49506 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Parts 410, 414, 416, 419, 421, 

485, and 488 

[CMS–1506–P; CMS–4125–P] 

RIN 0938–AO15 

Medicare Program; Hospital Outpatient 

Prospective Payment System and CY 

2007 Payment Rates; CY 2007 Update 

to the Ambulatory Surgical Center 

Covered Procedures List; Ambulatory 

Surgical Center Payment System and 

CY 2008 Payment Rates; Medicare 

Administrative Contractors; and 

Reporting Hospital Quality Data for FY 

2008 Inpatient Prospective Payment 

System Annual Payment Update 

Program—HCAHPS Survey, SCIP, 

and Mortality 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Proposed rule. 

SUMMARY: This proposed rule would 

revise the Medicare hospital outpatient 

prospective payment system to 

implement applicable statutory 

requirements and changes arising from 

our continuing experience with this 

system, and to implement certain 

related provisions of the Medicare 

Prescription Drug, Improvement, and 

Modernization Act (MMA) of 2003, and 

the Deficit Reduction Act (DRA) of 

2005. The proposed rule describes 

proposed changes to the amounts and 

factors used to determine the payment 

rates for Medicare hospital outpatient 

services paid under the prospective 

payment system. These changes would 

be applicable to services furnished on or 

after January 1, 2007. 

In addition, this proposed rule would 

revise the current list of procedures that 

are approved when furnished in a 

Medicare-approved ambulatory surgical 

center (ASC), which would be 

applicable to services furnished on or 

after January 1, 2007. Further, this 

proposed rule would revise the ASC 

facility payment system to implement 

provisions of the MMA and other 

applicable statutory requirements, and 

update the ASC payment rates. Changes 

to the ASC facility payment system and 

the payment rates would be applicable 

to services furnished on or after January 

1, 2008. 

This proposed rule would revise the 

emergency medical screening 

requirements for critical access 

hospitals (CAHs). 

In addition, this proposed rule would 

support implementation of a 

restructuring of the contracting entities 

responsibilities and functions that 

support the adjudication of Medicare 

fee-for-service (FFS) claims. This 

restructuring is directed by section 

1874A of the Act, as added by section 

911 of the MMA. The prior separate 

Medicare intermediary and Medicare 

carrier contracting authorities under 

Title XVIII of the Act have been 

replaced with the Medicare 

Administrative Contractor (MAC) 

authority. 

This proposed rule would also 

continue to implement the requirements 

of the DRA that require that we expand 

the ‘‘starter set’’ of 10 quality measures 

that we used in FY 2005 and FY 2006 

for the hospital Inpatient Prospective 

Payment System (IPPS) Reporting 

Hospital Quality Data for the Annual 

Payment Update (RHQDAPU) program. 

We began to adopt expanded measures 

effective for payments beginning in FY 

2007. We are proposing to add 

additional quality measures to the 

expanded set of measures for FY 2008 

payment purposes. These measures 

include the HCAHPS survey, as well as 

Surgical Care Improvement Project 

(SCIP, formerly Surgical Infection 

Prevention (SIP)), and Mortality quality 

measures. 

DATES: To be assured consideration, 

comments on all sections of the 

preamble of this proposed rule, except 

section XVIII. and section XXIII., must 

be received at one of the addresses 

provided in the ADDRESSES section, no 

later than 5 p.m. October 10, 2006. 

To be assured consideration, 

comments on section XVIII. of this 

preamble relating to the proposed 

revised ASC payment system and the 

related regulation changes for 

implementation January 1, 2008, must 

be received at one of the addresses 

provided in the ADDRESSES section, no 

later than 5 p.m. on November 6, 2006. 

ADDRESSES: In commenting on all 

provisions except those found in section 

XXIII. of the preamble, please refer to 

file code CMS–1506–P. In commenting 

on the provisions found in section 

XXIII. of the preamble for the FY 2008 

IPPS RHQDAPU program, please refer to 

file code CMS–4125–P. Because of staff 

and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (no duplicates, please): 

1. Electronically. You may submit 

electronic comments on specific issues 

in this regulation to http:// 

www.cms.hhs.gov/eRulemaking. Click 

on the link ‘‘Submit electronic 

comments on CMS regulations with an 

open comment period.’’ (Attachments 

should be in Microsoft Word, 

WordPerfect, or Excel; however, we 

prefer Microsoft Word.) 

2. By regular mail. You may mail 

written comments (one original and two 

copies) to the following address ONLY: 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Attention: CMS–1506– 

P, or CMS–4125–P, P.O. Box 8011, 

Baltimore, MD 21244–1850. 

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 (one 

original and two copies) to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–1506–P, or CMS–4125–P, Mail 

Stop C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

4. By hand or courier. If you prefer, 

you may deliver (by hand or courier) 

your written comments (one original 

and two copies) before the close of the 

comment period to one of the following 

addresses: Room 445–G, Hubert H. 

Humphrey Building, 200 Independence 

Avenue, SW., Washington, DC 20201; or 

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. 

(Because access to the interior of the 

Hubert H. Humphrey Building is not 

readily available to persons without 

Federal Government identification, 

commenters are encouraged to leave 

their comments in the CMS drop slots 

located in the main lobby of the 

building. A stamp-in clock is available 

for persons wishing to retain proof of 

filing by stamping in and retaining an 

extra copy of the comments being filed.) 

Comments mailed to the addresses 

indicated as appropriate for hand or 

courier delivery may be delayed and 

received after the comment period. 

Submission of Comments on 

Paperwork Requirements. You may 

submit comments on this document’s 

paperwork requirements by mailing 

your comments to the addresses 

provided at the end of the ‘‘Collection 

of Information Requirements’’ section in 

this document. 

For information on viewing public 

comments, see the beginning of the 

SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49507 

Alberta Dwivedi, (410) 786–0378, 

Hospital outpatient prospective 

payment issues. 

Dana Burley, (410) 786–0378, 

Ambulatory surgery center issues. 

Suzanne Asplen, (410) 786–4558, Partial 

hospitalization and community 

mental health centers issues. 

Mary Collins, (410) 786–3189, Critical 

access hospital emergency medical 

planning issues. 

Sandra M. Clarke, (410) 786–6975, 

Medicare Administrative Contractors 

issues. 

Mark Zobel, (410) 786–6905, Medicare 

Administrative Contractors issues. 

Liz Goldstein, (410) 786–6665, FY 2008 

IPPS RHQDAPU HCAHPS issues. 

Bill Lehrman, (410) 786–1037, FY 2008 

IPPS RHQDAPU HCAHPS issues. 

Sheila Blackstock, (410) 786–3506, FY 

2008 IPPS RHQDAPU SCIP and 

mortality issues. 

SUPPLEMENTARY INFORMATION: 

comments from the public on all issues 

set forth in this proposed rule to assist 

us in fully considering issues and 

developing policies. You can assist us 

by referencing the file code CMS–1506- 

P or file code CMS–4125-P for FY 2008 

RHQDAPU program issues, and the 

specific ‘‘issue identifier’’ that precedes 

the section on which you choose to 

comment. 

Inspection of Public Comments: All 

comments received before the close of 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http://www.cms.hhs.gov/ 

eRulemaking. Click on the link 

‘‘Electronic Comments on CMS 

Regulations’’ on that Web site to view 

public comments. 

Comments received timely will also 

be available for public inspection as 

they are received, generally beginning 

approximately 3 weeks after publication 

of a document, at the headquarters of 

the Centers for Medicare & Medicaid 

Services, 7500 Security Boulevard, 

Baltimore, MD 21244, on 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. 

Electronic Access 

This Federal Register document is 

also available from the Federal Register 

online database through GPO Access, a 

service of the U.S. Government Printing 

Office. Free public access is available on 

a Wide Area Information Server (WAIS) 

through the Internet and via 

asynchronous dial-in. Internet users can 

access the database by using the World 

Wide Web; the Superintendent of 

Documents’ home page address is 

http://www.gpoaccess.gov/index.html, 

by using local WAIS client software, or 

by telnet to swais.access.gpo.gov, then 

login as guest (no password required). 

Dial-in users should use 

communications software and modem 

to call (202) 512–1661; type swais, then 

login as guest (no password required). 

Alphabetical List of Acronyms 

Appearing in the Proposed Rule 

ACEP American College of Emergency 

Physicians 

AHA American Hospital Association 

AHIMA American Health Information 

Management Association 

AMA American Medical Association 

APC Ambulatory payment classification 

AMP Average manufacturer price 

ASC Ambulatory Surgical Center 

ASP Average sales price 

AWP Average wholesale price 

BBA Balanced Budget Act of 1997, Pub. L. 

105–33 

BBRA Medicare, Medicaid, and SCHIP 

[State Children’s Health Insurance 

Program] Balanced Budget Refinement Act 

of 1999, Pub. L. 106–113 

BCA Blue Cross Association 

BCBSA Blue Cross and Blue Shield 

Association 

BIPA Medicare, Medicaid, and SCHIP 

Benefits Improvement and Protection Act 

of 2000, Pub. L. 106–554 

CAH Critical access hospital 

CBSA Core-Based Statistical Area 

CCR Cost-to-charge ratio 

CMHC Community mental health center 

CMS Centers for Medicare & Medicaid 

Services 

CNS Clinical nurse specialist 

CORF Comprehensive outpatient 

rehabilitation facility 

CPT [Physicians’] Current Procedural 

Terminology, Fourth Edition, 2006, 

copyrighted by the American Medical 

Association 

CRNA Certified registered nurse anesthetist 

CY Calendar year 

DMEPOS Durable medical equipment, 

prosthetics, orthotics, and supplies 

DMERC Durable medical equipment 

regional carrier 

DRA Deficit Reduction Act of 2005, Pub. L. 

109–171 

DSH Disproportionate share hospital 

EACH Essential Access Community 

Hospital 

E/M Evaluation and management 

EPO Erythropoietin 

ESRD End-stage renal disease 

FACA Federal Advisory Committee Act, 

Pub. L. 92–463 

FAR Federal Acquisition Regulations 

FDA Food and Drug Administration 

FFS Fee-for-service 

FSS Federal Supply Schedule 

FY Federal fiscal year 

GAO Government Accountability Office 

HCPCS Healthcare Common Procedure 

Coding System 

HCRIS Hospital Cost Report Information 

System 

HHA Home health agency 

HIPAA Health Insurance Portability and 

Accountability Act of 1996, Pub. L. 104–

191 

ICD–9–CM International Classification of 

Diseases, Ninth Edition, Clinical 

Modification 

IDE Investigational device exemption 

IPPS [Hospital] Inpatient prospective 

payment system 

IVIG Intravenous immune globulin 

MAC Medicare Administrative Contractors 

MedPAC Medicare Payment Advisory 

Commission 

MDH Medicare-dependent, small rural 

hospital 

MMA Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003, Pub. L. 108–173 

MPFS Medicare Physician Fee Schedule 

MSA Metropolitan Statistical Area 

NCCI National Correct Coding Initiative 

NCD National Coverage Determination 

NTIOL New technology intraocular lens 

OCE Outpatient Code Editor 

OMB Office of Management and Budget 

OPD [Hospital] Outpatient department 

OPPS [Hospital] Outpatient prospective 

payment system 

PA Physician assistant 

PHP Partial hospitalization program 

PM Program memorandum 

PPI Producer Price Index 

PPS Prospective payment system 

PPV Pneumococcal pneumonia (virus) 

PRA Paperwork Reduction Act 

QIO Quality Improvement Organization 

RFA Regulatory Flexibility Act 

RHQDAPU Reporting hospital quality data 

for annual payment update 

RHHI Regional home health intermediary 

SBA Small Business Administration 

SCH Sole community hospital 

SDP Single Drug Pricer 

SI Status indicator 

TEFRA Tax Equity and Fiscal 

Responsibility Act of 1982, Pub. L. 97–248 

TOPS Transitional outpatient payments 

USPDI United States Pharmacopoeia Drug 

Information 

In this document, we address three 

payment systems under the Medicare 

program: the hospital outpatient 

prospective payment system (OPPS), the 

hospital inpatient prospective payment 

system (IPPS), and the ambulatory 

surgical center (ASC) payment system. 

The provisions relating to the OPPS are 

included in sections I. through XIII., 

XV., XVI., XX., XXIV., XXVI., and 

XXVII. of the preamble and in Addenda 

A, B, C (available on the Internet only; 

see section XXIV. of the preamble of this 

proposed rule), D1, D2, and E of this 

proposed rule. The provisions related to 

IPPS are included in sections XXIII., 

XXV. through XXVII. of the preamble. 

The provisions related to ASCs are 


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49508 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

included in sections XVII,. XVIII., and 

XXIV. through XXVII. of the preamble 

and in Addenda AA, BB, and CC of the 

proposed rule. 

In addition, in this document, we 

address our proposed implementation of 

the Medicare contracting reform 

provisions of the MMA that replace the 

prior Medicare intermediary and carrier 

authorities formerly found in sections 

1816 and 1842 of the Act with Medicare 

administrative contractor (MAC) 

authority under a new section 1874A of 

the Act. The provisions relating to 

MACs are included in sections XIX., 

XXVI., and XXVII.E. of this preamble. 

To assist readers in referencing sections 

contained in this document, we are 

providing the following table of 

contents: 

Table of Contents 

I. Background for the OPPS 

A. Legislative and Regulatory Authority for 

the Hospital Outpatient Prospective 

Payment System 

B. Excluded OPPS Services and Hospitals 

C. Prior Rulemaking 

D. APC Advisory Panel 

1. Authority of the APC Panel 

2. Establishment of the APC Panel 

3. APC Panel Meetings and Organizational 

Structure 

E. Provisions of the Medicare Prescription 

Drug, Improvement, and Modernization 

Act of 2003 

1. Reduction in Threshold for Separate 

APCs for Drugs 

2. Special Payment for Brachytherapy 

F. Provisions of the Deficit Reduction Act 

of 2005 

1. 3-Year Transition of Hold Harmless 

Payments 

2. Medicare Coverage of Ultrasound 

Screening for Abdominal Aortic 

Aneurysms 

G. Summary of the Major Contents of This 

Proposed Rule 

1. Proposed Updates Affecting Payment for 

CY 2007 

2. Proposed Ambulatory Payment 

Classification (APC) Group Policies 

3. Proposed Payment Changes for Devices 

4. Proposed Payment Changes for Drugs, 

Biologicals, and Radiopharmaceuticals 

5. Estimate of Transitional Pass-Through 

Spending in CY 2007 for Drugs, 

Biologicals, and Radiopharmaceuticals 

6. Proposed Brachytherapy Payment 

Changes 

7. Proposed Coding and Payment for Drug 

and Vaccine Administration 

8. Proposed Hospital Coding for Evaluation 

and Management (E/M) Services 

9. Proposed Payment for Blood and Blood 

Products 

10. Proposed Payment for Observation 

Services 

11. Procedures That Will Be Paid Only as 

Inpatient Services 

12. Proposed Nonrecurring Policy Changes 

13. Emergency Medical Screening in 

Critical Access Hospitals (CAHs) 

14. Proposed OPPS Payment Status and 

Comment Indicator 

15. OPPS Policy and Payment 

Recommendations 

16. Proposed Policies Affecting 

Ambulatory Surgical Centers (ASCs) for 

CY 2007 

17. Proposed Revised Ambulatory Surgical 

Center (ASC) Payment System for 

Implementation January 1, 2008 

18. Medicare Provider Contractor Reform 

Mandate 

19. Reporting Quality Data for Improved 

Quality and Costs under the OPPS 

20. Promoting Effective Use of Health 

Information Technology 

21. Health Care Information Transparency 

Initiative 

22. Reporting Hospital Quality Data for 

Annual Payment Update under the IPPS 

23. Impact Analysis 

II. Proposed Updates Affecting OPPS 

Payments for CY 2007 

A. Proposed Recalibration of APC Relative 

Weights for CY 2007 

1. Database Construction 

a. Database Source and Methodology 

b. Proposed Use of Single and Multiple 

Procedure Claims 

c. Proposed Revision to the Overall Costto-Charge Ratio (CCR) Calculation 

2. Proposed Calculation of Median Costs 

for CY 2007 

3. Proposed Calculation of Scaled OPPS 

Payment Weights 

4. Proposed Changes to Packaged Services 

B. Proposed Payment for Partial 

Hospitalization 

1. Background 

2. Proposed PHP APC Update for CY 2007 

3. Proposed Separate Threshold for Outlier 

Payments to CMHCs 

C. Proposed Conversion Factor Update for 

CY 2007 

D. Proposed Wage Index Changes for CY 

2007 

E. Proposed Statewide Average Default 

CCRs 

F. OPPS Payments to Certain Rural 

Hospitals 

1. Hold Harmless Transitional Payment 

Changes Made by Pub. L. 109–171 (DRA) 

2. Proposed Adjustment for Rural SCHs 

Implemented in CY 2006 Related to Pub. 

