures 

of all of the changes discussed previously. We have included CY 2013 payment rates with and 

without the effect of the CY 2013 negative PFS CF update for comparison purposes. 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 final rule with comment period. 
TABLE 136: Impact of Final Rule with Comment Period on CY 2013 Payment for Selected Pro

Facility Nonfacili

CPT/ HCPCS 

1

MOD Short Descriptor 

CY 2012

2

CY 2013

3

 

(pre update) 

% Change 

 (pre update) 

CY 2013 4 

(post update) 

% Change 

(post update) 

CY 2012 

2

CY 20133 

(pre update) 

% Change 

(dt) 

11721 Debride nail 6 or more $25.19 $24.48 -3% $18.00 -29% $43.57 $44.89 317000 Destruct premalg lesion $56.16 $57.13 2% $42.00 -25% $81.01 $83.32 327130 Total hip arthroplasty $1,445.58 $1,452.08 0% $1,067.53 -26% NA NA N27244 Treat thigh fracture $1,231.48 $1,240.22 1% $911.78 -26% NA NA N27447 Total knee arthroplasty $1,544.29 $1,550.36 0% $1,139.79 -26% NA NA N33533 Cabg arterial single $1,950.35 $1,904.37 -2% $1,400.04 -28% NA NA N35301 Rechanneling of artery $1,112.35 $1,095.35 -2% $805.28 -28% NA NA N43239 Upper gi endoscopy biopsy $174.61 $174.45 0% $128.25 -27% $351.61 $359.45 266821 After cataract laser surgery $307.70 $324.76 6% $238.76 -22% $326.08 $344.15 666984 Cataract surg w/iol 1 stage $760.74 $666.53 -12% $490.02 -36% NA NA N67210 Treatment of retinal lesion $504.10 $519.28 3% $381.76 -24% $523.84 $537.64 371010 Chest x-ray 1 view frontal NA NA NA NA NA $23.83 $23.80 071010 26 Chest x-ray 1 view frontal $8.85 $8.84 0% $6.50 -27% $8.85 $8.84 077056 Mammogram both breasts NA NA NA NA NA $112.32 $115.28 377056 26 Mammogram both breasts $42.55 $42.17 -1% $31.00 -27% $42.55 $42.17 -177057 Mammogram screening NA NA NA NA NA $81.35 $82.30 177057 26 Mammogram screening $34.38 $34.01 -1% $25.00 -27% $34.38 $34.01 -177427 Radiation tx management x5 $177.00 $178.19 1% $131.00 -26% $177.00 $178.19 188305 26 Tissue exam by pathologist $36.08 $36.73 2% $27.00 -25% $36.08 $36.73 290935 Hemodialysis one evaluation $72.84 $71.07 -2% $52.25 -28% NA NA N92012 Eye exam establish patient $51.40 $53.05 3% $39.00 -24% $82.71 $87.40 692014 Eye exam&tx estab pt 1/>vst $78.29 $80.26 3% $59.00 -25% $119.81 $126.16 593000 Electrocardiogram complete NA NA NA NA NA $19.06 $18.36 -493010 Electrocardiogram report $8.51 $8.16 -4% $6.00 -29% $8.51 $8.16 -4
93307 26 Tte w/o doppler complete $45.95 $44.21 -4% 32.5 -29% $45.95 $44.21 -493458 26 L hrt artery/ventricle angio $315.87 $315.24 0% $231.76 -27% $315.87 $315.24 098941 Chiropract manj 3-4 regions $30.63 $30.27 -1% $22.25 -27% $36.08 $36.39 199203 Office/outpatient visit new $74.88 $74.81 0% $55.00 -27% $105.18 $107.80 299213 Office/outpatient visit est $49.69 $49.65 0% $36.50 -27% $70.46 $72.43 399214 Office/outpatient visit est $76.24 $76.51 0% $56.25 -26% $104.16 $106.44 299222 Initial hospital care $133.09 $134.33 1% $98.75 -26% NA NA N99223 Initial hospital care $195.38 $197.58 1% $145.25 -26% NA NA N99231 Subsequent hospital care $38.12 $38.09 0% $28.00 -27% NA NA N99232 Subsequent hospital care $69.78 $70.05 0% $51.50 -26% NA NA N99233 Subsequent hospital care $100.07 $101.00 1% $74.25 -26% NA NA N99236 Observ/hosp same date $212.05 $212.20 0% $156.00 -26% NA NA N99239 Hospital discharge day $103.13 $104.40 1% $76.75 -26% NA NA N99283 Emergency dept visit $60.25 $59.85 -1% $44.00 -27% NA NA N99284 Emergency dept visit $114.71 $114.26 0% $84.00 -27% NA NA N99291 Critical care first hour $217.16 $217.64 0% $160.01 -26% $267.20 $271.71 299292 Critical care addl 30 min $108.92 $109.50 1% $80.50 -26% $119.47 $120.72 199348 Home visit est patient NA NA NA NA NA $ 82.03 $ 82.30 099350 Home visit est patient NA NA NA NA NA $ 171.21 $ 173.43 1

G0008 Immunization admin NA NA NA NA NA $ 24.17 $ 25.85 7

1 CPT codes and descriptions are copyright 2012American Medical Association. All Rights Reserved. Applicable FARS/DFARS 

2 Payments based on the 2012 conversion factor of 34.0376 3 Payments based on the 2012 conversion factor of 34.0376, adjusted to 34.0066 to include the budget neutrality adjustment. 

4 Payments based on the 2013 conversion factor of 25.0008, which includes the budget neutrality adjustment. 
1279 

D. Effect of Proposed Changes to Medicare Telehealth Services Under the PFS

As discussed in section III.E.3 of this final rule with comment period, we are finalizing 

our proposal to add several new codes to the list of Medicare telehealth services. While we 

expect these changes to increase access to care in rural areas, based on recent utilization of 

similar services already on the telehealth list, we estimate no significant impact on PFS 

expenditures from the additions. 

E. Effect of Proposed Definition of Certified Registered Nurse Anesthetists’ (CRNA) Services 

As discussed in section III.K.1. of this final rule with comment period, we clarified that 

“anesthesia and related care”, with respect to the statutory benefit category for CRNAs under 

Section 1861(bb)(2) of the Social Security Act, means those services that a certified registered 

nurse anesthetist is legally authorized to perform in the state in which the service is furnished. 

.Our final rule clarification recognizes local variation in state scope of practice, which 

does not diverge significantly from current practice. Therefore, we estimate no significant 

budgetary impact from this proposed change. 

F. Effects of Proposed Change to Ordering Requirements for Portable X-Ray Services Under the 

PFS

As discussed in section III.K.2. of this final rule with comment period, we are finalizing 

our proposal to revise our current regulation that limits ordering of portable x-ray services to 

only a doctor of medicine or a doctor of osteopathy to allow other physicians and nonphysician 

practitioners (acting within the scope of state law and their Medicare benefit) to order portable xray services. We estimated no significant impact on PFS expenditures from the additions. 

G. Geographic Practice Cost Indices (GPCIs)

As discussed in section III.E. of this final rule with comment period, we are required to 
1280 

review and revise the GPCIs 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 2013, we did not propose any 

revisions related to the data or methodologies used to calculate the GPCIs. However, since the 

1.0 work GPCI floor provided in section 1848 (e)(1)(E) of the Act is set to expire prior to the 

implementation of the CY 2013 PFS, the CY 2013 physician work GPCIs and summarized 

geographic adjustment factors (GAFs) published in addendums D and E of this CY 2013 PFS 

final rule with comment period do not reflect the 1.0 work GPCI floor for CY 2013. As required 

by section 1848 (e)(1)(G) and section1848 (e)(1)(I) of the Act, the 1.5 work GPCI floor for 

Alaska and the 1.0 PE GPCI floor for frontier states are applicable in CY 2013. 

H. Other Provisions of the Final Regulation

1. Ambulance Fee ScheduleAs discussed in section III.A. of this final rule with comment period, section 306 of the 

TPTCCA and section 3007 of the MCTRJCA required the extension of certain add-on payments 

for ground ambulance services, and the extension of certain rural area designations for purposes 

of air ambulance payment, through CY 2012. As further discussed in section III.A. of this final 

rule with comment period, this legislation is self-implementing, and we proposed to amend the 

regulation text at §414.610 only to conform the regulations to these self-implementing statutory 

requirements. As a result, we did not make any policy proposals associated with these legislative 

provisions and there is no associated regulatory impact. 

2. Part B Drug Payment: ASP Issues 

As discussed in section III of this final rule with comment period, we proposed to update 

the AMP-based price substitution policy that would allow Medicare to pay based off lower 

market prices for those drugs and biologicals that consistently exceed the applicable threshold 
1281 

percentage. Our impact analysis is unchanged from last year (76 FR 73462): based on estimates 

published in various OIG reports cited in the CY 2012 PFS final rule with comment period (76 

FR 73290-1), we believe that this proposal will generate minor 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. 

Our policy clarification regarding Pharmacy Billing for Part B Drugs Administered 

Incident to a Physician’s Services, which is discussed in section III of this final rule with 

comment period states that only physicians and not pharmacies (or DME suppliers) are allowed 

to bill Medicare under Part B for drugs administered to beneficiaries in physicians’ offices. We 

do not believe that this clarification will significantly impact the quantity or payment amount for 

Part B drugs that are administered through implanted DME and or the procedures used to refill 

such pumps because it is a clarification of current policy. 

3. Medicare Program; Durable Medical Equipment (DME) Face-to-Face Encounters and Written 

Orders Prior to Delivery 

a. Overall Impact 

 The majority of changes regarding the impact between the proposed and the final result 

from the change in timeframe, from 90 days before the written order or 30 days after to six 

months before the written order. Moreover, the effective date for this regulation is July 1, 2013; 

therefore, only 6 months of year 1 (calendar year 2013) are included in this analysis. . We 

estimated the overall economic impact of this provision on the health care sector to be a cost of 

$30.2 million in the first year approximately half of which would be in CY 2013. The 5 year 

impact is $172.3 million. This overall impact is composed of additional administrative 

paperwork costs to private sector providers; a slight increase in Medicare spending, consisting of 
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additional costs and some offsetting savings; and additional opportunity and out-of-pocket costs 

to Medicare beneficiaries. We believe there are likely to be other benefits and cost savings that 

result from the DME face-to-face requirement; however, many of those benefits cannot be 

quantified. For instance, we expect to see savings in the form of reduced fraud, waste, and 

abuse, including a reduction in improper Medicare fee-for-service payments (note that not all 

improper payments are fraudulent). Our detailed cost and benefit analysis is explained below. 

We specifically solicited comments on the potential increased costs and benefits associated with 

this provision. 

The following is a summary of the comments we received regarding the potential increased costs 

and benefits associated with this provision. 

Comment: Several commenters stated that if the belief is that fraud is on the 

physician/non-physician provider side, then having a strong rationale for the DME equipment in 

their encounter note should provide the paper trail to determine the medical need for the DME 

and establish the trail of the request and justification for each piece of DME. No additional 

paperwork would need to be transmitted and no interpretation of the encounter note (by nonclinician DME suppliers) would need to be done. The process could create a clear auditing trail 

for investigators. 

Response: CMS appreciates these comments; however, CMS must implement the 

regulation based on the statutory requirement, which is to require a physician to document the 

occurrence of a face-to-face encounter for covered items of DME. Through the implementation 

of the statutory requirements and based on comments, CMS tried to balance the need to protect 

the trust fund and limit burden through many ways including the list of covered items and the 

documentation requirements. 
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Comment: Commenters appreciated CMS’s efforts to reduce waste, fraud and abuse.

Commenters stated that CMS should apply the new encounter and documentation requirements 

initially to a smaller number of HCPCS codes and first evaluate the impact of the requirements 

on beneficiary access to DME and costs to providers before expanding the list in the future. 

Response: CMS believes that this is an important requirement aimed at reducing waste, 

fraud and abuse. CMS utilized a criterion driven approach to select these items and did not 

receive sufficiently detailed alternative criteria to those proposed to be implementable. CMS will 

monitor the effects of this requirement on reducing waste, fraud and abuse and monitor 

beneficiary access to care. 

TABLE 137: Overall Economic Impact to Health Sector (in millions) 

Year 1 5 Years 

Private Sector (Paperwork Cost) $11.2 $ 64.8

Net Medicare impact of additional visits and G code billings $5 $30

Beneficiaries $14.4 $77.5

Total Economic Impact to Health Sector $ 30.6 $172.3 

Note: CY 2013 only includes the first 6 months of Year 1. 

The definition of small entity in the RFA includes non-profit organizations. Most 

suppliers and providers are small entities as that term is used in the RFA. Likewise, the vast 

majority of physician and NP practices are considered small businesses according to the Small 

Business Administration’s size standards with total revenues of $10 million or less in any 1 year. 

While the economic costs and benefits of this rule are substantial in the aggregate, the economic 

impacts on individual entities will be relatively small. We estimate that 90 to 95 percent of DME 

suppliers and practitioners who order DME are small entities under the RFA definition. 

Physicians and other professionals would receive extra payments for some of the costs imposed, 

and other costs (for example, for additional practitioner visits) would be reimbursed by Medicare 

under regular payment rules. The rationale behind requiring a face-to-face encounter is to reduce 
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inappropriate claims from those DME suppliers who have been abusing or defrauding the 

program. The impact on these suppliers could be significant; however, since we believe that the 

purpose of the statute and this regulation is to reduce abusive and fraudulent DME sales, we do 

not view the burden placed on those providers and suppliers in the form of lost revenues as a 

condition that we must mitigate. We believe that the effect on legitimate suppliers and 

practitioners would be minimal. 

Anticipated Effects 

b. Costs 

(1) Private Sector Paperwork Costs 

We believe that most practitioners are already seeing the beneficiary no more than 6 

months prior to the written order. However, this regulation potentially requires increased 

documentation. 

Although we have no quantitative data for a specific dollar figure for the additional DME 

that may now be authorized in accordance with §410.38(g), nor can we determine if there would 

be cost avoidance and a reduction of unnecessary DME, we acknowledge the potential for this 

provision to surpass the economically significant threshold. We do not believe that this final rule 

with comment period would significantly affect the number of legitimate written orders for 

DME. However, we would expect a decline in fraudulent, wasteful and abusive orders, thereby 

causing a decrease in the amount paid for DME overall. 