L. 108–173 (MMA) 

G. Proposed CY 2007 Hospital Outpatient 

Outlier Payments 

H. Calculation of the Proposed OPPS 

National Unadjusted Medicare Payment 

I. Proposed Beneficiary Copayments for CY 

2007 

1. Background 

2. Proposed Copayment for CY 2007 

3. Calculation of a Proposed Adjusted 

Copayment Amount for an APC Group 

for CY 2007 

III. Proposed OPPS Ambulatory Payment 

Classification (APC) Group Policies 

A. Proposed Treatment of New HCPCS and 

CPT Codes 

1. Proposed Treatment of New HCPCS 

Codes Included in the Second and Third 

Quarterly OPPS Updates for CY 2006 

2. Proposed Treatment of New CY 2007 

Category I and III CPT Codes and Level 

II HCPCS Codes 

3. Proposed Treatment of New Mid-Year 

CPT Codes 

B. Proposed Changes—Variations Within 

APCs 

1. Background 

2. Application of the 2 Times Rule 

3. Exceptions to the 2 Times Rule 

C. New Technology APCs 

1. Introduction 

2. Proposed Movement of Procedures from 

New Technology APCs to Clinical APCs 

a. Nonmyocardial Positron Emission 

Tomography (PET) Scans 

b. PET/Computed Tomography (CT) Scans 

c. Stereotactic Radiosurgery (SRS) 

Treatment Delivery Services 

d. Magnetoencephalography (MEG) 

Services 

e. Other Services in New Technology APCs 

D. Proposed APC-Specific Policies 

1. Skin Replacement Surgery and Skin 

Substitutes (APCs 0024, 0025 and 0027) 

2. Treatment of Fracture/Dislocation (APC 

0046) 

3. Electrophysiologic Recording/Mapping 

(APC 0087) 

4. Insertion of Mesh or Other Prosthesis 

(APC 0154) 

5. Percutaneous Renal Cryoablation (APC 

0163) 

6. Keratoprosthesis (APC 0244) 

7. Medication Therapy Management 

Services 

8. Complex Interstitial Radiation Source 

Application (APC 0651) 

9. Single Allergy Tests (APC 0381) 

10. Hyperbaric Oxygen Therapy (APC 

0659) 

11. Myocardial Positron Emission 

Tomography (PET) Scans (APCs 0306, 

0307) 

12. Radiology Procedures (APCs 0333, 

0662, and Other Imaging APCs) 

IV. Proposed OPPS Payment Changes for 

Devices 

A. Proposed Treatment of DeviceDependent APCs 

1. Background 

2. Proposed CY 2007 Payment Policy 

3. Devices Billed in the Absence of an 

Appropriate Procedure Code 

4. Proposed Payment Policy When Devices 

are Replaced Without Cost or Where 

Credit for a Replaced Device is 

Furnished to the Hospital 

B. Proposed Pass-Through Payments for 

Devices 

1. Expiration of Transitional Pass-Through 

Payments for Certain Devices 

a. Background 

b. Proposed Policy for CY 2007 

2. Provisions for Reducing Transitional 

Pass-Through Payments to Offset Costs 

Packaged Into APC Groups 

a. Background 

b. Proposed Policy for CY 2007 

V. Proposed OPPS Payment Changes for 

Drugs, Biologicals, and 

Radiopharmaceuticals 

A. Proposed Transitional Pass-Through 

Payment for Additional Costs of Drugs 

and Biologicals 

1. Background 

2. Expiration in CY 2006 of Pass-Through 

Status for Drugs and Biologicals 

3. Drugs and Biologicals With Proposed 

Pass-Through Status in CY 2007 


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B. Proposed Payment for Drugs, 

Biologicals, and Radiopharmaceuticals 

Without Pass-Through Status 

1. Background 

2. Proposed Criteria for Packaging Payment 

for Drugs, Biologicals, and 

Radiopharmaceuticals 

3. Proposed Payment for Drugs, 

Biologicals, and Radiopharmaceuticals 

Without Pass-Through Status That Are 

Not Packaged 

a. Proposed Payment for Specified Covered 

Outpatient Drugs 

b. Proposed CY 2007 Payment for NonpassThrough Drugs, Biologicals, 

Radiopharmaceuticals With HCPCS 

Codes, But Without OPPS Hospital 

Claims Data 

VI. Proposed Estimate of OPPS Transitional 

Pass-Through Spending in CY 2007 for 

Drugs, Biologicals, 

Radiopharmaceuticals, and Devices 

A. Total Allowed Pass-Through Spending 

B. Proposed Estimate of Pass-Through 

Spending for CY 2007 

VII. Proposed Brachytherapy Source Payment 

Changes 

A. Background 

B. Proposed Payments for Brachytherapy 

Sources in CY 2007 

VIII. Proposed Changes to OPPS Drug 

Administration Coding and Payment for 

CY 2007 

A. Background 

B. Proposed CY 2007 Drug Administration 

Coding Changes 

C. Proposed CY 2007 Drug Administration 

Payment Changes 

IX. Proposed Hospital Coding and Payment 

for Visits 

A. Background 

1. Guidelines Based on the Number or 

Type of Staff Interventions 

2. Guidelines Based on the Time Staff 

Spent With the Patient 

3. Guidelines Based on a Point System 

Where a Certain Number of Points Are 

Assigned to Each Staff Intervention 

Based on the Time, Intensity, and Staff 

Type Required for the Intervention 

4. Guidelines Based on Patient Complexity 

B. CY 2007 Proposed Coding 

1. Clinic Visits 

2. Emergency Department Visits 

3. Critical Care Services 

C. CY 2007 Proposed Payment Policy 

D. CY 2007 Proposed Treatment of 

Guidelines 

1. Background 

2. Outstanding Concerns With the AHA/ 

AHIMA Guidelines 

a. Three Versus Five Levels of Codes 

b. Lack of Clarity for Some Interventions 

c. Treatment of Separately Payable Services 

d. Some Interventions Appear Overvalued 

e. Concerns of Specialty Clinics 

f. American with Disabilities Act 

g. Differentiation Between New and 

Established Patients, and Between 

Standard Visits and Consultations 

h. Distinction Between Type A and Type 

B Emergency Departments 

X. Proposed Payment for Blood and Blood 

Products 

A. Background 

B. Proposed Policy Changes for CY 2007 

XI. Proposed OPPS Payment for Observation 

Services 

XII. Proposed Procedures That Will Be Paid 

Only as Inpatient Procedures 

A. Background 

B. Proposed Changes to the Inpatient Only 

List 

C. Proposed CY 2007 Payment for 

Ancillary Outpatient Services When 

Patient Expires (-CA Modifier) 

1. Background 

2. Proposed Policy for CY 2007 

XIII. Proposed OPPS Nonrecurring Policy 

Changes 

A. Removal of Comprehensive Outpatient 

Rehabilitation Facility (CORF) Services 

from the List of Services Paid under the 

OPPS 

B. Addition of Ultrasound Screening for 

Abdominal Aortic Aneurysms (AAAs) 

(Section 5112 of Pub. L. 109–171 (DRA)) 

1. Background 

2. Proposed Assignment of New HCPCS 

Code for Payment of Ultrasound 

Screening for Abdominal Aortic 

Aneurysm (AAA) (Section 5112) 

3. Handling of Comments Received in 

Response to This Proposal 

XIV. Emergency Medical Screening in 

Critical Access Hospitals (CAHs) 

A. Background 

B. Proposed Policy Change 

XV. Proposed OPPS Payment Status and 

Comment Indicators 

A. Proposed CY 2007 Status Indicator 

Definitions 

1. Proposed Payment Status Indicators to 

Designate Services That Are Paid Under 

the OPPS 

2. Proposed Payment Status Indicators to 

Designate Services That Are Paid Under 

a Payment System Other Than the OPPS 

3. Proposed Payment Status Indicators to 

Designate Services That Are Not 

Recognized Under the OPPS But That 

May Be Recognized by Other 

Institutional Providers 

4. Proposed Payment Status Indicators to 

Designate Services That Are Not Payable 

by Medicare 

B. Proposed CY 2007 Comment Indicator 

Definitions 

XVI. OPPS Policy and Payment 

Recommendations 

A. MedPAC Recommendations 

B. APC Panel Recommendations 

C. GAO Recommendations 

XVII. Proposed Policies Affecting 

Ambulatory Surgical Centers (ASCs) for 

CY 2007 

A. ASC Background 

1. Legislative History 

2. Current Payment Method 

3. Published Changes to the ASC List 

B. Proposed ASC List Update Effective for 

Services Furnished on or After January 1, 

2007 

1. Criteria for Additions to or Deletions 

from the ASC List 

2. Response to Comments to the May 4, 

2005 Interim Final Rule for the ASC 

Update 

3. Procedures Proposed for Additions to 

the ASC List 

4. Suggested Additions Not Accepted 

5. Rationale for Payment Assignment 

6. Other Comments on the May 4, 2005 

Interim Final Rule 

C. Proposed Regulatory Changes for CY 

2007 

D. Implementation of Section 5103 of Pub. 

L. 109–171 (DRA) 

E. Proposal to Modify the Current ASC 

Process for Adjusting Payment for New 

Technology Intraocular Lenses (NTIOLs) 

1. Background 

a. Current ASC Payment for Insertion of 

IOLs 

b. Classes of NTIOLs Approved for 

Payment Adjustment 

2. Proposed Changes 

a. Process for Recognizing IOLs as 

Belonging to an Active IOL Class 

b. Public Notice and Comment Regarding 

Adjustments of NTIOL Payment 

Amounts 

c. Factors CMS Considers in Determining 

Whether a Payment Adjustment for 

Insertion of a New Class of IOL is 

Appropriate 

d. Proposal to Revise Content of a Request 

to Review 

e. Notice of CMS Determination 

f. Proposed Payment Adjustment 

XVIII. Proposed Revised ASC Payment 

System for Implementation January 1, 

2008 

A. Background 

1. Provisions of Pub. L. 108–173 

2. Other Factors Considered 

B. Procedures Proposed for Medicare 

Payment in ASCs Effective for Services 

Furnished on or After January 1, 2008 

1. Proposed Payable Procedures 

a. Proposed Definition of Surgical 

Procedure 

b. Procedures Proposed for Exclusion from 

Payment Under the Revised ASC System 

2. Proposed Treatment of Unlisted 

Procedure Codes and Procedures That 

Are Not Paid Separately Under the OPPS 

3. Proposed Treatment of Office-Based 

Procedures 

4. Listing of Surgical Procedures Proposed 

for Exclusion from Payment of an ASC 

Facility Fee Under the Revised Payment 

System 

C. Proposed Ratesetting Method 

1. Overview of Current ASC Payment 

System 

2. Proposal to Base ASC Relative Payment 

Weights on APC Groups and Relative 

Payment Weights Established Under the 

OPPS 

3. Proposed Packaging Policy 

4. Payment for Corneal Tissue Under the 

Revised ASC Payment System 

5. Proposed Payment for Office-Based 

Procedures 

6. Payment Policy for Multiple Procedure 

Discounting 

7. Proposed Geographic Adjustment 

8. Proposed Adjustment for Inflation 

9. Proposed Beneficiary Coinsurance 

10. Proposed to Phase in Implementation 

of Payment Rates Calculated Under the 

CY 2008 Revised ASC Payment System 

11. Proposed Calculation of ASC 

Conversion Factor and Payment Rates for 

CY 2008 

a. Overview 

b. Budget Neutrality Requirement 


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c. Proposed Calculation of the ASC 

Payment Rates for CY 2008 

d. Proposed Calculation of the ASC 

Payment Rates for CY 2009 and Future 

Years 

e. Alternative Option for Calculating the 

Budget Neutrality Adjustment 

Considered 

12. Proposed Annual Updates 

D. Information in Addenda Related to the 

Revised CY 2008 ASC Payment System 

E. Technical Changes to 42 CFR Parts 414 

and 416 

XIX. Medicare Contracting Reform Mandate 

A. Background 

B. CMS’s Vision for Medicare Fee-forService and MACs 

C. Provider Nomination and the Former 

Medicare Acquisition Authorities 

D. Summary of Changes Made to Sections 

1816 of the Act 

E. Provisions of the Proposed Regulations 

1. Definitions 

2. Assignments of Providers and Suppliers 

to MACs 

3. Other Proposed Technical and 

Conforming Changes 

a. Definition of ‘‘Intermediary’’

b. Intermediary Functions 

c. Options Available to Providers and CMS 

d. Nomination for Intermediary 

e. Notification of Actions on Nominations, 

Changes to Another Intermediary or to 

Director Payment, and Requirements for 

Approval of an Agreement 

f. Considerations Relating to the Effective 

and Efficient Administration of the 

Medicare Program 

g. Assignment and Reassignment of 

Providers by CMS 

h. Designation of National or Regional 

Intermediaries and Designation of 

Regional and Alternative Designated 

Regional Intermediaries for Home Health 

Agencies and Hospices 

i. Awarding of Experimental Contracts 

XX. Reporting Quality Data for Improved 

Quality and Costs under the OPPS 

XXI. Promoting Effective Use of Health Care 

Technology 

XXII. Health Care Information Transparency 

Initiative 

XXIII. Additional Quality Measures and 

Procedures for Hospital Reporting of 

Quality Data for the FY 2008 IPPS 

Annual Payment Update 

A. Background 

B. Proposed Additional Quality Measures 

for FY 2008 

1. Introduction 

2. HCAHPS Survey and the Hospital 

Quality Initiative 

3. Surgical Care Improvement Project 

(SCIP) Quality Measures 

4. Mortality Outcome Measures 

C. General Procedures and Participation 

Requirements for the FY 2008 IPPS 

RHQDAPU Program 

D. HCAHPS Procedures and Participation 

Requirements for the FY 2008 IPPS 

RHQDAPU Program 

1. Introduction 

2. HCAHPS Hospital Pledge and 

Beginning Date for Data Collection 

3. HCAHPS Dry Run 

4. HCAHPS Data Collection Requirements 

5. HCAHPS Registration Requirements 

6. HCAHPS Additional Steps 

7. HCAHPS Survey Completion 

Requirements 

8. HCAHPS Public Reporting 

9. Reporting HCAHPS Results for MultiCampus Hospitals 

E. SCIP & Mortality Measure Requirements 

for the FY 2008 RHQDAPU Program 

F. Conclusion 

XXIV. Files Available to the Public Via the 

Internet 

XXV. Collection of Information Requirements 

XXVI. Response to Comments 

XXVII. Regulatory Impact Analysis 

A. Overall Impact 

1. Executive Order 12866 

2. Regulatory Flexibility Act (RFA) 

3. Small Rural Hospitals 

4. Unfunded Mandates 

5. Federalism 

B. Effects of Proposed OPPS Changes in 

This Proposed Rule 

1. Alternatives Considered 

a. Alternatives Considered for CPT Coding 

and Payment Policy for Evaluation and 

Management Codes 

b. Options Considered for Brachytherapy 

Source Payments 

c. Options Considered for Payment of 

Radiopharmaceuticals 

2. Limitation of Our Analysis 

3. Estimated Impact of This Proposed Rule 

on Hospitals 

4. Estimated Effect of This Proposed Rule 

on Beneficiaries 

5. Accounting Statement 

6. Conclusion 

C. Effects of Proposed Changes to the ASC 

Payment System for CY 2007 

1. Alternatives Considered 

2. Limitations on Our Analysis 

3. Estimated Effects of This Proposed Rule 

on ASCs 

4. Estimated Effects of This Proposed Rule 

on Beneficiaries 

5. Conclusion 

6. Accounting Statement 

D. Effects of the Proposed Revisions to the 

ASC Payment System for CY 2008 

1. Alternatives Considered 

2. Limitations on Our Analysis 

3. Estimated Effects of This Proposed Rule 

on ASCs 

4. Estimated Effects of This Proposed Rule 

on Beneficiaries 

5. Conclusion 

E. Effects of the Medicare Contractor 

Reform Mandate 

F. Effects of Proposed Additional Quality 

Measures and Procedures for Hospital 

Reporting of Quality Data for IPPS FY 

2008 

1. Alternatives Considered 

2. Estimated Effects of This Proposed Rule 

a. Effects on Hospitals 

b. Effects on Other Providers 

c. Effects on the Medicare and Medicaid 

Program 

G. Executive Order 12866 

Regulation Text 

Addenda 

Addendum A—OPPS Proposed List of 

Ambulatory Payment Classification 

(APCs) With Status Indicators (SI), 

Relative Weights, Payment Rates, and 

Copayment Amounts— CY 2007 

Addendum AA—Proposed List of Medicare 

Approved ASC Procedures for CY 2007 

With Additions and Payment Rates; 

Including Rates That Result From 

Implementation of Section 5103 of the 

DRA 

Addendum B—OPPS Proposed Payment 

Status by HCPCS Code and Related 

Information Calendar Year 2007 

Addendum BB—Proposed List of Medicare 

Approved ASC Procedures for CY 2008 

With Additions and Payment Rates 

Addendum CC—Proposed List of Procedures 

for CY 2008 Subject to Payment 

Limitation at the Medicare Physician Fee 

Schedule (MPFS) Nonfacility Amount 

Addendum D1—Proposed Payment Status 

Indicators 

Addendum D2—Proposed Comment 

Indicators 

Addendum E—Proposed CPT Codes That Are 

Paid Only as Inpatient Procedures 

I. Background for the OPPS 

A. Legislative and Regulatory Authority 

for the Hospital Outpatient Prospective 

Payment System 

When the Medicare statute was 

originally enacted, Medicare payment 

for hospital outpatient services was 

based on hospital-specific costs. In an 

effort to ensure that Medicare and its 

beneficiaries pay appropriately for 

services and to encourage more efficient 

delivery of care, the Congress mandated 

replacement of the reasonable costbased payment methodology with a 

prospective payment system (PPS). The 

Balanced Budget Act (BBA) of 1997 

(Pub. L. 105–33), added section 1833(t) 

to the Social Security Act (the Act) 

authorizing implementation of a PPS for 

hospital outpatient services (OPPS). 

The Medicare, Medicaid, and SCHIP 

Balanced Budget Refinement Act 

(BBRA) of 1999 (Pub. L. 106–113), made 

major changes in the hospital OPPS. 

The Medicare, Medicaid, and SCHIP 

Benefits Improvement and Protection 

Act (BIPA) of 2000 (Pub. L. 106–554), 

made further changes in the OPPS. 

Section 1833(t) of the Act was also 

amended by the Medicare Prescription 

Drug, Improvement, and Modernization 

Act (MMA) of 2003 (Pub. L. 108–173). 

The Deficit Reduction Act (DRA) of 

2005 (Pub. L. 109–171), enacted on 

February 8, 2006, made additional 

changes in the OPPS. A discussion of 

the provisions contained in Pub. L. 109–

171 that are specific to the calendar year 

(CY) 2007 OPPS is included in section 

II.F. of this preamble. 

The OPPS was first implemented for 

services furnished on or after August 1, 

2000. Implementing regulations for the 

OPPS are located at 42 CFR Part 419. 

Under the OPPS, we pay for hospital 

outpatient services on a rate-per-service 


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basis that varies according to the 

ambulatory payment classification 

(APC) group to which the service is 

assigned. We use Healthcare Common 

Procedure Coding System (HCPCS) 

codes (which include certain Current 

Procedural Terminology (CPT) codes) 

and descriptors to identify and group 

the services within each APC group. 

The OPPS includes payment for most 

hospital outpatient services, except 

those identified in section I.B. of this 

preamble. Section 1833(t)(1)(B)(ii) of the 

Act provides for Medicare payment 

under the OPPS for hospital outpatient 

services designated by the Secretary 

(which includes partial hospitalization 

services furnished by community 

mental health centers (CMHCs)) and 

hospital outpatient services that are 

furnished to inpatients who have 

exhausted their Part A benefits or who 

are otherwise not in a covered Part A 

stay. Section 611 of Pub. L. 108–173 

added provisions for Medicare coverage 

of an initial preventive physical 

examination, subject to the applicable 

deductible and coinsurance, as an 

outpatient department service, payable 

under the OPPS. 

The OPPS rate is an unadjusted 

national payment amount that includes 

the Medicare payment and the 

beneficiary copayment. This rate is 

divided into a labor-related amount and 

a nonlabor-related amount. The laborrelated amount is adjusted for area wage 

differences using the inpatient hospital 

wage index value for the locality in 

which the hospital or CMHC is located. 

All services and items within an APC 

group are comparable clinically and 

with respect to resource use (section 

1833(t)(2)(B) of the Act). In accordance 

with section 1833(t)(2) of the Act, 

subject to certain exceptions, services 

and items within an APC group cannot 

be considered comparable with respect 

to the use of resources if the highest 

median (or mean cost, if elected by the 

Secretary) for an item or service in the 

APC group is more than 2 times greater 

than the lowest median cost for an item 

or service within the same APC group 

(referred to as the ‘‘2 times rule’’). In 

implementing this provision, we use the 

median cost of the item or service 

assigned to an APC group. 

Special payments under the OPPS 

may be made for new technology items 

and services in one of two ways. Section 

1833(t)(6) of the Act provides for 

temporary additional payments which 

we refer to as ‘‘transitional pass-through 

payments’’ for at least 2 but not more 

than 3 years for certain drugs, biological 

agents, brachytherapy devices used for 

the treatment of cancer, and categories 

of other medical devices. For new 

technology services that are not eligible 

for transitional pass-through payments 

and for which we lack sufficient data to 

appropriately assign them to a clinical 

APC group, we have established special 

APC groups based on costs, which we 

refer to as new technology APCs. These 

new technology APCs are designated by 

cost bands which allow us to provide 

appropriate and consistent payment for 

designated new procedures that are not 

yet reflected in our claims data. Similar 

to pass-through payments, an 

assignment to a new technology APC is 

temporary; that is, we retain a service 

within a new technology APC until we 

acquire sufficient data to assign it to a 

clinically appropriate APC group. 

B. Excluded OPPS Services and 

Hospitals 

Section 1833(t)(1)(B)(i) of the Act 

authorizes the Secretary to designate the 

hospital outpatient services that are 

paid under the OPPS. While most 

hospital outpatient services are payable 

under the OPPS, section 

1833(t)(1)(B)(iv) of the Act excludes 

payment for ambulance, physical and 

occupational therapy, and speechlanguage pathology services, for which 

payment is made under a fee schedule. 

Section 614 of Pub. L. 108–173 

amended section 1833(t)(1)(B)(iv) of the 

Act to exclude OPPS payment for 

screening and diagnostic mammography 

services. The Secretary exercised the 

authority granted under the statute to 

exclude from the OPPS those services 

that are paid under fee schedules or 

other payment systems. Such excluded 

services include, for example, the 

professional services of physicians and 

nonphysician practitioners paid under 

the Medicare Physician Fee Schedule 

(MPFS); laboratory services paid under 

the clinical diagnostic laboratory fee 

schedule; services for beneficiaries with 

end-stage renal disease (ESRD) that are 

paid under the ESRD composite rate; 

and, services and procedures that 

require an inpatient stay that are paid 

under the hospital inpatient prospective 

payment system (IPPS). We set forth the 

services that are excluded from payment 

under the OPPS in § 419.22 of the 

regulations. 

Under § 419.20(b) of the regulations, 

we specify the types of hospitals and 

entities that are excluded from payment 

under the OPPS. These excluded 

entities include Maryland hospitals, but 

only for services that are paid under a 

cost containment waiver in accordance 

with section 1814(b)(3) of the Act; 

critical access hospitals (CAHs); 

hospitals located outside of the 50 

States, the District of Columbia, and 

Puerto Rico; and Indian Health Service 

hospitals. 

C. Prior Rulemaking 

On April 7, 2000, we published in the 

Federal Register a final rule with 

comment period (65 FR 18434) to 

implement a prospective payment 

system for hospital outpatient services. 

The hospital OPPS was first 

implemented for services furnished on 

or after August 1, 2000. Section 

1833(t)(9) of the Act requires the 

Secretary to review certain components 

of the OPPS not less often than annually 

and to revise the groups, relative 

payment weights, and other adjustments 

to take into account changes in medical 

practice, changes in technology, and the 

addition of new services, new cost data, 

and other relevant information and 

factors. 

Since initially implementing the 

OPPS, we have published final rules in 

the Federal Register annually to 

implement statutory requirements and 

changes arising from our experience 

with this system. We last published 

such a document on November 10, 2005 

(70 FR 68516). In that final rule with 

comment period, we revised the OPPS 

to update the payment weights and 

conversion factor for services payable 

under the CY 2006 OPPS on the basis 

of claims data from January 1, 2004, 

through December 31, 2004, and to 

implement certain provisions of Pub. L. 

108–173. In addition, we responded to 

public comments received on the 

provisions of November 15, 2004 final 

rule with comment period pertaining to 

the APC assignment of HCPCS codes 

identified in Addendum B of that rule 

with the new interim (NI) comment 

indicators; and public comments 

received on the July 25, 2005 OPPS 

proposed rule for CY 2006 (70 FR 

42674). 

We published a correction of the 

November 10, 2005 final rule with 

comment period on December 23, 2005 

(70 FR 76176). This correction 

document corrected a number of 

technical errors that appeared in the 

November 10, 2005 final rule with 

comment period. 

D. APC Advisory Panel 

1. Authority of the APC Panel 

Section 1833(t)(9)(A) of the Act, as 

amended by section 201(h) of the BBRA, 

requires that we consult with an outside 

panel of experts to review the clinical 

integrity of the payment groups and 

their weights under the OPPS. The Act 

further specifies that the panel will act 

in an advisory capacity. The Advisory 

Panel on Ambulatory Payment 


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Classification (APC) Groups (the APC 

Panel), discussed under section I.D.2. of 

this preamble, fulfills these 

requirements. The APC Panel is not 

restricted to using data compiled by 

CMS and may use data collected or 

developed by organizations outside the 

Department in conducting its review. 

2. Establishment of the APC Panel 

On November 21, 2000, the Secretary 

signed the initial charter establishing 

the APC Panel. This expert panel, which 

may be composed of up to 15 

representatives of providers subject to 

the OPPS (currently employed full-time, 

not as consultants, in their respective 

areas of expertise), reviews and advises 

CMS about the clinical integrity of the 

APC groups and their weights. For 

purposes of this Panel, consultants or 

independent contractors are not 

considered to be full-time employees. 

The APC Panel is technical in nature 

and is governed by the provisions of the 

Federal Advisory Committee Act 

(FACA). Since its initial chartering, the 

Secretary has twice renewed the APC 

Panel’s charter: on November 1, 2002, 

and on November 1, 2004. The current 

charter indicates, among other 

requirements, that the APC Panel 

continues to be technical in nature; is 

governed by the provisions of the 

FACA; may convene up to three 

meetings per year; has a Designated 

Federal Officer (DFO); and is chaired by 

a Federal official who also serves as a 

CMS medical officer. 

The current APC Panel membership 

and other information pertaining to the 

Panel, including its charter, Federal 

Register notices, meeting dates, agenda 

topics, and meeting reports can be 

viewed on the CMS Web site at http:// 

new.cms.hhs.gov/FACA/05_Advisory

PanelonAmbulatoryPayment

ClassificationGroups.asp. 

3. APC Panel Meetings and 

Organizational Structure 

The APC Panel first met on February 

27, February 28, and March 1, 2001. 

Since that initial meeting, the APC 

Panel has held nine subsequent 

meetings, with the last meeting taking 

place on March 1 and 2, 2006. (The APC 

Panel did not meet on March 3, 2006, 

as announced in the meeting notice 

published on December 23, 2005 (70 FR 

76313).) Prior to each meeting, we 

publish a notice in the Federal Register 

to announce the meeting and, when 

necessary, to solicit and announce 

nominations for APC Panel 

membership. 

The APC Panel has established an 

operational structure that, in part, 

includes the use of three subcommittees 

to facilitate its required APC review 

process. The three current 

subcommittees are the Data 

Subcommittee, the Observation 

Subcommittee, and the Packaging 

Subcommittee. The Data Subcommittee 

is responsible for studying the data 

issues confronting the APC Panel and 

for recommending options for resolving 

them. The Observation Subcommittee 

reviews and makes recommendations to 

the APC Panel on all issues pertaining 

to observation services paid under the 

OPPS, such as coding and operational 

issues. The Packaging Subcommittee 

studies and makes recommendations on 

issues pertaining to services that are not 

separately payable under the OPPS, but 

are bundled or packaged APC payments. 

Each of these subcommittees was 

established by a majority vote of the 

APC Panel during a scheduled APC 

Panel meeting. All subcommittee 

recommendations are discussed and 

voted upon by the full APC Panel. 

Discussions of the recommendations 

resulting from the APC Panel’s March 

2006 meeting are included in the 

sections of this preamble that are 

specific to each recommendation. For 

discussions of earlier APC Panel 

meetings and recommendations, we 

reference previous hospital OPPS final 

rules or the Web site mentioned earlier 

in this section. 

E. Provisions of the Medicare 

Prescription Drug, Improvement, and 

Modernization Act of 2003 

The Medicare Prescription Drug, 

Improvement, and Modernization Act 

(MMA) of 2003, Pub. L. 108–173, made 

changes to the Act relating to the 

Medicare OPPS. In the January 6, 2004 

interim final rule with comment period 

and the November 15, 2004 final rule 

with comment period, we implemented 

provisions of Pub. L. 108–173 relating to 

the OPPS that were effective for services 

provided in CY 2004 and CY 2005, 

respectively. In the November 10, 2005 

final rule with comment period, we 

implemented provisions of Pub. L. 108–

173 relating to the OPPS that went into 

effect for services provided in CY 2006 

(70 FR 68521). We note below those 

provisions of Pub. L. 108–173 that will 

expire at the end of CY 2006. 

1. Reduction in Threshold for Separate 

APCs for Drugs 

Section 621(a)(2) of Pub. L. 108–173 

amended section 1833(t)(16) of the Act 

to set a $50 per administration threshold 

for the establishment of separate APCs 

for drugs and biologicals furnished from 

January 1, 2005, through December 31, 

2006. Because this statutory provision 

will no longer be in effect for CY 2007, 

we have included a discussion of the 

proposed methodology that we would 

use for the drug administration 

threshold for CY 2007 in section V. of 

this preamble. 