The covered items of DME as outlined in III.C , including the list of specified covered 

items, contains items that meet at least one of the following four criteria: (1) items that currently 

require a written order prior to delivery per instructions in our Program Integrity Manual; (2) 

items that cost more than $1,000; (3) items that we, based on our experience and 
1285 

recommendations from the DME MACs, believe are particularly susceptible to fraud, waste, and 

abuse; (4) items determined by CMS as vulnerable to fraud, waste and abuse based on reports of 

the HHS Office of Inspector General, the Government Accountability Office or other oversight 

entities. CMS will not include items on the covered list of items that are cited in statute 

explicitly as not having a face-to-face encounter requirement. A summary of comments 

regarding the criteria is available in III.C. 

We also have estimated the number of different covered Medicare items subject to this 

final rule with comment period at approximately 155 HCPCS codes for items of DME. As new 

products enter the market this number could increase, which could increase the impact. In 

addition, we propose a G-code to pay physicians for documenting the encounter conducted by a 

PA, a NP, or a CNS. 

We anticipated there would be an impact as a result of additional office visits for the 

face-to-face encounter and the additional time spent by physicians to document the face-to-face 

encounters with a beneficiary when it is furnished by a PA, a NP, or a CNS. 

In our estimate of overall cost we included the estimates from section III, of this final rule 

with comment period (Collection of Information Requirements section). These are estimated at 

$11.2 million in year 1 and $ 64.8 million over 5 years. These are driven by the physician 

documenting face-to-face encounters with a beneficiary when it is furnished by a PA, a NP, or a 

CNS, including the time to communicate the practitioners’ findings to physicians so they can 

complete the necessary documentation. 

TABLE 138: Private Sector Paperwork Costs 

Year 1 

(in millions) 

5 Years 

(in millions) 

Physician time to document occurrence of a face-to-face 

encounter cost 

$9.8 $57 

PA, NP, or CNS costs $1.4 $7.8 
1286 

Year 1 

(in millions) 

5 Years 

(in millions) 

Total Cost $11.2 $64.8 

Note: CY 2013 only includes the first 6 months of Year 1. 

(2) Medicare Costs 

Medicare would incur additional costs associated with this final rule with comment 

period related to additional face-to-face encounters in the form of office visits, and additional 

payment for time spent documenting the face-to-face encounter if furnished by the PA, NP or 

CNS and not by the physician directly. Subsequently, a G-Code is being created to allow 

Medicare payment to physicians for documenting the face-to-face encounters that are furnished 

by a PA, NP, and CNS, and is included in this final rule with comment period. 

From a programmatic standpoint we believe that there would be 375,000 additional office 

visits billed and 500,000 G code claims for the documentation in year 1. It is difficult to 

determine how many PAs, NPs or CNSs wrote orders for covered items of DME and while we 

lack exact empirical data, in order to provide an estimate, we assumed that 5 percent of the 

orders for covered items of DME were written by a PA, NP or CNS. For the purpose of this 

estimate, we assumed that each order requires a separate face-to-face encounter, recognizing 

fully that the estimate might be inflated. 

While we believe that currently the majority of practitioners evaluate beneficiaries before 

ordering DME, some may not, and therefore, a certain number of beneficiaries would be required 

to have a new visit in order to fulfill the face-to-face encounter requirement. Actuarial estimates 

indicated approximately 2.5 percent of those obtaining covered items of DME in a given year did 

not see a practitioner in the 6 months preceding the order. This percentage changed due to the 

modified timeframe from the proposed rule. We estimated that 250,000 beneficiaries would not 

see their practitioners in the 6 months prior to the written order. We assumed that 1.5 visits per 
1287 

year per affected beneficiary would be required to cover the DME services that currently fail to 

meet the face- to- face requirement. The range would be about one to three; possibly less than 

one if many beneficiaries choose not to meet the requirement or reschedule services. DME 

claims for beneficiaries who failed to meet the physician contact requirements averaged 3 line 

items per beneficiary. However, about 40 percent of these line items occur on the same date and 

so probably refer to the same event and could be authorized during a single visit. Some 

additional coordination is probable for DME purchases within a narrow time frame. To estimate 

the impact of the additional office visits, we assumed 375,000 additional office visits (1.5 visits * 

250,000 beneficiaries). We also assumed that the average cost for these office visits is around 

$65, which is consistent with a mid-level office visit under the PFS. This represents the total 

amount that the practitioners would receive, either from Medicare or the beneficiary, who is 

responsible for the 20 percent coinsurance. 

Physicians are now required to document the face-to-face encounter if it was furnished by 

a PA, NP, or CNS. In order to allow payment for this documentation, a G code is established for 

this service. There are approximately 10 million DME users and it we assumed that roughly 5 

percent of face-to-face encounters are actually furnished by these other practitioner types, 

thereby requiring documentation of the encounter. Therefore, we assumed that about 500,000 of 

these documentation services would be billed. As discussed in section III.M.3 of this final rule 

with comment period, we are establishing work and malpractice RVUs for HCPCS codes for 

G0454 by crosswalking to the work and malpractice RVUs for CPT code 99211 ((Level 1 office 

or other outpatient visit, established patient). With regard to practice expense RVUs, we are not 

including any direct practice expense inputs for clinical labor, disposable medical supplies, or 

equipment in the direct PE input database for this code; practice expense RVUs will reflect 
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resources for overhead costs only. The work, malpractice, and practice expense RVUs for 

HCPCS code G0454 are reflected in Addendum B of this CY 2013 PFS final rule with comment 

period www.cms.gov/physicianfeesched/. A complete list of the interim final times assigned to 

HCPCS code G0454 is available on the CMS website at www.cms.gov/physicianfeesched/.” 

This represents the total amount that the physician would receive, either from Medicare or the 

beneficiary, who is responsible for the 20 percent coinsurance. 

Therefore the estimated gross cost is estimated to be $10 million in CY 2013 and $115 

million over 5 years; note that there are also savings to Medicare that must be netted against the 

cost of additional practitioner office visits, which are described later in the Benefits section. 

There is a high degree of uncertainty surrounding this estimate because it was difficult to predict 

how physicians and beneficiaries would respond to the new requirement. 

This provision would assist in providing better documentation which may help to lower 

the error rate and thus reduce improper payments, including those stemming from waste, fraud 

and abuse. Since there is a large amount of potential variation in the amount of time that a faceto-face encounter may take for an item of DME, as a proxy our estimate is based on the amount 

of time needed for a mid-level visit to evaluate a beneficiary (E&M code 99213). The time 

allotted for this visit to furnish the face-to-face evaluation under a 99213 is 15 minutes. We 

solicited comments as to the appropriateness of E&M Code 99213 as a proxy measure of time 

required for a face-to-face encounter but did not receive any public comments. 

Based on actual data, projecting these historical patterns in light of the draft regulation 

was not straight-forward. Some line items may be bundled (perhaps because they were used 

together). Beneficiaries may also change their behavior in response to the regulation. For 

example, beneficiaries who would be required to visit a physician in order for Medicare to pay 
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for a new piece of equipment may substitute this visit for a later visit that would have been for a 

routine service. In this situation, the overall number of visits would not increase. Moreover, 

some beneficiaries may choose not to pursue the DME item at that time. On the other hand, the 

final rule with comment period points out that some of the encounters reported on the 

practitioner claim now may not support the need for the item of DME. We assume that 

beneficiaries would decide not to schedule 10 percent of the additional visits required as a result 

of not needing the DME item and that some would substitute a required service for a later 

planned visit. 

TABLE 139: Medicare 5-Year Costs for Additional Face-to-Face Visits and G Code 

Billings 

2013 2014 2015 2016 2017 

$10 $25 $25 $25 $30 

Note: These costs represent 80 percent of the allowed charges for the additional visits and the new G codes. 

The requirement for a face-to-face encounter with a beneficiary in a certain time period 

as a condition of payment for DME is a new statutory requirement. It is not subject to the 

physician fee schedule budget neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the 

Act. However, by regulation, we are making an additional payment through a new G-code for 

physician work documenting the face-to-face encounters that are performed by a PA, NP, and 

CNS. This additional regulatory spending is subject to the physician fee schedule budget 

neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the Act. 

(c) Beneficiary Cost Impact 

From a programmatic standpoint, approximately 2.5 percent of those obtaining covered 

items of DME in that year did not see a practitioner in the 6 months preceding the order. We 

estimated that 250,000 beneficiaries would not see their practitioners in the 6 months prior to the 

written order for the covered item. As mentioned above, we assumed that 1.5 visits per year per 
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affected beneficiary would be required to cover the DME services that currently fail to meet the 

face-to-face requirement. The range would be about one to three; possibly less than one if many 

beneficiaries chose not to meet the requirement or reschedule services. DME claims for 

beneficiaries who failed to meet the physician contact requirements averaged 3 line items per 

beneficiary. However, about 40 percent of these line items occur on the same date and so 

probably refer to the same event and could be authorized during a single visit. Some additional 

coordination is probable for DME purchases within a narrow time frame. There are effects on 

travel time and cost for these beneficiaries. We estimate that there will be an additional 375,000 

office visits as a number of beneficiaries would not have seen their practitioner in the six months 

prior to the written order for the covered item. If it takes a beneficiary 1.25 hours to go to a 

practitioner, the total estimate is approximately 468,750 hours of time for this final rule with 

comment period. We assumed that an average trip requires one hour and 15 minutes (1.25 

hours) (45 minutes of round trip travel time and 30 minutes in the doctor's office—half for 

waiting and half for time with the staff). As a proxy we use $20 to estimate the cost per hour 

including loss of leisure time and travel cost for a beneficiary to see a practitioner. This is 

consistent with previous estimates of beneficiary leisure time as proposed in the May 4, 2011 

proposed rule entitled “Medicare & Medicaid Programs; Influenza Vaccination Standard for 

Certain Medicare & Medicaid Participating Providers and Suppliers” (76 FR 25469). This 

creates an economic cost of nearly $9,375,000 in year 1 and $52.5 million over 5 years. There 

will be additional out of pocket expenses at the 20 percent Medicare Part B coinsurance. We 

estimated this cost to be $5 million in year 1 and $25 million over 5 years.

TABLE 140: Beneficiary Cost Impact Resulting from Additional Face-to-Face 

Visits to Obtain DME Services 

Beneficiary Cost: Out of Pocket Expense (in millions) 
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2013 2014 2015 2016 2017 

$5 $5 $5 $5 $5 

Year 1 5 Years 

Total beneficiaries visits impacted 375,000 2,100,000 

Time per beneficiary 1.25 hours 1.25 hours 

Total Time 468,750 2,625,000 

Beneficiary Time Cost ($20) $9.4 million $52,500,000 

Out of Pocket Expense $5million $25,000,000 

Estimated Total Beneficiary Cost 

Impact 

$ 14.4 million $ 77.5million 

Note: These costs represent 20 percent of the allowed charges for the additional visits and the new G codes. 

b. Benefits

There would be quantifiable benefits from an expected reduction in Medicare DME 

services provided. In addition, we anticipated additional, qualitative benefits from a decrease in 

waste, fraud, and abuse, which would decrease the number of services. Further, requiring that 

there be a face-to-face evaluation of the beneficiary helps ensure appropriate orders are based on 

the individual’s medical condition, which increases the quality of care that the beneficiary 

receives. It is difficult to measure how much waste, fraud, and abuse will be prevented as a 

result of this final rule with comment period since it is impossible to determine what would have 

happened in the absence of the final rule with comment period. This provision is expected to 

improve physician’s documentation of DME, and therefore, will help reduce improper payments 

and move the agency towards its strategic goal to reduce the Medicare fee-for-service error rate 

for DME items, which has a higher error rate than other Medicare services. Fraud is an 

improper payment, but not all improper payments are fraud. 

Therefore, creating a measure of how much this final rule with comment period would 

save in terms of a reduction in waste, fraud and abuse is not possible. With that stated, in 2009 

Medicare paid $1.7 billion for DME items covered by this proposed rule, and we estimated that 
1292 

$1.9 billion would be paid for covered items in 2012, and $9.9 billion over 5 years. Preventing 

waste, fraud and abuse by changing behavior that results in just a small percentage reduction in 

inappropriate or unnecessary ordering of DME services will generate Medicare savings. This is 

an area where savings can be found through increased oversight We believe that the cost of the 

visits will be offset by the savings produced by this provision. 

We project Medicare savings from reduced DME services; these savings partially offset 

the costs of additional physician office visits and documentation payments described earlier in 

the impact analysis. The year-to-year Medicare savings from reduced DME services is as 

follows: 

TABLE 141: Year-to-Year Medicare Savings from Reduced DME Services in millions 

 2013 2014 2015 2016 2017 

DME 

savings -$5 -$20 -$20 -$20 -$20 

Based on an analysis of 2007 DME claims, approximately 1 percent of total DME 

spending was for those beneficiaries who had little contact with their physician during the year. 

The gross savings to Medicare has been reduced from the estimated savings in the proposed rule 

due to the change in timeframe from 90 days to 6 months. We believe that some beneficiaries 

who would not order a DME service because they did not have face-to-face visit within 90 days 

prior to the written order, would likely have a face-to-face visit within the 6-month timeframe. 

For this subset of spending we assumed that there would be a 20 percent reduction in spending 

due to the face-to- face requirement. We found similar reductions in DME expenditures among 

managed care enrollees compared to fee-for service (FFS) beneficiaries in the Medical 

Expenditure Panel Survey. This assumption is fairly speculative but we think it is modest 

compared to the estimates of improper payments across Medicare services including DME. The 
1293 

savings would occur because some beneficiaries would not choose to go to the physician to 

authorize the DME item, some physicians would not order the items that would otherwise have 

been provided in the absence of the regulation, and some suppliers would not be able to achieve 

a payment that might have occurred through an unnecessary sale or outright fraud. 

The overall net impact to Medicare of the DME face-to-face encounter policy is $5 

million in the first year and $30 million over the first 5 years. 

This regulation produced an extra benefit that is difficult to quantify, but is an extremely 

positive one in terms of greater practitioner involvement. By increasing practitioner interactions 

with beneficiaries before ordering DME, beneficiaries would receive more appropriate DME and 

benefit from higher quality care. Beneficiaries would also benefit from reduced out-of-pocket 

costs by not having to pay for unnecessary DME. This accomplished the objective of achieving 

greater practitioner accountability noted in the provisions of and the amendments made by 

section 6407 and other sections of the Affordable Care Act. 