2. Special Payment for Brachytherapy 

Section 621(b)(1) of Pub. L. 108–173 

amended section 1833(t)(16) of the Act 

to require that payment for 

brachytherapy devices consisting of a 

seed or seeds (or radioactive source) 

furnished on or after January 1, 2004, 

and before January 1, 2007, be paid 

based on the hospital’s charge for each 

device furnished, adjusted to cost. 

Because this statutory provision will no 

longer be in effect for CY 2007, we 

discuss our proposed methodology for 

payment for brachytherapy devices for 

CY 2007 in section VII.B. of this 

preamble. 

F. Provisions of the Deficit Reduction 

Act of 2005 

The Deficit Reduction Act (DRA) of 

2005, Pub. L. 109–171, enacted on 

February 8, 2006, included three 

provisions affecting the OPPS, as 

discussed below. 

1. 3-Year Transition of Hold Harmless 

Payments 

Section 5105 of Pub. L. 109–171 

provides a 3-year transition of hold 

harmless OPPS payments for hospitals 

located in a rural area with not more 

than 100 beds that are not defined as 

sole community hospitals (SCHs). This 

provision provides an increased 

payment for such hospitals for covered 

OPD services furnished on or after 

January 1, 2006, and before January 1, 

2009, if the OPPS payment they receive 

is less than the pre-BBA payment 

amount that they would have received 

for the same covered OPD services. This 

provision specifies that, in such cases, 

the amount of payment to the specified 

hospitals shall be increased by the 

applicable percentage of such 

difference. Section 5105 specifies the 

applicable percentage as 95 percent for 

CY 2006, 90 percent for CY 2007, and 

85 percent for CY 2008. 

2. Medicare Coverage of Ultrasound 

Screening for Abdominal Aortic 

Aneurysms 

Section 5112 of Pub. L. 109–171 

amended section 1861 of the Act to 

include coverage of ultrasound 

screening for abdominal aortic 

aneurysms for certain individuals on or 

after January 1, 2007. The provision will 

apply to individuals (a) Who receive a 

referral for such an ultrasound screening 

as a result of an initial preventive 

physical examination; (b) who have not 


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been previously furnished with an 

ultrasound screening under Medicare; 

and (c) who have a family history of 

abdominal aortic aneurysm or manifest 

risk factors included in a beneficiary 

category recommended for screening (as 

determined by the United States 

Preventive Services Task Force). 

Ultrasound screening for abdominal 

aortic aneurysm will be included in the 

initial preventive physical examination. 

Section 5112 also added ultrasound 

screening for abdominal aortic 

aneurysm to the list of services for 

which the beneficiary deductible does 

not apply. These amendments apply to 

services furnished on or after January 1, 

2007. 

G. Summary of the Major Content of 

This Proposed Rule 

In this proposed rule, we are setting 

forth proposed changes to the Medicare 

hospital OPPS for CY 2007. These 

changes would be effective for services 

furnished on or after January 1, 2007. 

We are setting forth proposed changes to 

the Medicare ASC program for CY 2007 

and CY 2008. We are setting forth 

proposed changes to the way we process 

FFS claims under Medicare Part A and 

Part B. Some of these changes were 

effective on October 1, 2005 and all of 

the changes are to be fully implemented 

by October 1, 2011. Finally, we are 

setting forth a notice seeking comments 

on the RHQDAPU program under the 

Medicare hospital IPPS for FY 2008. 

These changes would be effective for 

payments beginning with FY 2008. The 

following is a summary of the major 

changes that we are proposing to make: 

1. Proposed Updates Affecting Payments 

for CY 2007 

In section II. of this preamble, we set 

forth—

• The methodology used to 

recalibrate the proposed APC relative 

payment weights and the proposed 

recalibration of the relative payment 

weights for CY 2007. 

• The proposed payment for partial 

hospitalization, including the proposed 

separate threshold for outlier payments 

for CMHCs. 

• The proposed update to the 

conversion factor used to determine 

payment rates under the OPPS for CY 

2007. 

• The proposed retention of our 

current policy to apply the IPPS wage 

indices to wage adjust the APC median 

costs in determining the OPPS payment 

rate and the copayment standardized 

amount for CY 2007. 

• The proposed update of statewide 

average default cost-to-charge ratios. 

• Proposed changes relating to the 

expiring hold harmless payment 

provision. 

• Proposed changes to payment for 

rural sole community hospitals for CY 

2007. 

• Proposed changes in the way we 

calculate hospital outpatient outlier 

payments for CY 2007. 

• Calculation of the proposed 

national unadjusted Medicare OPPS 

payment. 

• The proposed beneficiary 

copayment for OPPS services for CY 

2007. 

2. Proposed Ambulatory Payment 

Classification (APC) Group Policies 

In section III. of this preamble, we 

discuss the proposed additions of new 

procedure codes to the APCs; our 

proposal to establish a number of new 

APCs; and our proposal to make 

changes to the assignment of HCPCS 

codes under a number of existing APCs 

based on our analyses of Medicare 

claims data and recommendations of the 

APC Panel. We also discuss the 

application of the 2 times rule and 

proposed exceptions to it; proposed 

changes for specific APCs; the proposed 

refinement of the New Technology cost 

bands; and the proposed movement of 

procedures from the New Technology 

APCs. 

3. Proposed Payment Changes for 

Devices 

In section IV. of this preamble, we 

discuss proposed changes to the devicedependent APCs, and to the passthrough payment for categories of 

devices. 

4. Proposed Payment Changes for Drugs, 

Biologicals, and Radiopharmaceuticals 

In section V. of this preamble, we 

discuss proposed changes for drugs, 

biologicals, and radiopharmaceuticals. 

5. Estimate of Transitional Pass-Through 

Spending in CY 2007 for Drugs, 

Biologicals, and Devices 

In section VI. of this preamble, we 

discuss the proposed methodology for 

estimating total pass-through spending 

and whether there should be a pro rata 

reduction for transitional pass-through 

drugs, biologicals, 

radiopharmaceuticals, and categories of 

devices for CY 2007. 

6. Proposed Brachytherapy Payment 

Changes 

In section VII. of this preamble, we 

discuss our proposal concerning coding 

and payment for the sources of 

brachytherapy. 

7. Proposed Coding and Payment for 

Drug and Vaccine Administration 

In section VIII. of this preamble, we 

discuss our proposed coding and 

payment changes for drug and vaccine 

administration services. 

8. Proposed Hospital Coding for 

Evaluation and Management (E/M) 

Services 

In section IX. of this preamble, we 

discuss our proposal for developing the 

coding guidelines for evaluation and 

management services. 

9. Proposed Payment for Blood and 

Blood Products 

In section X. of this preamble, we 

discuss our proposed payment changes 

for blood and blood products. 

10. Proposed Payment for Observation 

Services 

In section XI. of this preamble, we 

discuss our proposed criteria and 

coding changes for separately payable 

observation services. 

11. Procedures That Will Be Paid Only 

as Inpatient Services 

In section XII. of this preamble, we 

discuss the procedures that we propose 

to remove from the inpatient list and 

assign to APCs. 

12. Proposed Nonrecurring Policy 

Changes 

In section XIII. of this preamble, we 

discuss proposed changes to certain 

comprehensive outpatient rehabilitation 

facility (CORF) services paid under the 

OPPS. In this section, we also discuss 

proposed payment for ultrasound 

screening for abdominal aortic 

aneurysms (AAAs). 

13. Emergency Medical Screening in 

Critical Access Hospitals (CAHs) 

In section XIV. of this preamble, we 

discuss proposed changes to a 

regulation governing emergency medical 

screening in critical access hospitals 

(CAHs). 

14. Proposed OPPS Payment Status and 

Comment Indicator 

In section XV. of this preamble, we 

discuss proposed changes to the list of 

status indicators assigned to APCs and 

present our proposed comment 

indicators for the CY 2007 OPPS final 

rule. 

15. OPPS Policy and Payment 

Recommendations 

In section XVI. of this preamble, we 

address recommendations made by 

MedPAC and the APC Panel regarding 

the OPPS for CY 2007. 


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16. Proposed Policies Affecting 

Ambulatory Surgical Centers (ASCs) for 

CY 2007 

In section XVII. of this preamble we 

discuss proposed payment changes 

affecting ASCs in CY 2007, the proposed 

list of updated ASC procedures, and 

proposed modification of the ASC 

payment adjustment process for new 

technology intraocular lenses (NTIOLs). 

17. Proposed Revised Ambulatory 

Surgical Center (ASC) Payment System 

for Implementation January 1, 2008 

In section XVIII. of this preamble, we 

discuss our proposal to implement a 

new ASC payment system for services 

furnished on or after January 1, 2008, 

and the regulatory changes related to the 

proposed new system. 

18. Medicare Provider Contractor 

Reform Mandate 

In section XIX. of this preamble, we 

discuss proposed changes to the 

regulations under 42 CFR Part 421, 

Subpart B to conform them to the 

statutory changes required by section 

911 of Public Law 108–173 related to 

Medicare contracting reform. 

19. Reporting Quality Data for Improved 

Quality and Costs Under the OPPS 

In section XX. of this preamble, we 

discuss the expenditure growth in 

outpatient hospital services, invite 

comment on value-based purchasing 

specifically related to hospital 

outpatient departments, and discuss a 

value-based purchasing program 

proposal for the CY 2007 OPPS. 

20. Promoting Effective Use of Health 

Information Technology 

In section XXI. of this preamble, we 

invite comments on promoting 

hospitals’ effective use of health 

information technology. 

21. Health Care Information 

Transparency Initiative 

In section XXII. of this preamble, we 

discuss HHS’ major health information 

transparency initiative which we are 

launching in 2006. 

22. Reporting Hospital Quality Data for 

Annual Payment Update Under the IPPS 

In section XXIII. of this preamble, we 

invite comment on our proposal for the 

FY 2008 IPPS annual payment update to 

add the HCAHPS survey, measures 

from the Surgical Care Improvement 

Project (SCIP), and Mortality measures 

to the quality of care measures to be 

used in FY 2007 for purposes of the 

IPPS annual payment update. 

23. Impact Analysis 

In section XXVII. of this preamble, we 

set forth an analysis of the impact that 

the proposed changes will have on 

affected entities and beneficiaries. 

II. Proposed Updates Affecting OPPS 

Payments for CY 2007 

A. Proposed Recalibration of APC 

Relative Weights for CY 2007 

(If you choose to comment on the 

issues in this section, please include the 

caption ‘‘APC Relative Weights’’ at the 

beginning of your comment.) 

1. Database Construction 

a. Database Source and Methodology 

Section 1833(t)(9)(A) of the Act 

requires that the Secretary review and 

revise the relative payment weights for 

APCs at least annually. In the April 7, 

2000 OPPS final rule with comment 

period (65 FR 18482), we explained in 

detail how we calculated the relative 

payment weights that were 

implemented on August 1, 2000, for 

each APC group. Except for some 

reweighting due to a small number of 

APC changes, these relative payment 

weights continued to be in effect for CY 

2001. This policy is discussed in the 

November 13, 2000 interim final rule 

(65 FR 67824 through 67827). 

We are proposing to use the same 

basic methodology that we described in 

the April 7, 2000 final rule with 

comment period to recalibrate the APC 

relative payment weights for services 

furnished on or after January 1, 2007, 

and before January 1, 2008. That is, we 

would recalibrate the relative payment 

weights for each APC based on claims 

and cost report data for outpatient 

services. We are proposing to use the 

most recent available data to construct 

the database for calculating APC group 

weights. For the purpose of recalibrating 

APC relative payment weights in this 

proposed rule for CY 2007, we used 

approximately 131.9 million final action 

claims for hospital OPD services 

furnished on or after January 1, 2005, 

and before January 1, 2006. Of the 131.9 

million final action claims for services 

provided in hospital outpatient settings, 

102.9 million claims were of the type of 

bill potentially appropriate for use in 

setting rates for OPPS services (but did 

not necessarily contain services payable 

under the OPPS). Of the 102.9 million 

claims, approximately 48.5 million were 

not for services paid under the OPPS or 

were excluded as not appropriate for 

use (for example, erroneous cost-tocharge ratios or no HCPCS codes 

reported on the claim). We were able to 

use 50.7 million whole claims of the 

remaining 54.4 million claims to set the 

proposed OPPS APC relative weights for 

CY 2007 OPPS. From the 50.7 million 

whole claims, we created 91.4 million 

single records, of which 62.8 million 

were ‘‘pseudo’’ single claims (created 

from multiple procedure claims using 

the process we discuss in this section). 

The proposed APC relative weights 

and payments for CY 2007 in Addenda 

A and B to this proposed rule were 

calculated using claims from this period 

that had been processed before January 

1, 2006. We selected claims for services 

paid under the OPPS and matched these 

claims to the most recent cost report 

filed by the individual hospitals 

represented in our claims data. We are 

proposing that the APC relative weights 

for CY 2007 continue to be based on the 

median hospital costs for services in the 

APC groups. For the CY 2007 OPPS 

final rule, we are proposing to base APC 

median costs on claims for services 

furnished in CY 2005 and processed 

before June 30, 2006. 

b. Proposed Use of Single and Multiple 

Procedure Claims 

For CY 2007, we are proposing to 

continue to use single procedure claims 

to set the medians on which the APC 

relative payment weights would be 

based. We have received many requests 

asking that we ensure that the data from 

claims that contain charges for multiple 

procedures are included in the data 

from which we calculate the relative 

payment weights. Requesters believe 

that relying solely on single procedure 

claims to recalibrate APC relative 

payment weights fails to take into 

account data for many frequently 

performed procedures, particularly 

those commonly performed in 

combination with other procedures. 

They believe that, by depending upon 

single procedure claims, we base 

relative payment weights on the least 

costly services, thereby introducing 

downward bias to the medians on 

which the weights are based. 

We agree that, optimally, it is 

desirable to use the data from as many 

claims as possible to recalibrate the APC 

relative payment weights, including 

those with multiple procedures. We 

generally use single procedure claims to 

set the median costs for APCs because 

we are, so far, unable to ensure that 

packaged costs can be appropriately 

allocated across multiple procedures 

performed on the same date of service. 

However, by bypassing specified codes 

that we believe do not have significant 

packaged costs, we are able to use more 

data from multiple procedure claims. In 

many cases, this enables us to create 

multiple ‘‘pseudo’’ single claims from 

claims that, as submitted, contained 


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multiple separately paid procedures on 

the same claim. For the CY 2007 OPPS, 

we are proposing to use the date of 

service on the claims and a list of codes 

to be bypassed to create ‘‘pseudo’’ single 

claims from multiple procedure claims, 

as we did in recalibrating the CY 2006 

APC relative payment weights. We refer 

to these newly created single procedure 

claims as ‘‘pseudo’’ single claims 

because they were submitted by 

providers as multiple procedure claims. 

For CY 2003, we created ‘‘pseudo’’

single claims by bypassing HCPCS 

codes 93005 (Electrocardiogram, 

tracing), 71010 (Chest x-ray), and 71020 

(Chest x-ray) on a submitted claim. 

However, we did not use claims data for 

the bypassed codes in the creation of the 

median costs for the APCs to which 

these three codes were assigned because 

the level of packaging that would have 

remained on the claim after we selected 

the bypass code was not apparent and, 

therefore, it was difficult to determine if 

the medians for these codes would be 

correct. 

For CY 2004, we created ‘‘pseudo’’

single claims by bypassing these three 

codes and also by bypassing an 

additional 269 HCPCS codes in APCs. 

We selected these codes based on a 

clinical review of the services and 

because it was presumed that these 

codes had only very limited packaging 

and could appropriately be bypassed for 

the purpose of creating ‘‘pseudo’’ single 

claims. The APCs to which these codes 

were assigned were varied and included 

mammography, cardiac rehabilitation, 

and Level I plain film x-rays. To derive 

more ‘‘pseudo’’ single claims, we also 

split the claims where there were dates 

of service for revenue code charges on 

that claim that could be matched to a 

single procedure code on the claim on 

the same date. 

For the CY 2004 OPPS, as in CY 2003, 

we did not include the claims data for 

the bypassed codes in the creation of the 

APCs to which the 269 codes were 

assigned because, again, we had not 

established that such an approach was 

appropriate and would aid in accurately 

estimating the median costs for those 

APCs. For CY 2004, from approximately 

16.3 million otherwise unusable claims, 

we used approximately 9.5 million 

multiple procedure claims to create 

approximately 27 million ‘‘pseudo’’

single claims. For CY 2005, we 

identified 383 bypass codes and from 

approximately 24 million otherwise 

unusable claims, we used 

approximately 18 million multiple 

procedure claims to create 

approximately 52 million ‘‘pseudo’’

single claims. For CY 2005, we used the 

claims data for the bypass codes 

combined with the single procedure 

claims to set the median costs for the 

bypass codes. 

For CY 2006, we continued using the 

codes on the CY 2005 OPPS bypass list 

and expanded it to include 404 bypass 

codes, including 3 bladder 

catheterization codes (CPT codes 51701, 

51702, and 51703), which did not meet 

the empirical criteria discussed below 

for the selection of bypass codes. We 

added these three codes to the CY 2006 

bypass list because a decision to change 

their payment status from packaged to 

separately paid would have resulted in 

a reduction of the number of single bills 

on which we could base median costs 

for other major separately paid 

procedures that were billed on the same 

claim with these three procedure codes. 

That is, single bills which contained 

other procedures would have become 

multiple procedure claims when these 

bladder catheterization codes were 

converted to separately paid status. We 

believed and continue to believe that 

bypassing these three codes does not 

adversely affect the medians for other 

procedures because we believe that 

when these services are performed on 

the same day as another separately paid 

service, any packaging that appears on 

the claim would be appropriately 

associated with the other procedure and 

not with these codes. 

Consequently, for CY 2006, we 

identified 404 bypass codes for use in 

creating ‘‘pseudo’’ single claims and 

used some part of 90 percent of the total 

claims that were eligible for use in 

OPPS ratesetting and modeling in 

developing the final rule with comment 

period. This process enabled us to use, 

for CY 2006 OPPS, 88 million single 

bills for ratesetting: 55 million ‘‘pseudo’’

singles and 34 million ‘‘natural’’ single 

bills (bills that were submitted 

containing only one separately payable 

major HCPCS code). (These numbers do 

not sum to 88 million because more 

than 800,000 single bills were removed 

when we trimmed at the HCPCS level at 

+/¥3 standard deviations from the 

geometric mean.) 

For CY 2007, we are proposing to 

continue using date-of-service matching 

as a tool for creation of ‘‘pseudo’’ single 

claims and to continue the use of a 

bypass list to create ‘‘pseudo’’ single 

claims. The process we are proposing 

for CY 2007 OPPS results in our being 

able to use some part of 94.8 percent of 

the total claims that are eligible for use 

in the OPPS ratesetting and modeling in 

developing this proposed rule. This 

process enabled us to use, for CY 2007, 

62.8 million ‘‘pseudo’’ singles and 29.6 

million ‘‘natural’’ single bills. 

We are proposing to bypass the 454 

codes identified in Table 1 to create new 

single claims and to use the line-item 

costs associated with the bypass codes 

on these claims, together with the single 

procedure claims, in the creation of the 

median costs for the APCS into which 

they are assigned. Of the codes on this 

list, 404 codes were used for bypass in 

CY 2006. We are proposing to continue 

the use of the codes on the CY 2006 

OPPS bypass list and to expand it by 

adding codes that, using data presented 

to the APC Panel at its March 2006 

meeting, meet the same empirical 

criteria as those used in CY 2006 to 

create the bypass list, or which our 

clinicians believe would contain 

minimal packaging if the services were 

correctly coded (for example, 

ultrasound guidance). Our examination 

of the data against the criteria for 

inclusion on the bypass list, as 

discussed below for the addition of new 

codes, shows that the empirically 

selected codes used for bypass for the 

CY 2006 OPPS generally continue to 

meet the criteria or come very close to 

meeting the criteria, and we have 

received no comments against bypassing 

them. 

To facilitate comment, Table 1 

indicates the list of codes we are 

proposing to bypass for creation of 

‘‘pseudo’’ singles for CY 2007 OPPS. 

Bypass codes shown in Table 1 with an 

asterisk indicate the HCPCS codes we 

are proposing to add to the CY 2006 

OPPS listed codes for bypass in CY 

2007. The criteria we are proposing to 

use to determine the additional codes to 

add to the CY 2006 OPPS bypass list in 

order to create the bypass list for CY 

2007 OPPS are discussed below. 

The following empirical criteria were 

developed by reviewing the frequency 

and magnitude of packaging in the 

single claims for payable codes other 

than drugs and biologicals. We assumed 

that the representation of packaging on 

the single claims for any given code is 

comparable to packaging for that code in 

the multiple claims: 

• There were 100 or more single 

claims for the code. This number of 

single claims ensured that observed 

outcomes were sufficiently 

representative of packaging that might 

occur in the multiple claims. 

• Five percent or fewer of the single 

claims for the code had packaged costs 

on that single claim for the code. This 

criterion results in limiting the amount 

of packaging being redistributed to the 

payable procedure remaining on the 

claim after the bypass code is removed 

and ensures that the costs associated 

with the bypass code represent the cost 

of the bypassed service. 


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• The median cost of packaging 

observed in the single claim was equal 

to or less than $50. This limits the 

amount of error in redistributed costs. 

• The code is not a code for an 

unlisted service. 

In addition, we are proposing to add 

to the bypass list codes that our 

clinicians believe contain minimal 

packaging and codes for specified drug 

administration for which hospitals have 

requested separate payment but for 

which it is not possible to acquire 

median costs unless we add these codes 

to the bypass list. A more complete 

discussion of the effects of adding these 

drug administration codes to the bypass 

list is contained in the discussion of 

drug administration in section VIII.C. of 

this preamble. 

We specifically invite public 

comment on the ‘‘pseudo’’ single 

process, including the bypass list and 

the criteria. 

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c. Proposed Revision to the Overall 

Cost-to-Charge Ratio (CCR) Calculation 

We calculate both an overall CCR and 

cost center-specific cost-to-charge ratios 

(CCRs) for each hospital. For CY 2007 

OPPS, we are proposing to change the 

methodology for calculating the overall 

CCR. The overall CCR is used in many 

components of the OPPS. We use the 

overall CCR to estimate costs from 

charges on a claim when we do not have 

an accurate cost center CCR. This does 

not happen very often. For the vast 

majority of services, we are able to use 

a cost center CCR to estimate costs from 

charges. However, we also use the 

overall CCR to identify the outlier 

threshold, to model payments for 

services that are paid at charges reduced 

to cost, and, during implementation, to 

determine outlier payments and 

payments for other services. 

We have discovered that the 

calculation of the overall CCR that the 

fiscal intermediaries are using to 

determine outlier payment and payment 

for services paid at charges reduced to 

cost differs from the overall CCR that we 

use to model the OPPS. In Program 

Transmittal A–03–04 on ‘‘Calculating 

Provider-Specific Outpatient Cost-toCharge Ratios (CCRs) and Instructions 

on Cost Report Treatment of Hospital 

Outpatient Services Paid on a 

Reasonable Cost Basis’’ (January 17, 

2003), we revised the overall CCR 

calculation that the fiscal intermediaries 

use in determining outlier and other 

cost payments. Until this point, each 

fiscal intermediary had used an overall 

CCR provided by CMS, or calculated an 

updated CCR at the provider’s request 

using the same calculation. The 

calculation in Program Transmittal A–

03–04, that is, the fiscal intermediary 

calculation, diverged from the 

‘‘traditional’’ overall CCR that we used 

for modeling. It should be noted that the 

fiscal intermediary overall CCR 

calculation noted in Program 

Transmittal A–03–04 was created with 

feedback and input from the fiscal 

intermediaries. 

CMS’ ‘‘traditional’’ calculation 

consists of summing the total costs from 

Worksheet B, Part I (Column 27), after 

removing the costs for nursing and 

paramedical education (Columns 21 and 

24), for those ancillary cost centers that 

we believe contain most OPPS services, 

summing the total charges from 

Worksheet C, Part I (Columns 6 and 7) 

for the same set of ancillary cost centers, 

and dividing the former by the later. We 

exclude selected ancillary cost centers 

from our overall CCR calculation, such 

as 5700 Renal Dialysis, because we 

believe that the costs and charges in 

these cost centers are largely paid for 

under other payment systems. The 

specific list of ancillary cost centers, 

both standard and nonstandard, 

included in our overall CCR calculation 

is available on our Web site in the 

revenue center-to-cost center crosswalk 

workbook: http://www.cms.hhs.gov/ 

HospitalOutpatientPPS. 

The overall CCR calculation provided 

in Program Transmittal A–03–04, on the 

other hand, takes the CCRs from 

Worksheet C, Part I, Column 9, for each 

specified ancillary cost center; 

multiplies them by the Medicare Part B 

outpatient specific charges in each 

corresponding ancillary cost center from 

Worksheet D, Parts V and VI (Columns 

2, 3, 4, and 5 and subscripts thereof); 

and then divides the sum of these costs 

by the sum of charges for the specified 

ancillary cost centers from Worksheet D, 

Parts V and VI (Columns 2, 3, 4, and 5 

and subscripts thereof). Compared with 

our ‘‘traditional’’ overall CCR 

calculation that has been used for 

modeling OPPS and to calculate the 

median costs, this fiscal intermediary 

calculation of overall CCR fails to 

remove allied health costs and adds 

weighting by Medicare Part B charges. 

In comparing these two calculations, 

we discovered that, on average, the 

overall CCR calculation being used by 

the fiscal intermediary resulted in 

higher overall CCRs than under our 

‘‘traditional’’ calculation. Using the 

most recent cost report data available for 

every provider with valid claims for CY 

2004 as of November 2005, we 

estimated the median overall CCR using 

the traditional calculation to be 0.3040 

(mean 0.3223) and the median overall 

CCR using the fiscal intermediary 

calculation to be 0.3309 (mean 0.3742). 

There also was much greater variability 

in the fiscal intermediary calculation of 

the overall CCR. The standard deviation 

under the ‘‘traditional’’ calculation was 

0.1318, while the standard deviation 

using the fiscal intermediary’s 

calculation was 0.2143. In part, the 

higher median estimate for the fiscal 

intermediary calculation is attributable 

to the inclusion of allied health costs for 

the over 700 hospitals with allied health 

programs. It is inappropriate to include 

these costs in the overall CCR 

calculation, because CMS already 

reimburses hospitals for the costs of 

these programs through cost report 

settlement. The higher median estimate 

and greater variability also is a function 

of the weighting by Medicare Part B 

charges. Because the fiscal intermediary 

overall CCR calculation is higher, on 

average, CMS has underestimated the 

outlier payment thresholds and, 

therefore, overpaid outlier payments. 

We also have underestimated spending 

for services paid at charges reduced to 

cost in our budget neutrality estimates. 

In examining the two different 

calculations, we decided that elements 

of each methodology had merit. Clearly, 

as noted above, allied health costs 

should not be included in an overall 

CCR calculation. However, weighting by 

Medicare Part B charges from Worksheet 

D, Parts V and VI, makes the overall 

CCR calculation more specific to OPPS. 

Therefore, we are proposing to adopt a 

single overall CCR calculation that 

incorporates weighting by Medicare Part 

B charges but excludes allied health 

costs for modeling and payment. 

Specifically, the proposed calculation 

removes allied health costs from cost 

center CCR calculations for specified 

ancillary cost centers, as discussed 

above, multiplies them by the Medicare 

Part B charges on Worksheet D, Parts V 

and VI, and sums these estimated 

Medicare costs. This sum is then 

divided by the sum of the same 

Medicare Part B charges for the same 

specified set of ancillary cost centers. 

Using the same cost report data, we 

estimated a median overall CCR for the 

proposed calculation of 0.3081 (mean 

0.3389) with a standard deviation of 

0.1583. The similarity to the median 

and standard deviation of the 

‘‘traditional’’ overall CCR calculation 

noted above (median 0.3040 and 

standard deviation of 0.1318) masks 

some sizeable changes in overall CCR 

calculations for specific hospitals due 

largely to the inclusion of Medicare Part 

B weighting. 

In order to isolate the overall impact 

of adopting this methodology on APC 

medians, we used the first 9 months of 

CY 2005 claims data to estimate APC 

median costs varying only the two 

methods of determining overall CCR. 

We expected the impact to be limited 

because the majority of costs are 

estimated using a cost center-specific 

CCR and not the overall. As predicted, 

we observed minor changes in APC 

median costs from the adoption of the 

proposed overall CCR calculation. We 

largely observed differences of no more 

than 5 percent in either direction. The 

median overall percent change in APC 

cost estimates was -0.3 percent. We 

typically observe comparable changes in 

APC medians when we update our cost 

report data. The impact of the proposed 

CCR calculation on the outlier threshold 

is discussed further in section II. G. of 

this preamble. Using updated cost 

report data for the calculations in this 

proposed rule, we estimate a median 

overall CCR across all hospitals of 

0.2999 using the proposed overall CCR 

calculation. 


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We believe that a single overall CCR 

calculation should be used for all 

components of the OPPS for both 

modeling and payment. Therefore, we 

are proposing to use the modified 

overall CCR calculation as discussed 

above when the hospital-specific overall 

CCR is used for any of the following 

calculations—in the CMS calculation of 

median costs for OPPS ratesetting, in 

the CMS calculation of the outlier 

threshold, in the fiscal intermediary 

calculation of outlier payments, in the 

CMS calculation of statewide CCRs, in 

the fiscal intermediary calculation of 

pass-through payments for devices, and 

for any other fiscal intermediary 

payment calculation in which the 

current hospital-specific overall CCR 

may be used now or in the future. If this 

proposal is finalized, we would issue a 

Medicare program instruction to fiscal 

intermediaries that would instruct them 

to recalculate and use the hospitalspecific overall CCR as we are proposing 

for these purposes. 

2. Proposed Calculation of Median Costs 

for CY 2007 

In this section of the preamble, we 

discuss the use of claims to calculate the 

proposed OPPS payment rates for CY 

2007. The hospital outpatient 

prospective payment page on the CMS 

Web site on which this proposed rule is 

posted provides an accounting of claims 

used in the development of the 

proposed rates: http:// 

www.cms.hhs.gov/ 

HospitalOutpatientPPS. The accounting 

of claims used in the development of 

this proposed rule is included on the 

Web site under supplemental materials 

for the CY 2007 proposed rule. That 

accounting provides additional detail 

regarding the number of claims derived 

at each stage of the process. In addition, 

below we discuss the files of claims that 

comprise the data sets that are available 

for purchase under a CMS data user 

contract. Our CMS Web site, http:// 

www.cms.hhs.gov/ 

HospitalOutpatientPPS, includes 

information about purchasing the 

following two OPPS data files: ‘‘OPPS 

Limited Data Set’’ and ‘‘OPPS 

Identifiable Data Set.’’

We are proposing to use the following 

methodology to establish the relative 

weights to be used in calculating the 

proposed OPPS payment rates for CY 

2007 shown in Addenda A and B to this 

proposed rule. This methodology is as 

follows: 

We used outpatient claims for the full 

CY 2005, processed before January 1, 

2006, to set the relative weights for this 

proposed rule for CY 2007. To begin the 

calculation of the relative weights for 

CY 2007, we pulled all claims for 

outpatient services furnished in CY 

2005 from the national claims history 

file. This is not the population of claims 

paid under the OPPS, but all outpatient 

claims (including, for example, CAH 

claims, and hospital claims for clinical 

laboratory services for persons who are 

neither inpatients nor outpatients of the 

hospital). 