Alternatives Considered

In this final rule with comment period, we considered a variety of options and sought 

comments on these options in other sections of this final rule with comment period. We 

expected public comment on how to limit the burden associated with the supplier being notified 

that a face-to-face encounter has occurred. We proposed several options for the physician 

documentation of a face-to-face encounter furnished by that physician. We believe just 

submitting the medical record for the applicable date of service would create the least cost while 

still producing the desired benefits. We had also proposed different options for how the 

physician must document the face-to-face encounter if performed by a NP, PA, or CNS. In this 

final rule with comment period we establish that physicians must document a face-to-face 
1294 

encounter furnished by a PA, NP or CNS by signing or cosigning the pertinent portion of the 

medical record thereby documenting that the beneficiary was evaluated or treated for a condition 

relevant to an item of DME on that date of service. 

Finally, there are other possible periods of time that could be set as the window within 

which face-to-face encounters must occur. We believe the 6 month timeframe for the face-toface to occur helps to best limit burden. 

4. Non-Random Prepayment Review 

We estimated no significant budgetary impact. We believe that the overall costs for most 

providers and suppliers would remain the same unless they are subject to non-random 

prepayment complex medical review for an extended period of time. 

5. Ambulance Coverage-Physician Certification Statement 

 We estimated no significant budgetary impact. 

6. Physician Compare Website 

Section IV.N.2. of this final rule with comment period addresses the background of the 

Physician Compare website. As described in section IV.N.2. of this final rule with comment 

period, we are developing aspects of the Physician Compare website using a phased approach. In 

the first phase, which was completed in 2011, we posted the names of those eligible 

professionals who satisfactorily participated in the 2009 Physician Quality Reporting System. 

The second phase of the plan, which was completed in 2012, included posting the names of 

eligible professionals who were successful electronic prescribers under the 2009 eRx Incentive 

Program, as well as eligible professionals (EPs) who participated in the EHR Incentive Program. 

The next phase of the plan included posting of performance information with respect to the 2012 

Physician Quality Reporting System GPRO measures which is targeted to be completed in 2013. 
1295 

We are finalizing proposals to include performance information for the 2013 Physician 

Quality Reporting System GPRO web interface measures data, and targeted posting this data in 

2014, in addition to 2013 patient experience data for group practices participating in the 2013 

Physician Quality Reporting System GPRO. As reporting of physician performance rates and 

patient experience data on the Physician Compare website would be performed directly by us 

using the data that we collect under the 2012 Physician Quality Reporting System GPRO and 

other data collection methods, we did not anticipate any notable impact on eligible professionals 

with respect to the posting of information on the Physician Compare website. 

 We invited but received no public comment on the Regulatory Impact Analysis related to 

Physician Compare and are therefore finalizing this analysis. 

7. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting 

System 

According to the 2010 Reporting Experience Report, a total of $391,635,495 in Physician 

Quality Reporting System (PQRS) incentives was paid by CMS for the 2010 program year, 

which encompassed 168,843 individual eligible professionals. In 2010, eligible professionals 

earned a 2.0 percent incentive (that is, a bonus payment equal to 2.0 percent of the total allowed 

part B charges for covered professional services under the PFS furnished by the eligible 

professional during the reporting period) for satisfactory reporting under the PQRS. For 2013 

and 2014, eligible professionals can earn a 0.5 percent incentive for satisfactory reporting, a 

reduction of 1.5 percent from 2010. Therefore, based on 2010, which is the latest year in which 

PQRS has full participation data, we would expect that approximately $97 million 

(approximately 1⁄4 of $391,635,495) in incentive payments would be distributed to eligible 

professionals who satisfactorily report. However, we expect that due to the implementation of 
1296 

payment adjustments beginning in 2015, participation in the PQRS would rise incrementally to 

approximately 300,000 eligible professionals and 400,000 eligible professionals in 2013 and 

2014, respectively. 

 The average incentive distributed to each eligible professional in 2010 was $2,157. 

Taking into account the 1.5 percent incentive reduction from 2.0 percent in 2010 to 0.5 percent 

in 2013 and 2014, we estimated that the average amount per eligible professional earning an 

incentive in 2013 and 2014 would be $539. Therefore, we estimate that the PQRS would 

distribute approximately $162 million ($539 x 300,000 eligible professionals) and $216 million 

($539 x 400,000 eligible professionals) in incentive payments in 2013 and 2014, respectively. 

We believe these incentive payments will help offset the cost to eligible professionals for 

participating in the PQRS for the applicable year. Please note that, beginning 2015, incentive 

payments for satisfactory reporting in the PQRS will cease and payment adjustments for not 

satisfactorily reporting will commence. 

 We note that the total burden associated with participating in the PQRS is the time and 

effort associated with indicating intent to participate in the PQRS, if applicable, and submitting 

PQRS quality measures data. When establishing these burden estimates, we assumed the 

following: 

• The requirements for reporting for the PQRS 2013 and 2014 incentives and payment 

adjustments for 2015 and beyond would be established as proposed in this 2013 Medicare 

PFS final rule with comment period. 

• For an eligible professional or group practice using the claims, registry, or EHR-based 

reporting mechanisms, we assume that the eligible professional or group practice would 

report on 3 measures. 
1297 

• With respect to labor costs, we believe that a billing clerk will handle the administrative 

duties associated with participating, while a computer analyst will handle duties related to 

reporting PQRS quality measures. According to the Bureau of Labor Statistics, the mean 

hourly wage for a billing clerk is approximately $16/hour whereas the mean hourly wage 

for a computer analyst is approximately $40/hour. 

 For an eligible professional who wished to participate in the PQRS as an individual, the 

eligible professional need not indicate his/her intent to participate, if using the traditional 

reporting mechanisms. The eligible professional may simply begin reporting quality measures 

data. Therefore, these burden estimates for individual eligible professionals participating in the 

PQRS are based on the traditional reporting mechanism the individual eligible professional 

chooses. However, we believe a new eligible professional or group practice would spend 5 

hours—which includes 2 hours to review the PQRS measures list, review the various reporting 

options, and select a reporting option and measures on which to report and 3 hours to review the 

measure specifications and develop a mechanism for incorporating reporting of the selected 

measures into their office work flows. Therefore, we believe that the initial administrative costs 

associated with participating in the PQRS would be approximately $80 ($16/hour x 5 hours). 

Traditional Claims-based Reporting Mechanism. With respect to an eligible 

professional who participates in the PQRS via claims, the eligible professional 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 PQRS collects QDCs as 

additional (optional) line items on the existing HIPAA transaction 837-P and/or CMS Form 1500 

(OCN: 0938-0999). Based on our experience with Physician Voluntary Reporting Program 

(PVRP), we continued to estimate that the time needed to perform all the steps necessary to 
1298 

report each measure via claims would range from 0.25 minutes to 12 minutes, depending on the 

complexity of the measure. Therefore, the time spent reporting 3 measures would range from 

0.75 minutes to 36 minutes. Using an average labor cost of $40/hour, we estimated that time 

cost of reporting for an eligible professional via claims would range from $0.50 (0.75 minutes x 

$40/hour) to $24.00 (36 minutes x $40/hour) per reported case. With respect to how many cases 

an eligible professional would report when using the claims-based reporting mechanism, we 

established that an eligible professional would need to report on 50 percent of the eligible 

professional’s applicable cases. The actual number of cases on which an eligible professional 

would report would vary depending on the number of the eligible professional’s applicable cases. 

However, in prior years, when the reporting threshold was 80 percent, we found that the median 

number of reporting cases for each measure was 9. Since we reduced the reporting threshold to 

50 percent, we estimated that the average number of reporting cases for each measure would be 

reduced to 6. Based on these estimates, we estimated that the total cost of reporting for an 

eligible professional choosing the claims-based reporting mechanism would range from 

($0.50/per reported case x 6 reported cases) $3.00 to ($24.00/reported case x 6 reported cases) 

$144. 

Administrative Claims-based Reporting Mechanism. We note that, for the 2015 

PQRS payment adjustments, we are finalizing an administrative claims reporting option for 

eligible professionals and group practices. The burden associated with reporting using the 

administrative claims reporting option is the time and effort associated with using this option. 

To submit quality measures data for PQRS using the administrative claims reporting option, an 

eligible professional or group practice would need to (1) register as an administrative claims 

reporter for the applicable payment adjustment and (2) report quality measures data. With 
1299 

respect to registration, we believe it would take approximately 2 hours to register for and to 

participate in PQRS as an administrative claims reporter. Therefore, we estimated that the cost 

of undergoing the GPRO selection process would be ($16/hour x 2 hours) $32. With respect to 

reporting, we noted that any burden associated with reporting would be negligible, as an eligible 

professional or group practice would not be required to attach reporting G-codes on the claims 

they submitted. Rather, CMS would bear the burden with respect to calculating the measure 

rates for claims. We noted that there would be no additional burden on the eligible professional 

or group practice to submit these claims, as the eligible professional or group practice would 

have already submitted these claims for reimbursement purposes. 

Registry-based and EHR-based Reporting Mechanisms. With respect to an eligible 

professional or group practice who participates in the PQRS via a qualified registry, direct EHR 

product, or EHR data submission vendor product, we believe there would be little to no burden 

associated for an eligible professional to report PQRS quality measures data to CMS, because the 

selected reporting mechanism submits the quality measures data for the eligible professional. 

While we note that there may be start-up costs associated with purchasing a qualified registry, 

direct EHR product, or EHR data submission vendor, we believe that an eligible professional or 

group practice would not purchase a qualified registry, direct EHR product, or EHR data 

submission vendor product solely for the purpose of reporting PQRS quality measures. 

Therefore, we did not include the cost of purchasing a qualified registry, direct EHR, or EHR 

data submission vendor product in our burden estimates. 

The Group Practice Reporting Option. Unlike eligible professionals who choose to 

report individually, we noted that eligible professionals choosing to participate as part of a group 

practice under the GPRO must indicate their intent to participate in the PQRS as a group 
1300 

practice. The total burden for group practices who submitted PQRS quality measures data via 

the proposed GPRO web-interface would be the time and effort associated with submitting this 

data. To submit quality measures data for the PQRS, a group practice would need to (1) be 

selected to participate in the PQRS GPRO and (2) report quality measures data. With respect to 

the administrative duties for being selected to participate in the PQRS as a group practice, we 

believe it would take approximately 6 hours – including 2 hours to decide whether to participate 

in the PQRS GPRO as a group practice, 2 hours to self-nominate, and 2 hours to undergo the 

vetting process with CMS officials – for a group practice to be selected to participate in the 

PQRS GPRO for the applicable year. Therefore, we estimated that the cost of undergoing the 

GPRO selection process would be ($16/hour x 6 hours) $96. With respect to reporting, the total 

reporting burden was the time and effort associated with the group practice submitting the 

quality measures data (that is, completed the data collection interface). Based on burden 

estimates for the PGP demonstration, which uses the same data submission methods, we 

estimated the burden associated with a group practice completing the data collection interface 

would be approximately 79 hours. Therefore, we estimated that the report cost for a group 

practice to submit PQRS quality measures data for the final reporting options in an applicable 

year would be ($40/hour x 79 hours) $3,160. 

Maintenance of Certification Program Incentive. Eligible professionals who wish to 

quality for an additional 0.5 percent Maintenance of Certification Program incentive must “more 

frequently” than is required to qualify for or maintain board certification status participate in a 

qualified Maintenance of Certification Program for 2013 and/or 2014 and successfully complete 

a qualified Maintenance of Certification Program practice assessment for the applicable year. 

Although we understand that there is a cost associated with participating in a Maintenance of 
1301 

Certification Board, we believe that most of the eligible professionals attempting to earn this 

additional incentive would already be enrolled in a Maintenance of Certification Board for 

reasons other than earning the additional Maintenance of Certification Program incentive. 

Therefore, the burden to earn this additional incentive would depend on what a certification 

board establishes as “more frequently” and the time needed to complete the practice assessment 

component. We expect that the amount of time needed to complete a qualified Maintenance of 

Certification Program practice assessment would be spread out over time since a quality 

improvement component is often required. With respect to the practice assessment component, 

according to an informal poll conducted by ABMS in 2012, the time an individual spent to 

complete the practice assessment component of the Maintenance of Certification ranged from 8-

12 hours. 

Registry and EHR Vendors. Aside from the burden of eligible professionals and group 

practices participating in the PQRS, we believe that registry, direct EHR, and EHR data 

submission vendor products incur costs associated with participating in the PQRS. 

Registry Vendors. With respect to qualified registries, the total burden for qualified 

registries who submit PQRS quality measures data would be the time and effort associated with 

submitting this data. To submit quality measures data for the program years we are finalizing for 

PQRS, a registry would need to (1) become qualified for the applicable year and (2) report 

quality measures data on behalf of its eligible professionals. With respect to administrative 

duties related to the qualification process, we estimated that it will take a total of 10 hours – 

including 1 hour to complete the self-nomination statement, 2 hours to interview with CMS, 2 

hours to calculate numerators, denominators, and measure results for each measure the registry 

wishes to report using a CMS-provided measure flow, and 5 hours to complete an XML 
1302 

submission – to become qualified to report PQRS quality measures data. Therefore, we 

estimated that it would cost a registry approximately ($16.00/hour x 10 hours) $160 to become 

qualified to submit PQRS quality measures data on behalf of its eligible professionals. 

With respect to the reporting of quality measures data, we believe the burden associated 

with reporting was the time and effort associated with the registry calculating quality measures 

results from the data submitted to the registry by its eligible professionals, submitting numerator 

and denominator data on quality measures, and calculating these measure results. We believe, 

however, that registries already perform these functions for its eligible professionals irrespective 

of participating in the PQRS. Therefore, we believe there would be little to no additional burden 

associated with reporting PQRS quality measures data. Whether there is any additional reporting 

burden will vary with each registry, depending on the registry’s level of savvy with submitting 

quality measures data for the PQRS. 

EHR Vendors. With respect to EHR products, the total burden for direct EHR products 

and EHR data submission vendors who submit PQRS quality measures data would be the time 

and effort associated with submitting this data. To submit quality measures data for the proposed 

program years under the PQRS, a direct EHR product or EHR data submission vendor would 

need to report quality measures data on behalf of its eligible professionals. Please note that we 

are not continuing to require direct EHR products and EHR data submission vendors to become 

qualified to submit PQRS quality measures data. With respect to reporting quality measures 

data, we believe the burden associated with the EHR vendor programming its EHR product(s) to 

extract the clinical data that the eligible professional must submit to CMS would depend on the 

vendor’s familiarity with the PQRS and the vendor’s system and programming capabilities. We 

believe it would take a vendor approximately 40 hours (for experienced vendors) to 200 hours 
1303 

(for first-time vendor participants) to submit PQRS quality measures data. Therefore, we 

estimated that it would cost an EHR vendor ($40/hour x 40 hours) $1,600 to $8,000 to submit 

PQRS quality measures data for its eligible professionals. 