We then excluded claims with 

condition codes 04, 20, 21, and 77. 

These are claims that providers 

submitted to Medicare knowing that no 

payment will be made. For example, 

providers submit claims with a 

condition code 21 to elicit an official 

denial notice from Medicare and 

document that a service is not covered. 

We then excluded claims for services 

furnished in Maryland, Guam, and the 

U.S. Virgin Islands because hospitals in 

those geographic areas are not paid 

under the OPPS. 

We divided the remaining claims into 

the three groups shown below. Groups 

2 and 3 comprise the 103 million claims 

that contain hospital bill types paid 

under the OPPS. 

1. Claims that were not bill types 12X, 

13X, 14X (hospital bill types), or 76X 

(CMHC bill types). Other bill types are 

not paid under the OPPS and, therefore, 

these claims were not used to set OPPS 

payment. 

2. Claims that were bill types 12X, 

13X, or 14X (hospital bill types). These 

claims are hospital outpatient claims. 

3. Claims that were bill type 76X 

(CMHC). (These claims are later 

combined with any claims in item 2 

above with a condition code 41 to set 

the per diem partial hospitalization rate 

determined through a separate process.) 

For the CCR calculation process, we 

used the same general approach as we 

used in developing the final APC rates 

for CY 2006 (70 FR 68537), with a 

change to the development of the 

overall CCR as discussed above. That is, 

we first limited the population of cost 

reports to only those for hospitals that 

filed outpatient claims in CY 2005 

before determining whether the CCRs 

for such hospitals were valid. 

We then calculated the CCRs at a cost 

center level and overall for each 

hospital for which we had claims data. 

We did this using hospital-specific data 

from the Healthcare Cost Report 

Information System (HCRIS). We used 

the most recent available cost report 

data, in most cases, cost reports for CY 

2004. For this proposed rule, we used 

the most recent cost report available, 

whether submitted or settled. If the most 

recent available cost report was 

submitted but not settled, we looked at 

the last settled cost report to determine 

the ratio of submitted to settled cost 

using the overall CCR, and we then 

adjusted the most recent available 

submitted but not settled cost report 

using that ratio. We are proposing to use 

the most recently submitted cost reports 

to calculate the CCRs to be used to 

calculate median costs for the OPPS CY 

2007 final rule. We calculated both an 

overall CCR and cost center-specific 

CCRs for each hospital. We used the 

proposed overall CCR calculation 

discussed in II.A.1.c. of this preamble 

for all purposes. 

We then flagged CAH claims, which 

are not paid under the OPPS, and claims 

from hospitals with invalid CCRs. The 

latter included claims from hospitals 

without a CCR; those from hospitals 

paid an all-inclusive rate; those from 

hospitals with obviously erroneous 

CCRs (greater than 90 or less than 

.0001); and those from hospitals with 

CCRs that were identified as outliers (3 

standard deviations from the geometric 

mean after removing error CCRs). In 

addition, we trimmed the CCRs at the 

cost center level by removing the CCRs 

for each cost center as outliers if they 

exceeded +/-3 standard deviations from 

the geometric mean. This is the same 

methodology that we used in 

developing the final CY 2006 CCRs. For 

CY 2007, we are proposing to trim at the 

departmental CCR level to eliminate 

aberrant CCRs that, if found in high 

volume hospitals, could skew the 

medians. We used a four-tiered 

hierarchy of cost center CCRs to match 

a cost center to every possible revenue 

code appearing in the outpatient claims, 

with the top tier being the most 

common cost center and the last tier 

being the default CCR. If a hospital’s 

cost center CCR was deleted by 

trimming, we set the CCR for that cost 

center to ‘‘missing,’’ so that another cost 

center CCR in the revenue center 

hierarchy could apply. If no other 

departmental CCR could apply to the 

revenue code on the claim, we used the 

hospital’s overall CCR for the revenue 

code in question. For example, a visit 

reported under the clinic revenue code, 

but the hospital did not have a clinic 

cost center, we mapped the hospitalspecific overall CCR to the clinic 

revenue code. The hierarchy of CCRs is 

available for inspection and comment at 

the CMS Web site: http:// 

www.cms.hhs.gov/ 

HospitalOutpatientPPS. 

We then converted the charges to 

costs on each claim by applying the CCR 

that we believed was best suited to the 

revenue code indicated on the line with 

the charge. Table 2 below contains a list 

of the allowed revenue codes. Revenue 

codes not included in Table 2 are those 


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not allowed under the OPPS because 

their services cannot be paid under the 

OPPS (for example, inpatient room and 

board charges) and, thus charges with 

those revenue codes were not packaged 

for creation of the OPPS median costs. 

One exception is the calculation of 

median blood costs, as discussed in 

section X. of this preamble. 

Thus, we applied CCRs as described 

above to claims with bill types 12X, 

13X, or 14X, excluding all claims from 

CAHs and hospitals in Maryland, Guam, 

and the U.S. Virgin Islands, and claims 

from all hospitals for which CCRs were 

flagged as invalid. 

We identified claims with condition 

code 41 as partial hospitalization 

services of hospitals and moved them to 

another file. These claims were 

combined with the 76X claims 

identified previously to calculate the 

partial hospitalization per diem rate. 

We then excluded claims without a 

HCPCS code. We also moved claims for 

observation services to another file. We 

moved to another file claims that 

contained nothing but flu and 

pneumococcal pneumonia (‘‘PPV’’) 

vaccine. Influenza and PPV vaccines are 

paid at reasonable cost and, therefore, 

these claims are not used to set OPPS 

rates. We note that the two above 

mentioned separate files containing 

partial hospitalization claims and the 

observation services claims are included 

in the files that are available for 

purchase as discussed above. 

We next copied line-item costs for 

drugs, blood, and devices (the lines stay 

on the claim, but are copied off onto 

another file) to a separate file. No claims 

were deleted when we copied these 

lines onto another file. These line-items 

are used to calculate a per unit mean 

and median and a per administration 

mean and median for drugs, 

radiopharmaceutical agents, blood and 

blood products, and devices, including 

but not limited to brachytherapy 

sources, as well as other information 

used to set payment rates, including a 

unit to day ratio for drugs. 

We then divided the remaining claims 

into the following five groups: 

1. Single Major Claims: Claims with a 

single separately payable procedure 

(that is, status indicator S, T, V, or X), 

all of which would be used in median 

setting. 

2. Multiple Major Claims: Claims with 

more than one separately payable 

procedure (that is, status indicator S, T, 

V, or X), or multiple units for one 

payable procedure. As discussed below, 

some of these can be used in median 

setting. 

3. Single Minor Claims: Claims with a 

single HCPCS code that is packaged 

(that is, status indicator N) and not 

separately payable. 

4. Multiple Minor Claims: Claims with 

multiple HCPCS codes that are 

packaged (that is, status indicator N) 

and not separately payable. 

5. Non-OPPS Claims: Claims that 

contain no services payable under the 

OPPS (that is, all status indicators other 

than S, T, V, X, or N). These claims are 

excluded from the files used for the 

OPPS. Non-OPPS claims have codes 

paid under other fee schedules, for 

example, durable medical equipment or 

clinical laboratory, and do not contain 

either a code for a separately paid 

service or a code for a packaged service. 

In previous years, we made a 

determination of whether each HCPCS 

code was a major code, or a minor code, 

or a code other than a major or minor 

code. We used those code specific 

determinations to sort claims into these 

five identified groups. For CY 2007 

OPPS, we are proposing to use status 

indicators, as described above, to sort 

the claims into these groups. We believe 

that using status indicators is an 

appropriate way to sort the claims into 

these groups and also to make our 

process more transparent to the public. 

We further believe that this proposed 

method of sorting claims will enhance 

the public’s ability to derive useful 

information and become a more 

informed commenter on this proposed 

rule. 

We note that the claims listed in 

numbers 1, 2, 3, and 4 above are 

included in the data files that can be 

purchased as described above. 

We set aside the single minor, 

multiple minor claims and the nonOPPS claims (numbers 3, 4, and 5 

above) because we did not use these 

claims in calculating median cost. We 

then examined the multiple major 

claims for date of service to determine 

if we could break them into single 

procedure claims using the dates of 

service on all lines on the claim. If we 

could create claims with single major 

procedures by using date of service, we 

created a single procedure claim record 

for each separately paid procedure on a 

different date of service (that is, a 

‘‘pseudo’’ single). 

We then used the ‘‘bypass codes’’

listed in Table 1 of this preamble and 

discussed in section II.A.1.b. to remove 

separately payable procedures that we 

determined contain limited costs or no 

packaged costs, or were otherwise 

suitable for inclusion on the bypass list, 

from a multiple procedure bill. When 

one of the two separately payable 

procedures on a multiple procedure 

claim was on the bypass code list, we 

split the claim into two single procedure 

claims records. The single procedure 

claim record that contained the bypass 

code did not retain packaged services. 

The single procedure claim record that 

contained the other separately payable 

procedure (but no bypass code) retained 

the packaged revenue code charges and 

the packaged HCPCS charges. 

We also removed lines that contained 

multiple units of codes on the bypass 

list and treated them as ‘‘pseudo’’ single 

claims by dividing the cost for the 

multiple units by the number of units 

on the line. Where one unit of a single 

separately paid procedure code 

remained on the claim after removal of 

the multiple units of the bypass code, 

we created a ‘‘pseudo’’ single claim 

from that residual claim record, which 

retained the costs of packaged revenue 

codes and packaged HCPCS codes. This 

enables us to use claims that would 

otherwise be multiple procedure claims 

and could not be used. We excluded 

those claims that we were not able to 

convert to singles even after applying all 

of the techniques for creation of 

‘‘pseudo’’ singles. 

We then packaged the costs of 

packaged HCPCS codes (codes with 

status indicator ‘‘N’’ listed in 

Addendum B to this proposed rule) and 

packaged revenue codes into the cost of 

the single major procedure remaining on 

the claim. The list of packaged revenue 

codes is shown below in Table 2. 

After removing claims for hospitals 

with error CCRs, claims without HCPCS 

codes, claims for immunizations not 

covered under the OPPS, and claims for 

services not paid under the OPPS, 97.5 

million claims were left. Of these 97.5 

million claims, we were able to use 

some portion of 50.7 million whole 

claims (93.2 percent of the 54.4 million 

potentially usable claims) to create the 

91.4 million single and ‘‘pseudo’’ single 

claims for use in the CY 2007 median 

payment ratesetting. Approximately 43 

million claims were for services not 

paid under the OPPS. 

We also excluded (1) Claims that had 

zero costs after summing all costs on the 

claim and (2) claims containing 

payment flag 3. Effective for services 

furnished on or after July 1, 2004, the 

Outpatient Code Editor (OCE) assigns 

payment flag number 3 to claims on 

which hospitals submitted token 

charges for a service with status 

indicator ‘‘S’’ or ‘‘T’’ (a major separately 

paid service under OPPS) for which the 

fiscal intermediary is required to 

allocate the sum of charges for services 

with a status indicator equaling ‘‘S’’ or 

‘‘T’’ based on the weight for the APC to 

which each code is assigned. We do not 

believe that these charges, which were 

token charges as submitted by the 


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hospital, are valid reflections of hospital 

resources. Therefore, we are proposing 

to delete these claims. We also deleted 

claims for which the charges equal the 

revenue center payment (that is, the 

Medicare payment) on the assumption 

that where the charge equals the 

payment, to apply a CCR to the charge 

would not yield a valid estimate of 

relative provider cost. 

For the remaining claims, we then 

standardized 60 percent of the costs of 

the claim (which we have previously 

determined to be the labor-related 

portion) for geographic differences in 

labor input costs. We made this 

adjustment by determining the wage 

index that applied to the hospital that 

furnished the service and dividing the 

cost for the separately paid HCPCS code 

furnished by the hospital by that wage 

index. As has been our policy since the 

inception of the OPPS, we are proposing 

to use the pre-reclassified wage indices 

for standardization because we believe 

that they better reflect the true costs of 

items and services in the area in which 

the hospital is located than the postreclassification wage indices, and would 

result in the most accurate adjusted 

median costs. 

We also excluded claims that were 

outside 3 standard deviations from the 

geometric mean of units for each HCPCS 

code on the bypass list (because, as 

discussed above, we used claims that 

contain multiple units of the bypass 

codes). We then deleted 299,022 single 

bills reported with modifier 50 that 

were assigned to APCs that contained 

HCPCS codes that are considered to be 

conditional or independent bilateral 

procedures under the OPPS and that are 

subject to special payment provisions 

implemented through the OCE. Modifier 

50 signifies that the procedure was 

performed bilaterally. Although these 

are apparently single claims for a 

separately payable service and although 

there is only one unit of the code 

reported on the claim, the presence of 

modifier 50 signifies that two services 

were furnished. Therefore, costs 

reported on these claims are for two 

procedures and not for a single 

procedure. Hence, we deleted these 

multiple procedure records, which we 

would have treated as single procedure 

claims in prior OPPS updates. We are 

seeking comments on the relative 

benefits of deleting these claims versus 

dividing the costs for the two 

procedures by two to create two 

‘‘pseudo’’ single claims. 

We used the remaining claims to 

calculate median costs for each 

separately payable HCPCS code and 

each APC. The comparison of HCPCS 

and APC medians determines the 

applicability of the ‘‘2 times’’ rule. As 

stated previously, section 1833(t)(2) of 

the Act provides that, subject to certain 

exceptions, the items and services 

within an APC group cannot be 

considered comparable with respect to 

the use of resources if the highest 

median (or mean cost, if elected by the 

Secretary) for an item or service in the 

group is more than 2 times greater than 

the lowest median cost for an item or 

service within the same group (‘‘the 2 

times rule’’). Finally, we reviewed the 

medians and reassigned HCPCS codes to 

different APCs as deemed appropriate. 

Section III.B. of this preamble includes 

a discussion of the HCPCS code 

assignment changes that resulted from 

examination of the medians and for 

other reasons. The APC medians were 

recalculated after we reassigned the 

affected HCPCS codes. Both the HCPCS 

medians and the APC medians were 

weighted to account for the inclusion of 

multiple units of the bypass codes in the 

creation of pseudo single bills. 

A detailed discussion of the proposed 

medians for blood and blood products is 

included in section X. of this preamble. 

A discussion of the proposed medians 

for APCs that require one or more 

devices when the service is performed 

is included in section IV.A. of this 

preamble. A discussion of the proposed 

median for observation services is 

included in section XI. of this preamble 

and a discussion of the proposed 

median for partial hospitalization is 

included below in section II.B. of this 

preamble. 

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3. Proposed Calculation of Scaled OPPS 

Payment Weights 

Using the median APC costs 

discussed previously, we calculated the 

proposed relative payment weights for 

each APC for CY 2007 shown in 

Addenda A and B of this proposed rule. 

In prior years, we scaled all the relative 

payment weights to APC 0601 (Mid 

Level Clinic Visit) because it is one of 

the most frequently performed services 

in the hospital outpatient setting. We 

assigned APC 0601 a relative payment 

weight of 1.00 and divided the median 

cost for each APC by the median cost for 

APC 0601 to derive the relative payment 

weight for each APC. 

For CY 2007 OPPS, we are proposing 

to scale all of the relative payment 

weights to APC 0606 (Level III Clinic 

Visits) because we are proposing to 

delete APC 0601 as part of the 

reconfiguration of the visit APCs. We 

chose APC 0606 as the scaling base 

because under our proposal to 

reconfigure the APCs where clinic visits 

are assigned for CY 2007, APC 0606 is 

the middle level clinic visit APC (that 

is, Level III of five levels). We have 

historically used the median cost of the 

middle level clinic visit APC (that is 

APC 0601 through CY 2006) to calculate 

unscaled weights because mid-level 

clinic visits are among the most 

frequently performed services in the 

hospital outpatient setting. Therefore, to 

maintain consistency in using as a 

median the most frequently used 

services, we are proposing to continue 

to use the median cost of the middle 

clinic level, proposed ASC 0606, to 

calculate unscaled weights. Following 

our standard methodology, but using the 

proposed CY 2007 median for APC 

0606, we assigned APC 0606 a relative 

payment weight of 1.00 and divided the 

median cost of each APC by the median 

cost for APC 0606 to derive the unscaled 

relative payment weight for each APC. 

The choice of the APC on which to base 

the relative weights for all other APCs 

does not affect the payments made 

under the OPPS because we scale the 

weights for budget neutrality. 

Section 1833(t)(9)(B) of the Act 

requires that APC reclassification and 

recalibration changes, wage index 

changes, and other adjustments be made 

in a manner that assures that aggregate 

payments under the OPPS for CY 2007 

are neither greater than nor less than the 

aggregate payments that would have 

been made without the changes. To 

comply with this requirement 

concerning the APC changes, we 

compared aggregate payments using the 

CY 2006 relative weights to aggregate 

payments using the CY 2007 proposed 

relative payment weights. Based on this 

comparison, we adjusted the relative 

weights for purposes of budget 

neutrality. The unscaled relative 

payment weights were adjusted by 

1.354626473 for budget neutrality. We 

recognize the scaler, or weight scaling 

factor, for budget neutrality that we are 

proposing for CY 2007 is higher than 

any previous OPPS weight scaler as a 

result of our proposal to use APC 0606 

as the base for calculation of relative 

weights. Our proposed use of the 

median cost for APC 0606 of $83.67 

causes the unscaled weights to be lower 

than they would have been if we had 

chosen APC 0605 (Level 2 Clinic Visits; 

median $62.12) as the scaling base. The 

CY 2007 median cost of APC 0606 is 

significantly higher than the CY 2006 

median cost of APC 0601 for mid-level 

clinic visits, which was used in CY 2006 

and earlier years to calculate unscaled 

weights. Historically, the median cost 

for APC 0601 has been similar to the CY 

2007 proposed median cost for APC 

0605. In order to appropriately scale the 

total weight estimated for OPPS in CY 

2007 to be similar to the total weight in 

OPPS for CY 2006, we calculated a 

scaler of 1.354626473, which is higher 

using APC 0606 as the base than it 

would be if we used APC 0605 as the 

base. In addition to adjusting for 

increases and decreases in weight due 

the recalibration of APC medians, the 

scaler also accounts for any change in 

the base. 

The proposed relative payment 

weights listed in Addenda A and B of 

this proposed rule incorporate the 

recalibration adjustments discussed in 

sections II.A.1. and 2. of this preamble. 

Section 1833(t)(14)(H) of the Act, as 

added by section 621(a)(1) of Pub. L. 

108–173, states that ‘‘Additional 

expenditures resulting from this 

paragraph shall not be taken into 

account in establishing the conversion 

factor, weighting and other adjustment 

factors for 2004 and 2005 under 

paragraph (9) but shall be taken into 

account for subsequent years.’’ Section 

1833(t)(14) of the Act provides the 

payment rates for certain ‘‘specified 

covered outpatient drugs.’’ Therefore, 

the cost of those specified covered 

outpatient drugs (as discussed in section 

V. of this preamble) is now included in 

the budget neutrality calculations for CY 

2007 OPPS. 

Under section 1833(t)(16)(C) of the 

Act, as added by section 621(b)(1) of 

Pub. L. 108–173, payment for devices of 

brachytherapy consisting of a seed or 

seeds (or radioactive source) is to be 

made at charges adjusted to cost for 

services furnished on or after January 1, 

2004, and before January 1, 2007. As we 

stated in our January 6, 2004 interim 

final rule, charges for the brachytherapy 

sources were not used in determining 

outlier payments, and payments for 

these items were excluded from budget 

neutrality calculations for the CY 2006 

OPPS. We excluded these payments 

from budget neutrality calculations, in 

part, because of the challenge posed by 

estimating hospital-specific cost 

payment. For CY 2007, we are 

proposing a specific payment rate for 

brachytherapy sources, which will be 

subject to scaling for budget neutrality. 

(We provide a discussion of 

brachytherapy payment issues, 

including their continued exclusion 

from outlier payments, under section 

VII. of this preamble.) Therefore, the 

costs of brachytherapy sources are 

accounted for in the scaler of 

1.354626473. 

4. Proposed Changes to Packaged 

Services 

(If you choose to comment on the 

issues in this section, please include the 

caption ‘‘Packaged Services’’ at the 

beginning of your comment.) 

Payments for packaged services under 

the OPPS are bundled into the payments 

providers receive for separately payable 

services provided on the same day. 

Packaged services are identified by the 

status indicator ‘‘N.’’ Hospitals include 

charges for packaged services on their 

claims, and the costs associated with 

these packaged services are then 

bundled into the costs for separately 

payable procedures on those same 

claims in establishing payment rates for 

the separately payable services. This is 

consistent with the principles of a 

prospective payment system based upon 

groupings of services and in contrast to 

a fee schedule that provides individual 

payment for each service billed. 

Hospitals may use CPT codes to report 

any packaged services that were 

performed, consistent with CPT coding 

guidelines. 

As a result of requests from the 

public, a Packaging Subcommittee to the 

APC Panel was established to review all 

the procedural CPT codes with a status 

indicator of ‘‘N.’’ Providers have often 

suggested that many packaged services 

could be provided alone, without any 

other separately payable services on the 

claim, and requested that these codes 

not be assigned status indicator ‘‘N.’’ In 

deciding whether to package a service or 

pay for a code separately, we consider 

a variety of factors, including whether 

the service is normally provided 

separately or in conjunction with other 

services; how likely it is for the costs of 

the packaged code to be appropriately 

mapped to the separately payable codes 


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with which it was performed; and 

whether the expected cost of the service 

is relatively low. 

The Packaging Subcommittee 

identified areas for change for some 

packaged CPT codes that it believed 

could frequently be provided to patients 

as the sole service on a given date and 

that required significant hospital 

resources as determined from hospital 

claims data. 

Based on the comments received, 

additional issues, and new data that we 

shared with the Packaging 

Subcommittee concerning the packaging 

status of codes for CY 2007, the 

Packaging Subcommittee reviewed the 

packaging status of numerous HCPCS 

codes and reported its findings to the 

APC Panel at its March 2006 meeting. 

The APC Panel accepted the report of 

the Packaging Subcommittee, heard 

several presentations on certain 

packaged services, discussed the 

deliberations of the Packaging 

Subcommittee, and recommended 

that—

• CMS pay separately for HCPCS 

code 0069T (Acoustic heart sound 

recording and computer analysis only). 

• CMS maintain the packaged status 

of HCPCS code 0152T (Computer aided 

detection with further physician review 

for interpretation, with or without 

digitization of films radiographic 

images; chest radiograph(s)). 

• CMS maintain the packaged status 

of CPT code 36500 (venous 

catheterization for selective blood organ 

sampling). 

• CMS pay separately for CPT code 

36540 (Collect blood, venous access 

device) if there are no separately 

payable OPPS services on the claim. 

• CMS pay separately for CPT code 

36600 (Arterial puncture; withdrawal of 

blood for diagnosis) if there are no 

separately payable OPPS services on the 

claim. 

• CMS pay separately for CPT code 

38792 (Sentinel node identification) if 

there are no separately payable OPPS 

services on the claim. 

• CMS maintain the packaged status 

of CPT codes 74328 (Endoscopic 

catheterization of the biliary ductal 

system, radiological supervision and 

interpretation), 74329 (Endoscopic 

catheterization of the pancreatic ductal 

system, radiological supervision and 

interpretation), and 74330 (Combined 

endoscopic catheterization of the biliary 

and pancreatic ductal systems, 

radiological supervision and 

interpretation). 

• CMS pay separately for CPT code 

75893 (Venous sampling through 

catheter, with or without angiography, 

radiological supervision and 

interpretation) if there are no separately 

payable OPPS services on the claim. 

• CMS continue to separately pay for 

CPT code 76000 (Fluoroscopy, up to one 

hour physician time). 

• CMS maintain the packaged status 

of CPT codes 76001 (Fluoroscopy, 

physician time more than one hour), 

76003 ((Fluoroscopic guidance for 

needle placement), and 76005 

(Fluoroscopic guidance and localization 

of needle or catheter tip). 

• CMS maintain the packaged status 

of CPT codes 76937 (Ultrasound 

guidance for vascular access) and 75998 

(Fluoroscopic guidance for central 

venous access device placement, 

replacement, or removal). 

• CMS provide separate payment for 

CPT codes 94760 (Noninvasive ear or 

pulse oximetry for oxygen saturation; 

single determination), 94761 

(Noninvasive ear or pulse oximetry for 

oxygen saturation; multiple 

determinations), and 94762 

(Noninvasive ear or pulse oximetry for 

oxygen saturation by continuous 

overnight monitoring) if there are no 

separately payable OPPS services on the 

claim. 

• CMS pay separately for CPT code 

96523 (Irrigation of implanted venous 

access device) if there are no separately 

payable OPPS services on the claim. 

• CMS maintain the packaged status 

of HCPCS code G0269 (Placement of 

occlusive device into either a venous or 

arterial access site). 

• CMS pay separately for HCPCS 

code P9612 (Catheterization for 

collection of specimen, single patient) if 

there are no separately payable OPPS 

services on the claim. 

• CMS bring data to the next APC 

Panel meeting that show the following: 

(a) how the costs of packaged items and 

services are incorporated into the 

median costs of APCs and (b) how the 

costs of these packaged items and 

services influence payments for 

associated procedures. 

• The Packaging Subcommittee 

continue until the next APC Panel 

meeting. 

For CY 2007, we are proposing to 

maintain CPT code 0069T as a packaged 

service and not adopt the APC Panel’s 

recommendation to pay separately for 

this code. The service uses signal 

processing technology to detect, 

interpret, and document acoustical 

activities of the heart through special 

sensors applied to a patient’s chest. This 

code was a new Category III CPT code 

implemented in the CY 2005 OPPS and 

assigned a new interim status indicator 

of ‘‘N’’ in the CY 2005 OPPS final rule. 

The APC Panel recommended packaging 

CPT code 0069T for CY 2006, and we 

accepted that recommendation when we 

finalized the status indicator ‘‘N’’

assignment to 0069T for CY 2006. This 

code is indicated as an add-on code to 

an electrocardiography service, 

according to the AMA’s CY 2006 CPT 

book. In its presentation to the APC 

Panel, the manufacturer requested that 

we pay separately for CPT code 0069T 

and assign it to APC 0099 

(Electrocardiograms), based on its 

estimated cost and clinical 

characteristics. 

At the APC Panel meeting, the 

manufacturer stated that the acoustic 

heart sounds recording and analysis 

service may be provided with or 

without a separately reportable 

electrocardiogram. Members of the APC 

Panel engaged in extensive discussion 

of clinical scenarios as they considered 

whether CPT code 0069T could or could 

not be appropriately reported alone or 

in conjunction with several different 

procedure codes. We note that the 

parenthetical information following the 

AMA’s code descriptor indicates that 

CPT code 0069T is to be reported in 

conjunction with CPT code 93005 

(Electrocardiogram, routine ECG with at 

least 12 leads; tracing only, without 

interpretation and report). In addition, 

we do not believe that, based on its 

expected clinical uses as described by 

the manufacturer, CPT code 0069T 

would ever be performed as a sole 

service without other separately payable 

OPPS services and payment for CPT 

code 0069T could always be packaged 

into payments for those other services. 

Therefore, we believe that CPT code 

0069T is appropriately packaged 

because it is closely linked to the 

performance of an ECG, should never be 

reported alone, and is estimated to 

require only modest hospital resources. 

Using CY 2005 claims, we had only 9 

single claims for CPT code 0069T, with 

a median line-item cost of $1.93, 

consistent with its low expected cost. 

Packaging payment for CPT code 0069T 

is consistent with the principles of a 

prospective payment system that 

provides payments for groups of 

services. To the extent that the acoustic 

heart sounding recording service may be 

more frequently provided in the future 

in association with ECGs or other OPPS 

services as its clinical indications 

evolve, we expect that its cost would 

also be increasingly reflected in the 

median costs for those other services, 

particularly ECG procedures. 

For CY 2007, we are proposing to 

accept the APC Panel’s recommendation 

to maintain the packaged status of CPT 

code 0152T. The service involves the 

application of computer algorithms and 

classification technologies to chest x-ray 


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images to acquire and display 

information regarding chest x-ray 

regions that may contain indications of 

cancer. This code was a new Category 

III CPT code implemented in the CY 

2006 OPPS and assigned a new interim 

status indicator of ‘‘N’’ in the CY 2006 

OPPS final rule with comment period. 

The code is indicated as an add-on code 

to chest x-ray CPT codes, according to 

the AMA’s CY 2006 CPT book. In its 

presentation to the APC Panel, the 

manufacturer requested that we pay 

separately for this service and assign it 

to a New Technology APC with a 

payment rate of $15, based on its 

estimated cost, clinical considerations, 

and similarity to other image postprocessing services that are paid 

separately. 

Under the OPPS we make payment for 

medically necessary services either 

separately or packaged into our 

payments for other services. We agree 

with the APC Panel that packaged 

payment for diagnostic chest x-ray 

computer-aided detection (CAD) under 

a prospective payment methodology for 

outpatient hospital services is 

appropriate because of the close 

relationship of chest x-ray CAD to chest 

x-ray services and its projected modest 

cost. Because 0152T is a new CPT code 

for CY 2006, we have no CY 2005 

hospital claims data available for 

analysis. To the extent that CAD may be 

more frequently provided in the future 

to aid in the review of diagnostic chest 

x-rays as its clinical indications evolve, 

we expect that its cost would also be 

increasingly reflected in the median 

costs for chest x-ray procedures. 

For CY 2007, we are proposing to 

accept the recommendation of the APC 

Panel and maintain the packaged status 

of CPT code 36500. We note that several 

providers have commented that CPT 

code 36500 is sometimes billed only 

with its corresponding radiological 

supervision and interpretation code, 

75893, but with no other separately 

payable OPPS services. In those cases, 

the provider would not receive any 

payment. For CY 2006, we accepted the 

APC Panel’s recommendation to 

package both CPT codes 36500 and 

75893 and to examine claims data. Our 

initial review of several clinical 

scenarios submitted by the public 

seemed to suggest that other separately 

payable procedures, such as 

venography, would likely be billed on 

the same claim. Our claims data 

indicate that there are usually separately 

payable codes that are billed on claims 

with CPT codes 36500 and 75893. 

However, we acknowledge that these 

two codes may occasionally be provided 

without any separately payable 

procedures. In these uncommon 

instances, the provider historically has 

not received any payment under the 

OPPS. We also understand that there is 

a cost associated with registering a 

patient and providing these services. 

For CY 2006, we have approximately 

160 single claims for CPT code 75893, 

with a median cost of $269. Based on 

the proposal described below for 

‘‘special’’ packaged codes, for CY 2007, 

when CPT codes 36500 and 75893 are 

billed on a claim with no separately 

payable OPPS services, CPT code 75893 

would become separately payable and 

would receive payment for APC 0668. In 

this circumstance, payment for CPT 

code 36500 would be packaged into the 

separate payment for CPT code 75893. 

For CY 2007, we are proposing to 

accept the APC Panel’s recommendation 

and pay separately for CPT codes 36540, 

36600, 38792, 75893, 94762, and 96523 

when any of these codes appear on a 

claim with no separately payable OPPS 

services also reported for the same date 

of service. We will refer to this subset 

of codes as ‘‘special’’ packaged codes. 