TABLE 142: ESTIMATED COSTS FOR REPORTING PHYSICIAN QUALITY 

REPORTING SYSTEM QUALITY MEASURES DATA FOR ELIGIBLE 

PROFESSIONALS 

 Estimated 

Hours 

Estimated 

Cases 

Number of 

Measures 

Hourly 

Rate 

Total 

Cost 

Individual Eligible Professional 

(EP): Preparation 

5.0 1 N/A $16 $80 

Individual EP: Claims 0.2 6 3 $40 $144 

Individual EP: Administrative 

Claims 

2 1 N/A $16 $32 

Individual EP: Registry N/A 1 N/A N/A Minimal

Individual EP: EHR N/A 1 N/A N/A Minimal

Group Practice: Self-Nomination 6.0 1 N/A $16 $96 

Group Practice: Reporting 79 1 N/A $40 $3,160 

TABLE 143: Estimated Costs to Vendors to Participate in the Physician Quality Reporting 

System 

 Estimated Hours Hourly Rate Total Cost 

Registry: Self-Nomination 10 $40 $400 

EHR: Programming 40-200 $40 $1,600 - $1,800 

 We invited but received no public comment on the Regulatory Impact Analysis related to 

PQRS and are therefore finalizing this analysis. 

8. Electronic Prescribing (eRx) Incentive Program 

 Please note that the requirements for becoming a successful electronic prescriber for the 

2013 incentive and 2014 payment adjustment were established in the CY 2012 MPFS final rule 

with comment period. The final provisions contained in this CY 2013 MPFS final rule with 

comment period would make additional changes to the requirements for the 2013 incentive and 

2014 payment adjustment for group practices. Specifically, CMS is finalizing a new criterion for 
1304 

being a successful electronic prescriber for the 2013 incentive and 2014 payment adjustments for 

group practices of 2-24 eligible professionals given that CMS is modifying the definition of 

group practice. However, we note that any additional impact as a result of this additional 

requirement would be minimal, as it is our understanding the eligible professionals who would 

use this new reporting option are already participating in the eRx Incentive Program as 

individual eligible professionals. 

 For the reasons stated, the final changes would have no additional impact other than the 

impact of the 2013 and 2014 payment adjustments described in the CY 2012 MPFS final rule 

with comment period. We invited but received no public comment on the Regulatory Impact 

Analysis related to the eRx Incentive Program and are therefore finalizing this analysis. 

9. Medicare Shared Savings Program 

 Please note that the requirements for participating in the Medicare Shared Saving 

Program and the impacts of these requirements were established in the final rule for the 

Medicare Shared Savings Program that appeared in the Federal Register on November 2, 2011 

(76 FR 67962). The requirements for the Medicare Shared Savings Program set forth in the CY 

2013 MPFS final rule with comment period imposed requirements that eligible professionals in 

group practices within accountable care organizations would need to satisfy for purposes of the 

PQRS payment adjustment under the Medicare Shared Savings Program as the proposals related 

to the ACOs for the PQRS payment adjustment mirror the requirements that were established for 

earning the PQRS incentives. 

 We invited but received no public comment on the Regulatory Impact Analysis related to 

the Medicare Shared Savings Program and are therefore finalizing this analysis. 

10. Medicare EHR Incentive Program 
1305 

 Please note that the requirements for reporting clinical quality measures (CQMs) to 

achieve meaningful use under the EHR Incentive Program were established in a standalone final 

rule published on July 28, 2010 (75 FR 44544) and September 4, 2012 (77 FR 53968). The 

requirements contained in this CY 2013 MPFS final rule with comment period merely propose 

methods to report CQMs for purposes of achieving meaningful use under the EHR Incentive 

Program. Therefore, the impacts of the extension of the use of attestation and the PQRSMedicare EHR Incentive Pilot to report CQMs were absorbed in the impacts discussion 

published in the EHR Incentive Program final rules published on July 28, 2010 and September 4, 

2012. 

 We invited but received no public comment on the Regulatory Impact Analysis related to 

The Medicare EHR Incentive Program and are therefore finalizing this analysis. 

11. Chiropractic Services Demonstration 

As discussed in section III of this final rule with comment period, we continue the 

recoupment of the $50 million in expenditures from this demonstration in order to satisfy the BN 

requirement in section 651(f)(1)(B) of the MMA. We initiated this recoupment in CY 2010 and 

this will be the fourth 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 CY s 2010 through 2014. To implement this required BN adjustment, we are 

recouping $10 million in CY 2013 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. 

12. Physician Value-Based Payment Modifier and the Physician Feedback Reporting Program 

The Physician Value-Based Payment Modifier and the Physician Feedback Program final 
1306 

policies discussed in section IV.I. of this final rule with comment period would not impact 

CY 2013 physician payments under the PFS. However, we expect that our proposals to use the 

PQRS quality measures in the Physician Feedback reports and in the value-based payment 

modifier to be implemented in CY 2015 may result in increased participation in the PQRS in 

CY 2013. We anticipate that as we approach implementation of the value-based payment 

modifier, physicians would increasingly participate in the PQRS to determine and understand 

how the value-based payment modifier could affect their payments. 

13. Medicare Coverage of Hepatitis B Vaccine: Modification of high risk groups eligible for 

Medicare Part B coverage of Hepatitis B vaccine. 

As discussed in section III of this final rule with comment period, section 1861(s)(10)(B) 

of the Act authorizes Medicare coverage of hepatitis B vaccine and its administration if furnished 

to an individual who is at high or intermediate risk of contracting hepatitis B, as determined by 

the Secretary under regulations. Our current regulations are established at 42 CFR §410.63. We 

proposed to modify §410.63(a)(1) by adding persons diagnosed with diabetes mellitus to the high 

risk group. While it is estimated that approximately 23 percent of non-institutionalized Medicare 

beneficiaries are diagnosed with diabetes mellitus, it is unclear how many of these beneficiaries 

would obtain these services. Therefore, the estimated impact of adding persons diagnosed with 

diabetes mellitus to the high risk group eligible for coverage of hepatitis B vaccine and its 

administration is unknown for CY 2013. 

14. Existing Standards for E-prescribing under Medicare Part D and Identification and Lifting 

the LTC Exemption 

The e-prescribing standard updates that are adopted in this final rule with comment 

period impose no new requirements as the burden of using the updated standards is anticipated to 
1307 

be the same as using the old standards. We believe that prescribers and dispensers that are now 

e-prescribing largely invested in the hardware, software, and connectivity necessary to eprescribe. We do not anticipate that the retirement of NCPDP SCRIPT 8.1 in favor of NCPDP 

SCRIPT 10.6 will result in significant costs. Nor do we believe that the eventual retirement of 

the NCPDP Formulary and Benefit 1.0 and the adoption of the updates for NCPDP Formulary 

and Benefits 3.0 as the official Part D standard will result in significant costs. 

The removal of the LTC exception to the NCPDP SCRIPT standard would impose a 

small burden on the LTC industry. LTC entities who use and developed proprietary solutions 

may need to invest in software programming updates if they had not already incorporated the 

Part D e-prescribing standards in their solutions. It is reasonable to assume that a small number 

of proprietary solutions would have to be modified to enable adherence to the adopted eprescribing standards. Other costs may be incurred through staff training on the use of the eprescribing standards and the use of any e-prescribing solution adopted by a LTC facility. 

Additional training cost may involve prescribers and dispensers learning the new workflows that 

an electronic prescription may or may not require. 

I. Alternatives Considered

 This final rule with comment period contains a range of policies, including some 

provisions related to specific statutory provisions. The preceding preamble provided 

descriptions of the statutory provisions that are addressed, identified those policies when 

discretion has been exercised, presented rationale for our final policies and, where relevant, 

alternatives that were considered. 

J. Impact on Beneficiaries 

There are a number of changes in this final rule with comment period that would have an 
1308 

effect on beneficiaries. In general, we believe that many of the changes adopted in this final rule 

with comment period, including the refinements of the PQRS with its focus on measuring, 

submitting, and analyzing quality data; establishing the value-based payment modifier to adjust 

physician payment beginning in CY 2015; creating a separate payment for post-discharge 

transitional care management services in the 30 days after a beneficiary has been discharged 

from an inpatient hospital admission, from outpatient observation services and partial 

hospitalization program, from a SNF, or from a CMHC; improved accuracy in payment through 

revisions to the inputs used to calculate payments under the PFS for certain radiation therapy 

services; capital interest rate assumptions; multiple procedure payment reduction for 

ophthalmology and cardiovascular diagnostic tests; revised values for many services identified 

through the misvalued codes initiative, and revisions to payment for Part B drugs would have a 

positive impact and improve the quality and value of care furnished to Medicare beneficiaries. 

 Most of the aforementioned policy changes could result in a change in beneficiary 

liability as it relates to coinsurance (which is 20 percent of the fee schedule amount if applicable 

for the particular provision after the beneficiary has met the deductible). To illustrate this point, 

as shown in Table 136, the CY 2012 national payment amount in the nonfacility setting for CPT 

code 99203 (Office/outpatient visit, new) is $105.18 which means that in CY 2012 a beneficiary 

would be responsible for 20 percent of this amount, or $21.04. Based on this final rule with 

comment period, using the current (CY 2012) CF of 34.0376, the CY 2013 national payment 

amount in the nonfacility setting for CPT code 99203, as shown in Table 136, is $107.80, which 

means that, in CY 2013, the proposed beneficiary coinsurance for this service would be $21.56. 

Payment amounts and associated coinsurance would be lower using the current law CY 2013 CF 

with the negative SGR adjustment. 
1309 

 The transitional care management policy would also have an impact on beneficiary 

coinsurance for those beneficiaries who have a hospital visit in CY 2013 and require moderate to 

high complexity decision-making by their community physician in the 30 days post discharge. 

Prior to the new TCM policy discussed in section III.H. of this final rule with comment period 

such a recently discharged beneficiary may have had an established patient follow-up visit with 

their community physician. The CY 2013 national payment amount in the nonfacility setting for 

CPT code 99215 (Office/outpatient visit, established), the highest level of an established patient 

office visit, is $142.96, which means that a beneficiary would be responsible for 20 percent of 

this amount, or $28.59. Under the new transitional care management policy, if a beneficiary 

received the highest level transitional care management visit, 99496, which has a national 

payment amount of $231.11, the beneficiary would be responsible for 20 percent of this amount, 

or $46.22 

K. Accounting Statement

As required by OMB Circular A-4 (available at 

http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Tables 144 and 145 (Accounting 

Statement), we have prepared an accounting statement showing the estimated expenditures 

associated with this final rule with comment period. This estimate includes the estimated 

FY 2012 cash benefit impact associated with certain Affordable Care Act and MCTRJCA 

provisions, and the CY 2013 incurred benefit impact associated with the estimated CY 2013 PFS 

conversion factor update based on the Mid-Session Review of the FY 2013 President's Budget 

baseline. 
1310 

TABLE 144: Accounting Statement: Classification of Estimated Expenditures 

CATEGORY TRANSFERS 

CY 2013 Annualized Monetized Transfers Estimated decrease in expenditures of $24.8 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. 

CY 2013 Annualized Monetized Transfers Estimated increase in payment of 162 millions 

From Whom To Whom? Federal Government to eligible professionals 

participated in (Physician Quality Reporting System 

(PQRS) 

TABLE 145: Accounting Statement: 

Classification of Estimated Costs, Transfer, and Savings in CY 2013($ In Millions) 

CATEGORY BENEFIT 

Qualitative (unquantified) benefits of fraud, 

waste, and abuse prevented, and of improved 

quality of services to patients improved 

quality of services to patients

No precise estimate available

CATEGORY COST 

Costs associated with DME face-to-face 

encounters and written orders prior to delivery 

$30.6 million*

Qualitative costs of reporting PQRS quality 

measures data for eligible professionals and 

for vendors to participate in the PQRS

No precise estimate available 

* It includes the monetized costs of beneficiary travel time ($9.4 million), out of pocket expenses ($5 

million), private sector paperwork costs ($11.2 million), and the increased Medicare payment to the 

providers associated with the additional visits and G code billings ($5 million).

L. Conclusion 

The analysis in the previous sections, together with the remainder of this preamble, 

provides an initial “Regulatory Flexibility Analysis.” 

 In accordance with the provisions of Executive Order 12866, this regulation was 

reviewed by the Office of Management and Budget. 
1311 

 

List of Subjects 

42 CFR Part 410 

Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, Reporting 

and recordkeeping requirements, Rural areas, X-rays. 

42 CFR Part 414 

Administrative practice and procedure, Health facilities, Health professions, Kidney 

diseases, Medicare, Reporting and recordkeeping requirements. 

42 CFR Part 415 

Health facilities, Health professions, Medicare, Reporting and recordkeeping 

requirements. 

42 CFR Part 421

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 

42 CFR Part 423

Administrative practice and procedure, Emergency medical services, Health facilities, 

Health maintenance organizations (HMO). Health professionals, Incorporation by reference, 

Medicare, Penalties, Privacy, Reporting and recordkeeping requirements. 

42 CFR Part 425

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 

42 CFR Part 486 

Grant programs-health, Health facilities, Medicare, Reporting and recordkeeping 

requirements, X-rays. 
1312 

 

42 CFR Part 495

Administrative practice and procedure, Electronic health records, Health facilities, Health 

professions, Health maintenance organizations (HMO), Medicaid, Medicare, Penalties, Privacy, 

Reporting and recordkeeping requirements. 
1313 

 

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services 

amend 42 CFR chapters IV as set forth below: 

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS 

1. The authority citation for part 410 continues to read as follows: 

Authority: Secs. 1102, 1834, 1871, 1881, and 1893 of the Social Security Act (42 U.S.C. 1302. 

1395m, 1395hh, and 1395ddd. 

2. Section 410.26 is amended by adding new paragraph (b)(8) to read as follows: 

§410.26 Services and supplies incident to a physician's professional services: Conditions. 

* * * * * 

(b) * * * 

(8) Claims for drugs payable administered by a physician as defined in section 1861(r) of 

the Social Security Act to refill an implanted item of DME may only be paid under Part B to the 

physician as a drug incident to a physician’s service under section 1861(s)(2)(A). These drugs 

are not payable to a pharmacy/supplier as DME under section 1861(s)(6) of the Act. 

* * * * * 

3. Section 410.32 is amended by-- 

A. Revising paragraphs (b)(2)(iii) introductory text, (d)(2)(i), and (e). 

B. Redesignating paragraphs (c)(2) and (c)(3) as paragraphs (c)(3) and (c)(4), 

respectively. 

C. Adding new paragraph (c)(2) 

The revisions and addition read as follows: 

§ 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: 

Conditions. 
1314 

 

* * * * * 

(b) * * * 

(2) * * * 

(iii) Diagnostic psychological and neuropsychological testing services when— 

* * * * * 

(c) * * * 

(2) These services are ordered by a physician as provided in paragraph (a) or by a 

nonphysician practitioner as provided in paragraph (a)(2) of this section. 

* * * * * 

(d) * * * 

(2) * * * 

(i) Ordering the service. The physician or (qualified nonphysican practitioner, as defined 

in paragraph (a)(2) of this section), who orders the service must maintain documentation of 

medical necessity in the beneficiary's medical record. 

* * * * * 

(e) Diagnostic laboratory tests furnished in hospitals and CAHs. The provisions of 

paragraphs (a) and (d)(2) through (d)(4) of this section, inclusive, of this section apply to all 

diagnostic laboratory test furnished by hospitals and CAHs to outpatients. 

§410.37 [Amended.] 

4. Amend §410.37 by-- 

A. Amending paragraph (a)(1)(iii) by removing the phrase “In the case of an individual 

at high risk for colorectal cancer,” and by removing “screening” and adding “Screening” in its 

place. 
1315 

 

B. Removing paragraph (g)(1). 

C. Redesignating paragraphs (g)(2) through (g)(4) as paragraph (g)(1) through (g)(3), 

respectively. 

D. In newly redesignated paragraph (g)(1), removing the reference “(g)(4)” and adding 

in its place the reference “(g)(3)”. 

5. Section 410.38 is amended by revising paragraph (g) to read as follows:

§410.38 Durable medical equipment: Scope and conditions. 

 * * * * * 

(g)(1) Items requiring a written order. As a condition of payment, Specified Covered 

Items (as described in paragraph (g)(2) of this section) require a written order that meets the 

requirements in paragraphs (g)(3) and (4) of this section before delivery of the item. 

(2) Specified covered items. (i) Specified Covered Items are items of durable medical 

equipment that CMS has specified in accordance with section 1834(a)(11)(B)(i) of the Act. A 

list of these items is updated annually in the Federal Register. 

(ii) The list of Specified Covered Items includes the following: 

 (A) Any item described by a Healthcare Common Procedure Coding System (HCPCS)

code for the following types of durable medical equipment: 

(1) Transcutaneous electrical nerve stimulation (TENS) unit. 

(2) Rollabout chair. 

(3) Oxygen and respiratory equipment. 

(4) Hospital beds and accessories. 

(5) Traction-cervical. 

(B) Any item of durable medical equipment that appears on the Durable Medical 
1316 

 

Equipment, Prosthetics, Orthotics, and Supplies Fee Schedule with a price ceiling at or greater 

than $1,000. 

(C) Any other item of durable medical equipment that CMS adds to the list of Specified 

Covered Items through the notice and comment rulemaking process in order to reduce the risk of 

fraud, waste, and abuse. 

(iii) The list of specific covered items excludes the following: 

(A) Any item that is no longer covered by Medicare. 

(B) Any HCPCS code that is discontinued. 

(3) Face-to-face encounter requirements. (i) For orders issued in accordance with 

paragraphs (g)(1) and (2) of this section, as a condition of payment for the Specified Covered 

Item, all of the following must occur: 

(A) The physician must document and communicate to the DME supplier that the 

physician or a physician assistant, a nurse practitioner, or a clinical nurse specialist has had a 

face-to-face encounter with the beneficiary on the date of the written order up to 6 months before 

the date of the written order. 

(B) During the face-to-face encounter the physician, a physician assistant, a nurse 

practitioner, or a clinical nurse specialist must conduct a needs assessment, evaluate, and/ or treat 

the beneficiary for the medical condition that supports the need for each covered item of DME 

ordered. 

(C) The face-to-face encounter must be documented in the pertinent portion of the 

medical record (for example, history, physical examination, diagnostic tests, summary of 

findings, diagnoses, treatment plans or other information as it may be appropriate). Physician 

must sign or cosign the pertinent portion of the medical record indicating the occurrence of a 
1317 

 

face-to-face encounter for the beneficiary for the date of the face-to-face encounter when 

performed by a physician assistant, a nurse practitioner, or a clinical nurse specialist. For 

purposes of this paragraph (g), a face-to-face encounter does not include DME items and 

services furnished from an "incident to" service. 

(ii) For purposes of this paragraph (g), a face-to-face encounter may occur via telehealth 

in accordance with all of the following: 

(A) Section 1834(m) of the Act. 

(B)(1) Medicare telehealth regulations in §410.78 and §414.65 of this chapter; and 

(2) Subject to the list of payable Medicare telehealth services established by the 

applicable PFS. 

(4) Written order issuance requirements. Written orders issued in accordance with 

paragraphs (g)(1) and (2) of this section must include all of the following: 

(i) Beneficiary's name. 

(ii) Item of DME ordered. 

(iii) Signature of the prescribing practitioner. 

(iv) Prescribing practitioner NPI 

(v) The date of the order. 

(5) Supplier's order and documentation requirements. (i) A supplier must maintain the 

written order and the supporting documentation provided by the physician, physician assistant, 

nurse practitioner, or clinical nurse specialist and make them available to CMS upon request for 

7 years from the date of service consistent with §424.516(f) of this chapter. 

 (ii) Upon request by CMS or its agents, a supplier must submit additional documentation 

to CMS or its agents to support and substantiate that a face-to-face encounter has occurred. 
1318 

 

6. Section 410.40 is amended by-- 

A. In paragraph (c)(3)(ii), the word “fro” is revised to read “from.” 

B. Redesignating paragraph (d)(2) as (d)(2)(i). 

C. Adding paragraph (d)(2)(ii). 

The addition reads as follows: 

§410.40 Coverage of ambulance services. 

* * * * * 

(d) * * * 

(2) * * * 

(ii) In all cases, the provider or supplier must keep appropriate documentation on file and, 

upon request, present it to the contractor. The presence of the signed physician certification 

statement does not alone demonstrate that the ambulance transport was medically necessary. All 

other program criteria must be met in order for payment to be made. 

* * * * * 

 7. Section 410.59 is amended by adding paragraph (a)(4) to read as follows: 

§410.59 Outpatient occupational therapy services: Conditions. 

(a) * * * 

(4) Claims submitted for furnished services contain prescribed information on patient 

functional limitations. 

* * * * * 

 8. Section 410.60 is amended by adding paragraph (a)(4) to read as follows: 

§ 410.60 Outpatient physical therapy services: Conditions. 

(a) * * * 
1319 

 

(4) Claims submitted for furnished services contain prescribed information on patient 

functional limitations. 

* * * * * 

9. Section 410.61 is amended by revising paragraph (c) to read as follows: 

§410.61 Plan of treatment requirements for outpatient rehabilitation services. 

* * * * * 

(c) Content of the plan. The plan prescribes the type, amount, frequency, and duration of 

the physical therapy, occupational therapy, or speech-language pathology services to be 

furnished to the individual, and indicates the diagnosis and anticipated goals that are consistent 

with the patient function reporting on claims for services. 

* * * * * 

10. Section 410.62 is amended by adding paragraph (a)(4) to read as follows: 

§ 410.62 Outpatient speech-language-pathology services: Conditions and exclusions. 

(a) * * * 

(4) Claims submitted for furnished services contain prescribed information on patient 

functional limitations. 

* * * * * 

11. Section 410.63 is amended by-- 

A. Removing “and” from the end of paragraph (a)(1)(vi). 

B. Removing the period from the end of paragraph (a)(1)(vii) and adding “; and” in its 

place. 

C. Adding paragraph (a)(1)(viii). 

The addition reads as follows: 
1320 

 

§410.63 Hepatitis B vaccine and blood clotting factors: Conditions. 

* * * 

(a) * * * 

(1) * * * 

(viii) Persons diagnosed with diabetes mellitus. 

* * * * * 

12. Section 410.69 is amended in paragraph (b) by adding the definition of “Anesthesia 

and related care” in alphabetical order to read as follows: 

§410.69 Services of a certified registered nurse anesthetist or an anesthesiologist's assistant: 

Basic rule and definitions.

* * * * * 

(b) * * * 

Anesthesia and related care means those services that a certified registered nurse 

anesthetist is legally authorized to perform in the state in which the services are furnished. 

.* * * * * 

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 by the patient’s 

admitting physician or practitioner), 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 by the patient’s admitting physician or nonphysician 
1321 

 

practitioner), 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 services (except for one hour of “hands on” services to be furnished in 

the initial year training period to ensure effective injection training), individual and group health 

and behavior assessment and intervention services, smoking cessation services, alcohol and/or 

substance abuse and brief intervention services, screening and behavioral counseling 

interventions in primary care to reduce alcohol misuse, screening for depression in adults, 

screening for sexually transmitted infections (STIs) and high intensity behavioral counseling 

(HIBC) to prevent STIs, intensive behavioral therapy for cardiovascular disease, and behavioral 

counseling for obesity furnished by an interactive telecommunications system if the following 

conditions are met: 

* * * * * 

14. Section 410.105 is amended by-- 

A. Revising paragraph (c)(1)(ii). 

B. Adding new paragraph (d). 

The revision and addition read as follows: 

§410.105 Requirement for coverage of CORF services. 

* * * * * 

(c) * * * 

(1) * * * 
1322 

 

(ii) Prescribes the type, amount, frequency, and duration of the services to be furnished, 

and indicates the diagnosis and anticipated rehabilitation goals that are consistent with the patient 

function reporting on the claims for services. 

* * * * * 

(d) Claims submitted for physical therapy, occupational therapy or speech-languagepathology services, contain prescribed information on patient functional limitations. 

15. Section 410.160 is amended by revising paragraph (b)(8) to read as follows: 

§410.160 Part B annual deductible. 

* * * * * 

(b) * * * 

(8) Beginning January 1, 2011, a surgical service furnished in connection with, as a result 

of, and in the same clinical encounter as a planned colorectal cancer screening test. A surgical 

service furnished in connection with, as a result of, and in the same clinical encounter as a 

colorectal cancer screening test means—a surgical service furnished on the same date as a 

planned colorectal cancer screening test as described in §410.37. 

* * * * * 

PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES 

16. 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)). 

17. Section 414.65 is amended by revising paragraph (a)(1) to read as follows: 

§414.65 Payment for telehealth services. 

(a) * * * 
1323 

 

(1) The Medicare payment amount for office or other outpatient visits, subsequent 

hospital care services (with the limitation of one telehealth visit every 3 days by the patient’s 

admitting physician or practitioner), subsequent nursing facility care services (with the limitation 

of one telehealth visit every 30 days by the patient’s admitting physician or nonphysician 

practitioner), 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 services (except for one hour of “hands on” services to be furnished in 

the initial year training period to ensure effective injection training), individual and group health 

and behavior assessment and intervention, smoking cessation services, alcohol and/or substance 

abuse and brief intervention services, screening and behavioral counseling interventions in 

primary care to reduce alcohol misuse, screening for depression in adults, screening for sexually 

transmitted infections (STIs) and high intensity behavioral counseling (HIBC) to prevent STIs, 

intensive behavioral therapy for cardiovascular disease, and behavioral counseling for obesity 

furnished via an interactive telecommunications system is equal to the current fee schedule 

amount applicable for the service of the physician or practitioner. 

(i) Emergency department or initial inpatient telehealth consultations. The Medicare 

payment amount for emergency department or initial inpatient telehealth consultations furnished 

via an interactive telecommunications system is equal to the current fee schedule amount 

applicable to initial hospital care provided by a physician or practitioner. 
1324 

 

(ii) Follow-up inpatient telehealth consultations. The Medicare payment amount for 

follow-up inpatient telehealth consultations furnished via an interactive telecommunications 

system is equal to the current fee schedule amount applicable to subsequent hospital care 

provided by a physician or practitioner. 

* * * * * 

18. Section 414.90 is amended by-- 

A. In paragraph (b), revising the definitions “Group practice” and “Qualified registry.” 

B. In paragraph (b), removing the term “Qualified electronic health record product”. 

C. In paragraph (b), adding the definitions “Administrative claims,” “Direct electronic 

health record (EHR) product,” “Electronic health record (EHR) data submission vendor 

product,” and “Group practice reporting option (GPRO) web interface” in alphabetical order. 

D. Revising paragraphs (c) and (d). 

E. Redesignating paragraphs (e), (f), (g), (h), (i), and (j) as paragraphs (f), (g), (i), (j), (k), 

and (l), respectively. 

F. Adding new paragraphs (e) and (h). 

G. Revising newly designated paragraphs (f), (g), (i), and (j). 

The revisions and additions read as follows: 

§414.90 Physician Quality Reporting System. 

* * * * * 

(b) * * * 

Administrative claims means a reporting mechanism under which an eligible professional 

or group practice uses claims to report data on the proposed PQRS quality measures. Under this 

reporting mechanism, CMS analyzes claims data to determine which measures an eligible 
1325 

 

professional or group practice reports. 

Direct electronic health record (EHR) product means an electronic health record vendor's 

product and version that submits data on Physician Quality Reporting System measures directly 

to CMS. 

Electronic health record (EHR) data submission vendor product means an entity that 

receives and transmits data on Physician Quality Reporting System measures from an EHR 

product to CMS. 

* * * * * 

Group practice means a physician group practice that is defined by a TIN, with 2 or more 

individual eligible professionals (or, as identified by NPIs) that has reassigned their billing rights 

to the TIN. 

Group practice reporting option (GPRO) web interface means a web product developed 

by CMS that is used by group practices that are selected to participate in the group practice 

reporting option (GPRO) to submit data on Physician Quality Reporting System quality 

measures. 

* * * * * 

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 Physician Quality Reporting System 

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 Physician Quality 

Reporting System data (as specified by CMS) on behalf of an eligible professional to CMS. If 
1326 

 

CMS finds that a qualified registry submits grossly inaccurate data for reporting periods 

occurring in a particular year, CMS reserves the right to disqualify a registry for reporting 

periods occurring in the subsequent year. 

* * * * * 

(c) Incentive payments. For 2007 to 2014, with respect to covered professional services 

furnished during a reporting period by an eligible professional, an eligible professional (or in the 

case of a group practice under paragraph (i) of this section, a group practice) may receive an 

incentive if -- 

(1) There are any quality measures that have been established under the Physician 

Quality Reporting System that are applicable to any such services furnished by such professional 

(or in the case of a group practice under paragraph (i) of this section, such group practice) for 

such reporting period; and 

(2) If the eligible professional (or in the case of a group practice under paragraph (j) of 

this section, the group practice) satisfactorily submits (as determined under paragraph (g) of this 

section for the eligible professional and paragraph (i) of this section for the group practice) to the 

Secretary data on such quality measures in accordance with the Physician Quality Reporting 

System for such reporting period, in addition to the amount otherwise paid under section 1848 of 

the Act, there also must 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 (i) 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 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 (i) of this section, the group 
1327 

 

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 (i) of this section, by the 

group practice) during the reporting period. 

(3) The applicable quality percent is as follows: 

(i) For 2007 and 2008, 1.5 percent. 

(ii) For 2009 and 2010, 2.0 percent. 

(iii) For 2011, 1.0 percent. 

(iv) For 2012, 2013, and 2014, 0.5 percent. 

(4) For purposes of this paragraph (c) -- 

(i) The eligible professional's (or, in the case of a group practice under paragraph (i) 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; 

(ii) In the case of the 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 to a group practice under this paragraph must be in lieu of the 

payments that would otherwise be made under the Physician Quality Reporting System to 

eligible professionals in the group practice for meeting the criteria for satisfactory reporting for 

individual eligible professionals. For any program year in which the group practice (as identified 

by the TIN) is selected to participate in the Physician Quality Reporting System group practice 

reporting option, the eligible professional cannot individually qualify for a Physician Quality 
1328 

 

Reporting System incentive payment by meeting the requirements specified in paragraph (g) of 

this section. 

(iv) Incentive payments earned by the eligible professional (or in the case of a group 

practice under paragraph (i) of this section, by the group practice) for a particular program year 

will be paid as a single consolidated payment to the TIN holder of record. 

(d) Additional incentive payment. 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)(iii) and (iv) of this section, must be increased by 0.5 percentage 

points. 

(1) In order to qualify for the additional incentive payment described in paragraph (d) of 

this section, an eligible professional must meet all of the following requirements: 

(i) Satisfactorily submits data on quality measures for purposes of this section for the 

applicable incentive year. 

(ii) Have such data submitted on their behalf through a Maintenance of Certification 

program (as defined in paragraph (b) of this section) that meets: 

(A) The criteria for a registry (as specified by CMS); or 

(B) An alternative form and manner determined appropriate by the Secretary. 

(iii) The eligible professional, more frequently than is required to qualify for or maintain 

board certification status— 

(A) Participates in a maintenance of certification program (as defined in paragraph (b) of 

this section) for a year; and 

(B) Successfully completes a qualified maintenance of certification program practice 

assessment (as defined in paragraph (b) of this section) for such year. 
1329 

 

(2) In order for an eligible professional to receive the additional incentive payment, a 

Maintenance of Certification Program must submit to the Secretary, on behalf of the eligible 

professional, information— 

(i) In a form and manner specified by the Secretary, that the eligible professional has 

successfully met the requirements of paragraph (d)(1)(iii) of this section, which may be in the 

form of a structural measure. 

(ii) If requested by the Secretary, on the survey of patient experience with care. 

(iii) 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) Payment adjustments. For 2015 and subsequent years, with respect to covered 

professional services furnished by an eligible professional, 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 section 1848(m)(3)(A) of the Act), the fee 

schedule amount for such services furnished by such professional during the year (including the 

fee schedule amount for purposes for determining a payment based on such amount) shall be 

equal to the applicable percent of the fee schedule amount that would otherwise apply to such 

services under this subsection. 

(1) The applicable percent is as follows: 

(i) For 2015, 98.5 percent; and 

(ii) For 2016 and each subsequent year, 98 percent. 

(2) [Reserved.] 

(f) Use of consensus-based quality measures. For measures selected for inclusion in the 
1330 

 

Physician Quality Reporting System quality measure set, CMS will use consensus-based quality 

measures that meet one of the following criteria: 

(1) 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) 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. 

(3) For each quality measure adopted by the Secretary under this paragraph, the Secretary 

ensures that eligible professionals have the opportunity to provide input during the development, 

endorsement, or selection of quality measures applicable to services they furnish. 

(g) Requirements for the incentive payments. In order to qualify to earn a Physician 

Quality Reporting System incentive payment for a particular program year, an individual eligible 

professional, as identified by a unique TIN/NPI combination, (or in the case of a group practice 

under paragraph (i) of this section, by the group practice) must meet the criteria for satisfactory 

reporting specified by CMS for such year by reporting on either individual Physician Quality 

Reporting System quality measures or Physician Quality Reporting System 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) or (g)(3) of this section. 

 (1) Reporting periods. For purposes of this paragraph, the reporting period is— 

 (i) The 12-month period from January 1 through December 31 of such program year. 

 (ii) A 6-month period from July 1 through December 31 of such program year. 
1331 

 

 (A) For 2011, such 6-month reporting period is not available for EHR-based reporting of 

individual Physician Quality Reporting System quality measures. 

 (B) For 2012 and subsequent program years, such 6-month reporting period from July 1 

through December 31 of such program year is only available for registry-based reporting of 

Physician Quality Reporting System measures groups by eligible professionals.

(2) Reporting mechanisms for individual eligible professionals. An individual eligible 

professional who wishes to participate in the Physician Quality Reporting System must report 

information on Physician Quality Reporting System quality measures identified by CMS in one 

of the following manners: 

 (i) Claims. Reporting Physician Quality Reporting System quality measures or Physician 

Quality Reporting System 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. 

 (A) If an eligible professional re-submits a Medicare Part B claim for reprocessing, the 

eligible professional may not attach a G-code at that time for reporting on individual Physician 

Quality Reporting System measures or measures groups. 

 (B) [Reserved] 

 (ii) Registry. Reporting Physician Quality Reporting System quality measures or 

Physician Quality Reporting System 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 must 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. 
1332 

 

 (iii) Direct EHR product. Reporting Physician Quality Reporting System quality 

measures to CMS by extracting clinical data using a secure data submission method, as required 

by CMS, from a direct 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. 

(iv) EHR data submission vendor. Reporting Physician Quality Reporting System quality 

measures to CMS by extracting clinical data using a secure data submission method, as required 

by CMS, from an EHR data submission vendor 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. 

(v) Although an eligible professional may attempt to qualify for the Physician Quality 

Reporting System incentive payment by reporting on both individual Physician Quality 

Reporting System 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 Physician Quality Reporting System incentive 

payment per TIN/NPI combination for a program year. 

(3) Reporting mechanisms for group practices. A group practice (as defined in paragraph 

(b) of this section) who wishes to participate in the Physician Quality Reporting System must 

report information on Physician Quality Reporting System quality measures identified by CMS 

in one of the following manners: 

(i) Web interface. For 2013 and subsequent years, reporting Physician Quality 

Reporting System quality measures to CMS using a CMS web interface in the form and manner 

and by the deadline specified by CMS. 
1333 

 

(ii) Registry. For 2013 and subsequent years, reporting on Physician Quality Reporting 

System quality measures 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 must 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. 

 (iii) Direct EHR product. For 2014 and subsequent years, reporting Physician Quality 

Reporting System quality measures to CMS by extracting clinical data using a secure data 

submission method, as required by CMS, from a direct 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. 

(iv) EHR data submission vendor. For 2014 and subsequent years, reporting Physician 

Quality Reporting System quality measures to CMS by extracting clinical data using a secure 

data submission method, as required by CMS, from an EHR data submission vendor 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. 

(v) Although a group practice may attempt to qualify for the Physician Quality Reporting 

System incentive payment by using more than one reporting mechanism (as specified in 

paragraph (g)(3) of this section), or reporting for more than one reporting period, the group 

practice will receive only one Physician Quality Reporting System incentive payment for a 

program year. 

(h) Requirements for the payment adjustments. In order to satisfy the requirements for 
1334 

 

the Physician Quality Reporting System payment adjustment for a particular program year, an 

individual eligible professional, as identified by a unique TIN/NPI combination (or in the case of 

a group practice under paragraph (i) of this section, by the group practice) must meet the criteria 

for satisfactory reporting specified by CMS for such year by reporting on either individual 

Physician Quality Reporting System measures or Physician Quality Reporting System measures 

groups identified by CMS during a reporting period specified in paragraph (h)(1) of this section 

and using one of the reporting mechanisms specified in paragraph (h)(2) or (h)(3) of this section. 

 (1) For purposes of this paragraph (h), the reporting period for the payment adjustment, 

with respect to a payment adjustment year, is the 12-month period from January 1 through 

December 31 that falls 2 years prior to the year in which the payment adjustment is applied. 

(i) For the 2015 and 2016 PQRS payment adjustments only, an alternative 6-month 

reporting period, from July 1—December 31 that fall 2 years prior to the year in which the 

payment adjustment is applied, is also available. 

(ii) [Reserved] 

(2) Reporting mechanisms for individual eligible professionals. An individual eligible 

professional participating in the Physician Quality Reporting System must report information on 

Physician Quality Reporting System quality measures identified by CMS in one of the following 

manners: 

(i) Claims. Reporting Physician Quality Reporting System quality measures or Physician 

Quality Reporting System 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. 

(A) If an eligible professional re-submits a Medicare Part B claim for reprocessing, the 
1335 

 

eligible professional may not attach a G-code at that time for reporting on individual Physician 

Quality Reporting System measures or measures groups. 

(B) [Reserved] 

(ii) Registry. Reporting Physician Quality Reporting System quality measures or 

Physician Quality Reporting System 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 must 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.

 (iii) Direct EHR product. Reporting Physician Quality Reporting System quality 

measures to CMS by extracting clinical data using a secure data submission method, as required 

by CMS, from a direct 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. 

(iv) EHR data submission vendor. Reporting Physician Quality Reporting System quality 

measures to CMS by extracting clinical data using a secure data submission method, as required 

by CMS, from an EHR data submission vendor 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. 

(v) Administrative claims. For 2015, reporting data on Physician Quality Reporting 

System quality measures via administrative claims during the applicable reporting period. 

Eligible professionals that are administrative claims reporters must meet the following 

requirement for the payment adjustment: 
1336 

 

(A) Elect to participate in the Physician Quality Reporting System using the 

administrative claims reporting option. 

(B) Reporting Medicare Part B claims data for CMS to determine whether the eligible 

professional has performed services applicable to certain individual Physician Quality Reporting 

System quality measures. 

 (3) Reporting mechanisms for group practices. A group practice (as defined in paragraph 

(b) of this section) participating in the Physician Quality Reporting System must report 

information on Physician Quality Reporting System quality measures identified by CMS in one 

of the following manners: 

(i) Web interface. For the 2015 payment adjustment and subsequent payment 

adjustments, reporting Physician Quality Reporting System quality measures to CMS using a 

CMS web interface in the form and manner and by the deadline specified by CMS. 

(ii) Registry. For the 2015 subsequent adjustment and subsequent payment adjustments, 

reporting on Physician Quality Reporting System quality measures 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. 

 (iii) Direct EHR product. For the 2016 subsequent adjustment and subsequent payment 

adjustments, reporting Physician Quality Reporting System quality measures to CMS by 

extracting clinical data using a secure data submission method, as required by CMS, from a 

direct EHR product (as defined in paragraph (b) of this section) by the deadline specified by 
1337 

 

CMS for covered professional services furnished by the eligible professional during the 

applicable reporting period. 

(iv) EHR data submission vendor. For the 2016 subsequent adjustment and subsequent 

payment adjustments, reporting Physician Quality Reporting System quality measures to CMS 

by extracting clinical data using a secure data submission method, as required by CMS, from an 

EHR data submission vendor product (as defined in paragraph (b) of this section) by the deadline 

specified by CMS for covered professional services furnished by the group practice during the 

applicable reporting period. 

 (v) Administrative claims. For 2015, reporting data on Physician Quality Reporting 

System quality measures via administrative claims during the applicable reporting period. Group 

practices that are administrative claims reporters must meet the following requirement for the 

payment adjustment: 

(A) Elect to participate in the Physician Quality Reporting System using the 

administrative claims reporting option. 

(B) Reporting Medicare Part B claims data for CMS to determine whether the group 

practice has performed services applicable to certain individual Physician Quality Reporting 

System quality measures. 

(i) Requirements for group practices. Under the Physician Quality Reporting System, a 

group practice (as defined in paragraph (b) of this section) must meet all of the following 

requirements: 

(1) Meet the participation requirements specified by CMS for the Physician Quality 

Reporting System group practice reporting option. 

(2) Report measures in the form and manner specified by CMS. 
1338 

 

(3) Meet other requirements for satisfactory reporting specified by CMS. 

(4) Meet other requirements for satisfactory reporting specified by CMS. 

(5) Meet participation requirements. 

 (i) If an eligible professional, as identified by an individual NPI, has reassigned his or 

her Medicare billing rights to a group practice (as identified by the TIN) selected to participate in 

the Physician Quality Reporting System group practice reporting option for a program year, then 

for that program year the eligible professional must participate in the Physician Quality 

Reporting System via the group practice reporting option. 

(ii) If, for the program year, the eligible professional participates in the Physician Quality 

Reporting System as part of a group practice (as identified by the TIN) that is not selected to 

participate in the Physician Quality Reporting System group practice reporting option for that 

program year, then the eligible professional may individually participate and qualify for a 

Physician Quality Reporting System incentive by meeting the requirements specified in 

paragraph (g) of this section under that TIN. 

(j) Informal review. Eligible professionals (or in the case of reporting under paragraph (g) 

of this section, group practices) may seek an informal review of the determination that an eligible 

professional (or in the case of reporting under paragraph (g) of this section, group practices) did 

not satisfactorily submit data on quality measures under the Physician Quality Reporting System. 

 (1) To request an informal review for the PQRS incentives, an eligible professional (or in 

the case of reporting under paragraph (g) of this section, group practices) must submit a request 

to CMS via the Web within 90 days of the release of the feedback reports. The request must be 

submitted in writing or via e-mail and summarize the concern(s) and reasons for requesting an 

informal review and may also include information to assist in the review. 
1339 

 

 (i) CMS will provide a written response within 90 days of the receipt of the original 

request. 

 (ii) All decisions based on the informal review will be final. 

 (iii) There will be no further review or appeal. 

(2) To request an informal review for the PQRS payment adjustments, an eligible 

professional or group practices must submit a request to CMS via the Web by February 28 of the 

year in which the eligible professional is receiving the applicable payment adjustment. The 

request must be submitted in writing and summarize the concern(s) and reasons for requesting an 

informal review and may also include information to assist in the review. 

 (i) CMS will provide a timely, written response after the receipt of the original request. 

 (ii) All decisions based on the informal review will be final. 

(iii) There will be no further review or appeal. 

* * * * * 

19. Section 414.92 is amended by -- 

A. Revising paragraphs (c)(2)(ii)(A)(5) and (c)(2)(ii)(A)(6). 

B. Adding paragraph (f)(2)(i)(A) and adding and reserving paragraph (f)(2)(i)(B). 

C. Redesignating paragraph (g) as paragraph (h), and adding new paragraph (g). 

The revision and addition reads as follows: 

§ 414.92 Electronic Prescribing Incentive Program. 

* * * * * 

(c) * * * 

(2) * * * 

(ii) * * * 
1340 

 

(A) * * * 

(5) Eligible professionals who achieve meaningful use during the respective 6 or 12-

month payment adjustment reporting periods. 

(6) Eligible professionals who have registered to participate in the EHR Incentive 

Program and adopted Certified EHR Technology prior to application of the respective payment 

adjustment. 

* * * * * 

(f) * * * 

(2) * * * 

(i) * * * 

(A) If an eligible professional re-submits a Medicare Part B claim for reprocessing, the 

eligible professional may not attach a G-code at that time for reporting on the electronic 

prescribing measure. 

(B) [Reserved] 

* * * * * 

 (g) Informal review. Eligible professionals (or in the case of reporting under paragraph 

(e) of this section, group practices) may seek an informal review of the determination that an 

eligible professional (or in the case of reporting under paragraph (e) of this section, group 

practices) did not meet the requirements for the 2012 and 2013 incentives or the 2013 and 2014 

payment adjustments. 

(1) To request an informal review for the 2012 and 2013 incentives, an eligible 

professional or group practice must submit a request to CMS via email within 90 days of the 

release of the feedback reports. The request must be submitted in writing and summarize the 
1341 

 

concern(s) and reasons for requesting an informal review and may also include information to 

assist in the review. 

(2) To request an informal review for the 2013 and 2014 payment adjustments, an 

eligible professional or group practices must submit a request to CMS via email by February 28 

of the year in which the eligible professional is receiving the applicable payment adjustment. 

The request must be submitted in writing and summarize the concern(s) and reasons for 

requesting an informal review and may also include information to assist in the review. 

(3) CMS will provide a written response of CMS’ determination. 

(i) All decisions based on the informal review will be final. 

(ii) There will be no further review or appeal. 

* * * * * 

20. Section 414.610 is amended by revising paragraphs (c)(1)(ii), (c)(5)(ii), and (h) to 

read as follows: 

§414.610 Basis of payment. 

* * * * * 

(c) * * * 

(1) * * * 

(ii) For services furnished during the period July 1, 2008 through December 31, 2012, 

ambulance services originating in--- 

(A) Urban areas (both base rate and mileage) are paid based on a rate that is 2 percent 

higher than otherwise is applicable under this section; and 

(B) Rural areas (both base rate and mileage) are paid based on a rate that is 3 percent 

higher than otherwise is applicable under this section. 
1342 

 

* * * * * 

(5) * * * 

(ii) For services furnished during the period July 1, 2004 through December 31, 2012, 

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. 

* * * * * 

(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, 2012. 

21. Section 414.904 is amended by revising paragraphs (d)(3)(ii), (d)(3)(iii), and 

(d)(3)(iv) to read as follows: 

§414.904 Average sales price as the basis for payment. 

* * * * * 

(d) * * * 

(3) * * * 

(ii) Payment at 103 percent of the average manufacturer price for a billing code will be 

applied at such times when all of the following criteria are met: 
1343 

 

(A) The threshold for making price substitutions, as defined in paragraph (d)(3)(iii) of 

this section is met. 

(B) 103 percent of the average manufacturer price is less than the 106 percent of the 

average sales price for the quarter in which the substitution would be applied. 

(C) Beginning in 2013, the drug and dosage form described by the HCPCS code is not 

identified by the FDA to be in short supply at the time that ASP calculations are finalized. 

(iii) The applicable percentage threshold for average manufacturer price comparisons is 5 

percent and is reached when-- 

(A) The average sales price for the billing code has exceeded the average manufacturer 

price for the billing code by 5 percent or more in 2 consecutive quarters, or 3 of the previous 4 

quarters immediately preceding the quarter to which the price substitution would be applied; and 

(B) The average manufacturer price for the billing code is calculated using the same set 

of National Drug Codes used for the average sales price for the billing code. 

(iv) The applicable percentage threshold for widely available market price comparisons is 

5 percent.

* * * * * 

22. Subpart N is added to Part 414 to read as follows: 

Subpart N--Value-Based Payment Modifier under the Physician Fee Schedule 

Sec. 

414.1200 Basis and scope. 

414.1205 Definitions. 

414.1210 Application of the value-based payment modifier. 

414.1215 Performance and payment adjustment periods for the value-based payment modifier. 
1344 

 

414.1220 Reporting mechanisms for the value-based payment modifier. 

414.1225 Alignment of Physician Quality Reporting System (PQRS) quality measures and 

quality measures for the value-based payment modifier. 

414.1230 Additional measures for groups of physicians. 

414.1235 Cost measures. 

414.1240 Attribution for quality of care and cost measures. 

414.1245 Scoring methods for the value-based payment modifier using the quality-tiering 

approach. 

414.1250 Benchmarks for quality of care measures. 

414.1255 Benchmarks for cost measures. 

414.1260 Composite scores. 

414.1265 Reliability of measures. 

414.1270 Determination and calculation of Value-Based Payment Modifier adjustments. 

414.1275 Value-based payment modifier quality-tiering scoring methodology. 

414.1280 Limitation on review. 

414.1285 Informal inquiry process. 

Subpart N--Value-Based Payment Modifier under the Physician Fee Schedule 

§ 414.1200 Basis and scope. 

(a) Basis. This subpart implements section 1848(p) of the Act by establishing a payment 

modifier that provides for differential payment starting in 2015 to a group of physicians under 

the Medicare physician fee schedule based on the quality of care furnished compared to cost 

during a performance period. 

(b) Scope. This subpart sets forth the following: 
1345 

 

(1) The application of the value-based payment modifier. 

(2) Performance and payment adjustment periods. 

(3) Reporting mechanisms for the value-based payment modifier. 

(4) Alignment of PQRS quality of care measures with the quality measures for the 

value-based payment modifier. 

(5) Additional measures for groups of physicians. 

(6) Cost measures. 

(7) Attribution for quality of care and cost measures. 

(8) Scoring methods for the value-based payment modifier. 

(9) Benchmarks for quality of care measures. 

(10) Benchmarks for cost measures. 

(11) Composite scores. 

(12) Reliability of measures. 

(13) Payment adjustments. 

(14) Value-based payment modifier quality-tiering scoring methodology. 

(15) Limitation of review. 

(16) Inquiry process. 

§ 414.1205 Definitions.

As used in this subpart, unless otherwise indicated— 

Accountable care organization (ACO) has the same meaning given this term under 

§425.20 of this chapter. 

Critical access hospital has the same meaning given this term under §400.202 of this 

chapter. 
1346 

 

Electronic health record (EHR) has the same meaning given this term under §414.92 of 

this chapter. 

Eligible professional has the same meaning given this term under section 1848(k)(3)(B) 

of the Act. 

Federally Qualified Health Center has the same meaning given this term under 

§405.2401(b) of this chapter. 

Group of physicians means a single Tax 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. 

Performance period means the calendar year that will be used to assess the quality of 

care furnished compared to cost. 

Performance rate mean the calculated rate for each quality or cost measure such as 

the percent of times that a particular clinical quality action was reported as being performed, or 

a particular outcome was attained, for the applicable persons to whom a measure applies as 

described in the denominator for the measure. 

Physician has the same meaning given this term under section 1861(r) of the Act. 

Physician Fee Schedule has the same meaning given this term under part 410 of this 

chapter. 

Physician Quality Reporting System means the system established under section 1848(k) 

of the Act. 

Risk score means the beneficiary risk score derived from the CMS Hierarchical 

Condition Categories (HCC) model. 
1347 

 

Taxpayer Identification Number (TIN) has the same meaning given this term under 

§425.20 of this chapter. 

Value-based payment modifier means the percentage as determined under §414.1270 by 

which amounts paid to a physician or group of physicians under the Medicare physician fee 

schedule established under section 1848 of the Act are adjusted based upon a comparison of the 

quality of care furnished to cost as determined by this subpart. 

§ 414.1210 Application of the value-based payment modifier. 

(a) The value-based payment modifier is applicable to physicians: 

(1) For CY 2015, in groups with 100 or more eligible professionals based on the 

performance period described at § 414.1215(a). 

(2) [Reserved] 

(b) Exceptions. (1) Groups of physicians that are participating in the Medicare Shared 

Savings Program, the testing of the Pioneer ACO model, or other similar Innovation Center or 

CMS initiatives shall not be subject to any adjustments under the value-based payment modifier 

for CY 2015 and CY 2016. 

 (2) [Reserved] 

(c) Group size determination. Identification of the groups of physicians subject to the 

value-based payment modifier is based on a query of PECOS on October 15, 2013. Groups of 

physicians are removed from this October 15 list if, based on a claims analysis, the group of 

physicians did not have 100 or more eligible professionals that submitted claims during the 

performance period. 

§ 414.1215 Performance and payment adjustment periods for the value-based payment 

modifier.
1348 

 

(a) The performance period is calendar year 2013 for value-based payment modifier 

adjustments made in the calendar year 2015 payment adjustment period. 

(b) The performance period is calendar year 2014 for value-based payment modifier 

adjustments made in the calendar year 2016 payment adjustment period. 

§ 414.1220 Reporting mechanisms for the value-based payment modifier. 

Groups of physicians subject to the value-based payment modifier may submit data on 

quality measures as specified under the Physician Quality Reporting System and in § 414.90(g) 

for which they are eligible and §414.90(h)(3)(vi) administrative claims. 

§ 414.1225 Alignment of Physician Quality Reporting System quality measures and 

quality measures for the value-based payment modifier. 

 All of the quality measures for which groups of physicians are eligible to report under 

the Physician Quality Reporting System starting in CY 2013 are used to calculate the valuebased payment modifier program to the extent the group of physicians submits data on such 

measures. 

§ 414.1230 Additional measures for groups of physicians. 

 The value-based payment modifier includes the following additional quality measures 

for all groups of physicians subject to the value-based payment modifier: 

(a) A composite of rates of potentially preventable hospital admissions for heart failure, 

chronic obstructive pulmonary disease, and diabetes. The rate of potentially preventable 

hospital admissions for diabetes is a composite measure of uncontrolled diabetes, short term 

diabetes complications, long term diabetes complications and lower extremity amputation for 

diabetes. 

(b) A composite of rates of potentially preventable hospital admissions for dehydration, 
1349 

 

urinary tract infections, and bacterial pneumonia. 

(c) Rates of an all-cause hospital readmissions measure. 

§ 414.1235 Cost measures. 

 Costs for groups of physicians subject to the value-based payment modifier are assessed 

based on the following 6 cost measures: 

(a) Total per capita costs for all attributed beneficiaries; and 

(b) Total per capita costs for all attributed beneficiaries with diabetes, coronary artery 

disease, chronic obstructive pulmonary disease, or heart failure. 

(c) Total per capita costs include all fee-for-service payments made under Medicare Part 

A and Part B. 

(1) Payments under Medicare Part A and Part B will be adjusted using CMS’ payment 

standardization methodology to ensure fair comparisons across geographic areas. 

(2) The CMS-HCC model (and adjustments for ESRD status) is used to adjust 

standardized payments for each cost measure; that is-- 

(i) Total per capita costs; and 

(ii) Total per capita costs for beneficiaries with the following conditions: coronary artery 

disease, COPD, diabetes, and heart failure. 

§ 414.1240 Attribution for quality of care and cost measures. 

Beneficiaries are attributed to groups of physicians subject to the value-based payment 

modifier using a method generally consistent with the method of assignment of beneficiaries 

under §425.402 of this chapter. 

§ 414.1245 Scoring methods for the value-based payment modifier using the qualitytiering approach. 
1350 

 

 For each quality of care and cost measure, a standardized score is calculated for each 

group of physicians subject to the value-based payment modifier by dividing-- 

(a) The difference between their performance rate and the benchmark, by 

(b) The measure’s standard deviation. 

§ 414.1250 Benchmarks for quality of care measures. 

(a) The benchmark for quality of care measures reported through the PQRS using the 

claims, registries, EHR, or web interface is the national mean for that measure’s performance 

rate (regardless of the reporting mechanism) during the year prior to the performance period. In 

calculating the national benchmark, individuals’ and groups of physicians’ performance rates 

are weighted by the number of beneficiaries used to calculate the individuals’ or group of 

physician’s performance rate. 

 (b) The benchmark for each quality of care measure reported through the PQRS using 

the administrative claims option is the national mean for that measure’s performance rate during 

the year prior to the performance period. 

§ 414.1255 Benchmarks for cost measures. 

The benchmark for each cost measure is the national mean of the performance rates 

calculated among all groups of physicians for which beneficiaries are attributed to the group of 

physicians and are subject to the value-based payment modifier. In calculating the national 

benchmark, groups of physicians’ performance rates are weighted by the number of 

beneficiaries used to calculate the group of physician’s performance rate. 

§ 414.1260 Composite scores. 

(a)(1) The standardized score for each quality of care measure is classified into one of 

the following equally weighted domains to determine the quality composite: 
1351 

 

(i) Patient safety. 

(ii) Patient experience. 

(iii) Care coordination. 

(iv) Clinical care. 

(v) Population/community health. 

(vi) Efficiency. 

(2) If a domain includes no measure or does not reach the minimum case size in 

§ 414.1265, the remaining domains are equally weighted to form the quality of care composite. 

(b)(1) The standardized score for each cost measure is grouped into two separate and 

equally weighted domains to determine the cost composite: 

(i) Total per capita costs for all attributed beneficiaries (one measures); and 

(ii) Total per capita costs for all attributed beneficiaries with specific conditions: 

diabetes, coronary artery disease, chronic obstructive pulmonary disease, or heart failure (four 

measures). 

(2) Measures within each domain are equally weighted. 

§ 414.1265 Reliability of measures. 

To calculate a composite score for a quality or cost measure based on claims, a group of 

physicians subject to the value-based payment modifier must have 20 or more cases for that 

measure. 

(a) In a performance period, if a group of physicians has fewer than 20 cases for a 

measure, that measure is excluded from its domain and the remaining measures in the domain 

are given equal weight. 

(b) In a performance period, if a reliable quality of care composite or cost composite 
1352 

 

cannot be calculated, payments shall not be adjusted under the value-based payment modifier. 

§ 414.1270 Determination and calculation of Value-Based Payment Modifier adjustments. 

(a) Downward payment adjustments. A downward payment adjustment will be applied 

to a group of physicians subject to the value-based payment modifier if: 

(1) Such group does neither self-nominates for the PQRS GPRO and reports at least one 

measure nor elects the PQRS administrative claims option for CY 2013 as defined in 

§414.90(h); 

(i) Such adjustment will be -1.0 percent. 

(ii) [Reserved] 

(2) Such group elects that its value-based payment modifier be calculated using a 

quality-tiering approach, and is determined to have poor performance (low quality and high 

costs), 

(i) Such adjustment will not exceed -1.0 percent as specified in § 414.1275. 

(ii) [Reserved] 

(b) No payment adjustments. There will be no value-based payment modifier 

adjustment applied to a group of physicians subject to the value-based payment modifier if such 

group either 

(1) Self-nominates for the PQRS GPRO and reports at least one measure; or 

(2) Elects the PQRS administrative claims option for CY 2013 as defined in §414.90(h). 

(c) Upward payment adjustments. If a group of physicians subject to the value-based 

payment modifier elects that the value-based payment modifier be calculated using a qualitytiering approach, upward payment adjustments are determined based on the projected aggregate 

amount of downward payment adjustments determined under paragraph (a) of this section and 
1353 

 

applied as specified in §414.1275.

§ 414.1275 Value-based payment modifier quality-tiering scoring methodology. 

(a) The value-based payment modifier amount for a group of physicians subject to the 

value-based payment modifier that elects the quality-tiering approach is based upon a 

comparison of the composite of quality of care measures and a composite of cost measures. 

(b) Quality composite and cost composite are classified into high, average, and low 

categories based on whether the composites are statistically above, not different from, or below 

the mean composite scores. 

(1) Quality composites that are one or more standard deviations above the mean are 

classified into the high category. Quality composites that are one or more standard deviations 

below the mean are classified into the low category. 

(2) Cost composites that are one or more standard deviations below the mean are 

classified into the low category. Cost composites that are one or more standard deviations 

above the mean are classified into the high category. 

(c) The following value-based payment modifier percents apply: 

Value-Based Payment Modifier Amounts for Groups of Physicians Requesting the 

Quality-Tiering Approach 

Quality/cost Low cost Average cost High cost 

High quality +2.0x1

 +1.0x1 +0.0% 

Average quality +1.0x1

 +0.0% -0.5% 

Low quality +0.0% -0.5% -1.0% 1 Groups of physicians eligible for an additional +1.0x if reporting Physician Quality Reporting 

System quality measures through the GPRO using the web interface, claims, registries, or EHRs, and 

average beneficiary risk score in the top 25 percent of all beneficiary risk scores. 

(d) Groups of physicians subject to the value-based payment modifier that have an 

attributed beneficiary population with an average risk score in the top 25 percent of the risk 

scores of beneficiaries nationwide and elect the quality-tiering approach, receive a greater 

upward payment adjustment as follows: 
1354 

 

(1) Classified as high quality/low cost receive an upward adjustment of +3x (rather than 

+2x); and 

(2) Classified as either high quality/average cost or average quality/low cost receive an 

upward adjustment of +2x (rather than +1x). 

§ 414.1280 Limitation on review. 

(a) There shall be no administrative or judicial review under section 1869 of the Act, 

section 1878 of the Act, or otherwise of all of the following: 

(1) The establishment of the value-based payment modifier. 

(2) The evaluation of the quality of care composite, including the establishment of 

appropriate measure of the quality of care. 

(3) The evaluation of costs composite, including establishment of appropriate measures 

of costs. 

(4) The dates of implementation of the value-based payment modifier. 

(5) The specification of the initial performance period and any other performance period. 

(6) The application of the value-based payment modifier. 

(7) The determination of costs. 

 (b) [Reserved.] 

§ 414.1285 Informal inquiry process. 
1355 

 

 After the dissemination of the annual Physician Feedback reports, a group of physicians 

may contact CMS to inquire about its report and the calculation of the value-based payment 

modifier. 

PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, 

SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN 

CERTAIN SETTINGS 

23. 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). 

§415.130 [Amended] 

 24. In §415.130(d)(1) and (d)(2), remove the reference to “December 31, 2011” and add 

in its place the reference to “June 30, 2012.”

PART 421--MEDICARE CONTRACTING 

25. The authority citation for part 421 continues to read as follows: 

 Authority: Sec. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). 

Subpart F--[REMOVED AND RESERVED] 

26. Subpart F is removed and reserved. 

PART 423--VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT 

27. The authority citation for part 423 continues to read as follows: 

Authority: Sections 1102, 1106, 1860D-1 through 1860D-42, and 1871 of the Social 

Security Act (42 U.S.C. 1302, 1306, 1395w-101 through 1395w-152, and 1395hh). 

28. Section 423.160 is amended by-- 

A. Revising paragraphs (a)(3)(iv), (b)(1)(i), and (b)(1)(ii). 
1356 

 

B. Adding paragraphs (b)(1)(iii) and (b)(2)(iii). 

The revisions and additions read as follows: 

§423.160 Standards for electronic prescribing. 

(a) * * * 

(3) * * * 

(iv) Until November 1, 2014, entities transmitting prescriptions or prescription-related 

information where the prescriber is required by law to issue a prescription for a patient to a nonprescribing provider (such as a nursing facility) that in turn forwards the prescription to a 

dispenser are exempt from the requirement to use the NCPDP SCRIPT Standard adopted by this 

section in transmitting such prescriptions or prescription-related information. As of November 1, 

2014, such entities will be required to use the adopted NCPCP SCRIPT standard(s). 

 * * * * * 

(b) * * * 

(1) * * * 

(i) Before April 1, 2009 the standards specified in paragraphs (b)(2)(i), (b)(3), (b)(4), 

(b)(5), and (b)(6) of this section. 

(ii) From April 1, 2009 until January 14, 2013, the standards specified in paragraphs 

(b)(2)(ii), (b)(3)-(b)(4), (b)(5) and (b)(6) of this section. 

(iii) From January 15, 2013 until October 31, 2013 the standards specified in paragraphs 

(b)(2)(ii), (b)(3)-(b)(4), (b)(5) and (b)(6) of this section. 

* * * * * 

 (2) * * * 

(iii) The National Council for Prescription Drug Programs SCRIPT standard, 
1357 

 

Implementation Guide Version 10.6 approved November 12, 2008 (incorporated by reference in 

paragraph (c)(1)(v) of this section), to provide for the communication of a prescription or related 

prescription related information between prescribers and dispensers for the following: 

(A) Get message transaction. 

(B) Status response transaction. 

(C) Error response transaction. 

(D) New prescription transaction. 

(E) Prescription change request transaction. 

(F) Prescription change response transaction. 

(G) Refill prescription request transaction. 

(H) Refill prescription response transaction. 

(I) Verification transaction. 

(J) Password change transaction. 

(K) Cancel prescription request transaction. 

(L) Cancel prescription response transaction. 

(M) Fill status notification. 

* * * * * 

PART 425--MEDICARE SHARED SAVINGS PROGRAM 

29. The authority citation for part 425 continues to read as follows: 

Authority: Secs. 1102, 1106, 1871, and 1899 of the Social Security Act (42 U.S.C. 1302 

and 1395hh). 

30. Section 425.308 is amended by revising paragraph (e) to read as follows: 

§425.308 Public reporting and transparency. 

* * * * * 
1358 

 

(e) Results of claims based measures. Quality measures reported using the GPRO web 

interface and patient experience of care survey measures will be reported on Physician Compare 

in the same way as for the group practices that report under the Physician Quality Reporting 

System. 

31. Section 425.504 is amended by adding paragraph (b) to read as follows: 

§425.504 Incorporating reporting requirements related to the Physician Quality Reporting 

System. 

* * * * * 

(b) Physician Quality Reporting System payment adjustment. (1) ACOs, on behalf of 

their ACO provider/suppliers who are eligible professionals, must submit one of the measures 

determined under §425.500 using the GPRO web interface established by CMS, to satisfactorily 

report on behalf of their eligible professionals for purposes of the 2015 Physician Quality 

Reporting System payment adjustment under the Shared Savings Program. 

(2)(i) ACO providers/suppliers that are eligible professionals within an ACO may only 

participate under their ACO participant TIN as a group practice under the Physician Quality 

Reporting System Group Practice Reporting Option of the Shared Savings Program for purposes 

of the 2015 Physician Quality Reporting System payment adjustment under the Shared Savings 

Program. 

(ii) Under the Shared Savings Program, an ACO, on behalf of its ACO 

providers/suppliers who are eligible professionals, must satisfactorily report one of the measures 

determined under Subpart F of this part during the reporting period for a year, as defined in 

paragraph (b)(6) of this section, according to the method of submission established by CMS 

under the Shared Savings Program for purposes of the 2015 Physician Quality Reporting System 
1359 

 

payment adjustment. 

(3) If an ACO, on behalf of its ACO providers/suppliers who are eligible professionals, 

does not satisfactorily report for purposes of a 2015 Physician Quality Reporting System 

payment adjustment, each ACO supplier/provider who is an eligible professional, will receive a 

payment adjustment, as described in paragraph (b)(5) of this section. 

(4) ACO participant TINs and individual ACO providers/suppliers who are eligible 

professionals cannot satisfactorily report for purposes of a 2015 Physician Quality Reporting 

System payment adjustment outside of the Medicare Shared Savings Program. 

(5) For eligible professionals subject to the 2015 Physician Quality Reporting System 

payment adjustment under the Medicare Shared Savings Program, the Medicare Part B Physician 

Fee Schedule amount for covered professional services furnished during the program year is 

equal to the applicable percent of the Medicare Part B Physician Fee Schedule amount that 

would otherwise apply to such services under section 1848 of the Act. 

(i) The applicable percent for 2015 is 98.5 percent. 

(ii) The applicable percent for 2016 and subsequent years is 98.0 percent. 

(6) The reporting period for a year is the calendar year from January 1 through 

December 31 that occurs 2 years prior to the program year in which the payment adjustment is 

applied. 

PART 486--CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES 

FURNISHED BY SUPPLIERS 

 32. The authority citation for part 486 continues to read as follows: 

Authority: Secs. 1102, 1138, and 1871 of the Social Security Act (42 U.S.C. 1302, 

1320b-8, and 1395hh) and section 371 of the Public Health Service Act (42 U.S.C 273). 
1360 

 

33. Section 486.106 is amended by revising the introductory text and paragraphs (a) and 

(b) to read as follows: 

§486.106 Condition for coverage: Referral for service and preservation of records. 

All portable X-ray services performed for Medicare beneficiaries are ordered by a 

physician or a nonphysician practitioner as provided in §410.32(a) of this chapter or by a 

nonphysician practitioner as provided in §410.32(a)(2) and records are properly preserved. 

(a) Standard—referral by a physician or nonphysician practitioners. Portable X-ray 

examinations are performed only on the order of a physician licensed to practice in the State or 

by a nonphysician practitioner acting within the scope of State law. Such nonphysician 

practitioners may be treated the same as physicians treating beneficiaries for the purpose of this 

paragraph. The supplier’s records show that: 

(1) The portable X-ray test was ordered by a licensed physician or a nonphysician 

practitioner acting within the State scope of law; and 

(2) Such physician or nonphysician practitioner’s written, signed order specifies the 

reason a portable X-ray test is required, the area of the body to be exposed, the number of 

radiographs to be obtained, and the views needed; it also includes a statement concerning the 

condition of the patient which indicates why portable X-ray services are necessary. 

(b) Standard—records of examinations performed. The supplier makes for each patient a 

record of the date of the portable X-ray examination, the name of the patient, a description of the 

procedures ordered and performed, the referring physician or nonphysician practitioner, the 

operator(s) of the portable X-ray equipment who performed the examination, the physician to

whom the radiograph was sent, and the date it was sent. 

* * * * * 
1361 

 

PART 495--STANDARDS FOR THE ELECTRONIC HEALTH RECORD 

TECHNOLOGY INCENTIVE PROGRAM 

34. The authority citation for part 495 continues to read as follows: 

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395hh). 

35. Section 495.8 is amended by revising paragraph (a)(2)(v) to read as follows: 

§ 495.8 Demonstration of meaningful use criteria. 

(a) * * * 

(2) * * * 

(v) Exception for Medicare EPs for 2012 and 2013—Participation in the Physician 

Quality Reporting System-Medicare EHR Incentive Pilot. To satisfy the clinical quality measure 

reporting requirements of meaningful use, aside from attestation, an EP participating in the 

Physician Quality Reporting System may also participate in the Physician Quality Reporting 

System-Medicare EHR Incentive Pilot through one of the following methods: 

(A) Submission of data extracted from the EP’s certified EHR technology through a 

Physician Quality Reporting System qualified EHR data submission vendor; or 

(B) Submission of data extracted from the EP’s certified EHR technology, which must 

also be through a Physician Quality Reporting System qualified EHR. 

* * * * * 
CMS-1590-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: October 24, 2012. 

 ______________________ 

 Marilyn Tavenner, 

 Acting Administrator,

Centers for Medicare & 

Medicaid Services 

Approved: October 25, 2012. 

 _____________________ 

 Kathleen Sebelius, 

 Secretary.

BILLING CODE 4120-01-P 

[FR Doc. 2012-26900 Filed 11/01/2012 at 4:15 pm; Publication Date: 11/16/2012]