We acknowledge that there is a cost to 

the hospital associated with registering 

and treating a patient, regardless of 

whether the specific service provided 

requires minimal or significant hospital 

resources. While we continue to believe 

that these ‘‘special’’ packaged codes are 

almost always provided along with a 

separately payable service, our claims 

analyses indicate that there are rare 

instances when one of these services is 

provided without another separately 

payable OPPS service on the claim for 

the same date of service. In these 

instances, providers do not currently 

receive any payment. Therefore, we are 

proposing to provide payment for the 

‘‘special’’ packaged codes listed above 

when they are billed on a claim without 

another separately payable OPPS service 

on the same date. When any of the 

‘‘special’’ packaged codes are billed 

with other codes that are separately 

payable under the OPPS on the same 

date of service, the ‘‘special’’ packaged 

code would be treated as a packaged 

code, and the cost of the packaged code 

would be bundled into the costs of the 

other separately payable services on the 

claim. The payments that the provider 

receives for the separately payable 

services would include the bundled 

payment for the packaged code(s). 

We have heard concerns from the 

public stating that they are unable to 

submit claims to CMS that report only 

packaged codes. We note that although 

these claims are processed by the OCE 

and are ultimately rejected for payment, 

they are received by CMS, and we have 

cost data for packaged services based 

upon these claims. However, we 

recognize that the data used in our 

analyses to assess the frequencies with 

which packaged services are provided 

alone and their median costs are 

somewhat limited. It is possible that an 

unknown number of hospitals chose not 

to submit claims to CMS when a 

packaged code(s) was provided without 

other separately payable services on 

their claims, realizing that they would 

not receive payment for those claims. 

While we have been told that some 

hospitals may bill for a low-level visit 

if a packaged service only is provided so 

that they receive some payment for the 

encounter, we note that providers 

should bill a low-level visit code in 

such circumstances only if the hospital 

provides a significant, separately 

identifiable low-level visit in 

association with the packaged service. 

Through OCE logic, the PRICER 

would automatically assign payment for 

a ‘‘special’’ packaged service reported 

on a claim if there are no other services 

separately payable under the OPPS on 

the claim for the same date of service. 

In all other circumstances, the ‘‘special’’

packaged codes would be treated as 

packaged services. We are proposing to 

assign status indicator ‘‘Q’’ to these 

‘‘special’’ packaged codes to indicate 

that they are usually packaged, except 

for special circumstances when they are 

separately payable. Through OCE logic, 

the status indicator of a ‘‘special’’

packaged code would be changed either 

to ‘‘N’’ or to the status indicator of the 

APC to which the code is assigned for 

separate payment, depending upon the 

presence or absence of other OPPS 

services also reported on the claim for 

the same date. Table 3 below lists the 

proposed status indicators and APC 

assignments for these ‘‘special’’

packaged codes when they are 

separately payable. We note that the 

payment for these ‘‘special’’ packaged 

codes is intended to make payment for 

all of the hospital costs, which may 

include patient registration and 

establishment of a medical record, in an 

outpatient hospital setting even when 

no separately payable services are 

provided to the patient on that day. 


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TABLE 3.—PROPOSED STATUS INDICATORS AND APC ASSIGNMENTS FOR ‘‘SPECIAL’’ PACKAGED CPT CODES

CPT code Descriptor Proposed CY 

2007 APC 

Proposed 

status 

indicator 

Proposed CY 

2007 APC 

median 

36540 ............................... Collect blood, venous access device .............................................. 0624 S .................. $32.96 

36600 ............................... Arterial puncture; withdrawal of blood for diagnosis ....................... 0035 T .................. 12.45 

38792 ............................... Sentinel node identification ............................................................. 0389 S .................. 86.92 

75893 ............................... Venous sampling through catheter, with or without angiography, 

radiological supervision and interpretation.

0668 S .................. 393.35 

94762 ............................... Noninvasive ear or pulse oximetry for oxygen saturation by continuous overnight monitoring.0443 X .................. 61.39 

96523 ............................... Irrigation of implanted venous access device ................................. 0624 S .................. 32.96 

In the case of a claim with two or 

more ‘‘special’’ packaged codes only 

reported on a single date of service, the 

PRICER would assign separate payment 

only to the ‘‘special’’ packaged code that 

would receive the highest payment. The 

other ‘‘special’’ codes would remain 

packaged and would not receive 

separate payment. 

We will monitor and analyze the 

claims frequency and claims detail for 

situations in which these codes are 

billed alone and then separately paid. 

This will allow us to determine both 

which providers are billing these codes 

most often and under what 

circumstances these codes are billed. 

We expect that hospitals scheduling and 

providing services efficiently to 

Medicare beneficiaries will continue to 

generally provide these minor services 

in conjunction with other medically 

necessary services. 

For CY 2007, we are proposing to 

accept the APC Panel’s recommendation 

and maintain the packaged status of 

CPT codes 74328, 74329, and 74330. 

The AMA notes that these radiological 

supervision and interpretation codes 

should be reported with procedure 

codes 43260–43272. In fact, our data 

indicate that these supervision and 

interpretation codes are billed with 

43260–43272 more than 90 percent of 

the time, indicating their routine use. 

We believe that some providers may be 

concerned that although the payment 

for the endoscopic procedure includes 

the bundled payment for the 

supervision and interpretation 

performed by the radiology department, 

the payment for the comprehensive 

service may be directed to the hospital 

department that performed the 

endoscopic procedure, rather than to the 

radiology department. While we 

understand this concern, the OPPS pays 

hospital for services provided, and we 

believe that hospitals are responsible for 

attributing payments to hospital 

departments as they believe appropriate. 

We do not believe that packaging these 

radiological supervision and 

interpretation codes leads to inaccurate 

payments for the full hospital resources 

associated with endoscopic retrograde 

cholangiopancreatography procedures. 

For CY 2007, we are proposing to 

accept the APC Panel’s recommendation 

to continue to package CPT codes 

76001, 76003, and 76005 and to 

continue to pay separately for CPT code 

76000. We received a comment which 

stated that it was inconsistent to pay 

separately for CPT code 76000 

(Fluoroscopy (separate procedure), up to 

one hour physician time) but to package 

CPT code 76001 (Fluoroscopy, 

physician time more than one hour) 

when CPT code 76001 appears to be a 

similar code, except that it is for a 

longer period of physician time. The 

Packaging Subcommittee believed that 

many of the claims that listed CPT code 

76001 were erroneously billed, as many 

of the procedure codes that were billed 

with CPT code 76001 included 

fluoroscopy as an integral part of the 

procedure. In other cases, the Packaging 

Subcommittee noted that a procedurespecific fluoroscopy code should 

probably have been billed, instead of 

CPT code 76001. The Packaging 

Subcommittee believed that CPT code 

76000 could often be provided as a sole 

service, with no other separately 

payable procedures. The Packaging 

Subcommittee recommended that CMS 

continue to pay separately for CPT code 

76000, consistent with the AMA’s 

definition of this code, which specifies 

that it is a separate procedure, and to 

continue to package CPT codes 76001, 

76003, and 76005. 

For CY 2007, we are proposing to 

accept the APC Panel’s recommendation 

to continue to package CPT codes 76937 

and 75998. In the CY 2006 OPPS final 

rule with comment period (70 FR 68544 

and 68545), we reviewed in detail the 

data related to these two codes and 

promised to share CY 2004 and early CY 

2005 data with the Packaging 

Subcommittee. We reviewed current 

data with the Packaging Subcommittee, 

and it recommended that we continue to 

package these codes. In summary, we 

believe that these services would always 

be provided with another separately 

payable procedure, so their costs would 

be appropriately bundled with the 

definitive vascular access device 

procedures. The costs for these guidance 

procedures are relatively low compared 

to the CY 2007 proposed payment rates 

for the separately payable services they 

most frequently accompany. If we were 

to unpackage CPT codes 76937 and 

75998, the single bills available to 

develop median costs for vascular 

access device insertion services would 

be significantly reduced. Therefore, we 

are proposing to continue to package 

both CPT codes 76937 and 75998 for CY 

2007. 

For CY 2007, we are proposing to 

accept the APC Panel’s recommendation 

to continue to package HCPCS code 

G0269. This code should never be billed 

without another separately payable 

procedure. Recent data indicate that 94 

percent of the time HCPCS code G0269 

was billed with either CPT code 93510 

or 93526. In addition, the median cost 

of G0269 is low compared to the costs 

of the procedures with which it is 

typically associated. 

For CY 2007, we are proposing to 

continue packaging CPT codes 94760 

(Noninvasive ear or pulse oximetry for 

oxygen saturation; single determination) 

and 94761 (Noninvasive ear or pulse 

oximetry for oxygen saturation; multiple 

determinations) and not adopt the APC 

Panel’s recommendation to provide 

separate payment for these services if 

there are no other separately payable 

OPPS services on the claim for the same 

date of service. Our data review 

revealed that these services are very 

frequently provided in the OPPS, with 

over 1 million claims in CY 2005 for the 

single pulse oximetry determination 

service and over 400,000 claims for the 

multiple determinations service. These 

high frequencies may actually be 

understated as both of these services are 

packaged codes, and we have been told 

that some hospitals may not report the 


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HCPCS codes for services for which 

they receive no separate payments. 

Single and multiple pulse oximetry 

determinations are almost always 

provided in association with other 

services that are separately payable 

under the OPPS, into which their costs 

may be appropriately packaged. 

Specifically, OPPS hospital claims data 

revealed that out of the total instances 

of CPT code 94760 appearing on claims 

used for setting payment rates for this 

CY 2007 OPPS proposed rule, CPT code 

94760 was billed only 4 percent of the 

time in association with no other 

separately payable OPPS services, with 

a median cost of $14. Using the same 

data, CPT code 94761 was billed only 7 

percent of the time in association with 

no other separately payable OPPS 

services, with a median cost of $36. 

These pulse oximetry services have a 

relatively low cost compared with the 

OPPS services they frequently 

accompany. If we were to provide 

separate payment for these pulse 

oximetry determinations when 

performed as stand alone procedures by 

hospitals, we are concerned that 

hospitals would lose their incentive to 

provide these basic, low cost, and brief 

services as efficiently as possible, 

generally during the same encounters 

where they are providing other services 

to the same patients. We believe their 

appropriate provision as single services 

should be very rare. Therefore, for CY 

2007 we are proposing not to include 

these codes on the list of ‘‘special’’

packaged codes, so their payment would 

remain packaged in all circumstances. 

For CY 2007, we are proposing to 

assign status indicator ‘‘A’’ to HCPCS 

code P9612 and reject the APC Panel’s 

recommendation to pay separately 

under the OPPS for this code when it is 

billed without any separately payable 

OPPS services. This code is currently 

payable on the clinical lab fee schedule. 

Its status indicator of ‘‘A’’ would 

provide payment for the service 

whenever it is billed, regardless of the 

presence or absence of other reported 

services. In addition, for consistency we 

are proposing to assign status indicator 

‘‘A’’ to HCPCS code P9615 as it is also 

payable on the clinical lab fee schedule. 

In general, when a code is payable on 

the clinical lab fee schedule, we defer to 

that fee schedule and do not assign 

payment under the OPPS. 

The APC Panel Packaging 

Subcommittee remains active, and 

additional issues and new data 

concerning the packaging status of 

codes will be shared for its 

consideration as information becomes 

available. We continue to encourage 

submission of common clinical 

scenarios involving currently packaged 

HCPCS codes to the Packaging 

Subcommittee for its ongoing review. 

Additional detailed suggestions for the 

Packaging Subcommittee should be 

submitted to APCPanel@cms.hhs.gov, 

with ‘‘Packaging Subcommittee’’ in the 

subject line. 

B. Proposed Payment for Partial 

Hospitalization 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Partial Hospitalization’’ at the 

beginning of your comment.) 

1. Background 

Partial hospitalization is an intensive 

outpatient program of psychiatric 

services provided to patients as an 

alternative to inpatient psychiatric care 

for beneficiaries who have an acute 

mental illness. A partial hospitalization 

program (PHP) may be provided by a 

hospital to its outpatients or by a 

Medicare-certified community mental 

health center (CMHC). Section 

1833(t)(1)(B)(i) of the Act provides the 

Secretary with the authority to designate 

the hospital outpatient services to be 

covered under the OPPS. The Medicare 

regulations at 42 CFR 419.21(c) that 

implement this provision specify that 

payments under the OPPS will be made 

for partial hospitalization services 

furnished by CMHCs. Section 

1883(t)(2)(C) of the Act requires that we 

establish relative payment weights 

based on median (or mean, at the 

election of the Secretary) hospital costs 

determined by 1996 claims data and 

data from the most recent available cost 

reports. Payment to providers under the 

OPPS for PHPs represents the provider’s 

overhead costs associated with the 

program. Because a day of care is the 

unit that defines the structure and 

scheduling of partial hospitalization 

services, we established a per diem 

payment methodology for the PHP APC, 

effective for services furnished on or 

after August 1, 2000. For a detailed 

discussion, we refer readers to the April 

7, 2000 OPPS final rule with comment 

period (65 FR 18452). 

Historically, the median per diem cost 

for CMHCs has greatly exceeded the 

median per diem cost for hospital-based 

PHPs and has fluctuated significantly 

from year to year while the median per 

diem cost for hospital-based PHPs has 

remained relatively constant ($200–

$225). We believe that CMHCs may have 

increased and decreased their charges in 

response to Medicare payment policies. 

As discussed in more detail in section 

II.B.2. of the preamble of this proposed 

rule and in the CY 2004 OPPS final rule 

with comment period (68 FR 63470), we 

believe that some CMHCs manipulated 

their charges in order to inappropriately 

receive outlier payments. 

In the CY 2003 OPPS update, the 

difference in median per diem cost for 

CMHCs and hospital-based PHPs was so 

great, $685 for CMHCs and $225 for 

hospital-based PHPs, that we applied an 

adjustment factor of .583 to CMHC costs 

to account for the difference between 

‘‘as submitted’’ and ‘‘final settled’’ cost 

reports. By doing so, the CMHC median 

per diem cost was reduced to $384, 

resulting in a combined hospital-based 

and CMHC PHP median per diem cost 

of $273. As with all APCs in the OPPS, 

the median cost for each APC was 

scaled relative to the cost of a mid-level 

office visit and the conversion factor 

was applied. The resulting per diem rate 

for PHP for CY 2003 was $240.03. 

In the CY 2004 OPPS update, the 

median per diem cost for CMHCs grew 

to $1,038, while the median per diem 

cost for hospital-based PHPs was again 

$225. After applying the .583 

adjustment factor in the CY 2004 

proposed rule to the median CMHC per 

diem cost, the median CMHC per diem 

cost was $605. Because the CMHC 

median per diem cost exceeded the 

average per diem cost of inpatient 

psychiatric care, we proposed a per 

diem rate for CY 2004 based solely on 

hospital-based PHP data. The proposed 

PHP per diem for CY 2004, after scaling, 

was $208.95. However, by the time we 

published the OPPS final rule with 

comment period for CY 2004, we had 

received updated CCRs for CMHCs. 

Using the updated CCRs significantly 

lowered the CMHC median per diem 

cost to $440. As a result, we determined 

that the higher per diem cost for CMHCs 

was not due to the difference between 

‘‘as submitted’’ and ‘‘final settled’’ cost 

reports, but was the result of excessive 

increases in charges which may have 

been done in order to receive higher 

outlier payments. Therefore, in 

calculating the PHP median per diem 

cost for CY 2004, we did not apply the 

.583 adjustment factor to CMHC costs to 

compute the PHP APC. Using the 

updated CCRs for CMHCs, the combined 

hospital-based and CMHC median per 

diem cost for PHP was $303. After 

scaling, we established the CY 2004 

PHP APC of $286.82. 

For CY 2005, the PHP per diem 

amount was based on 12 months of 

hospital and CMHC PHP claims data 

(for services furnished from January 1, 

2003, through December 31, 2003). We 

used data from all hospital bills 

reporting condition code 41, which 

identifies the claim as partial 

hospitalization, and all bills from 

CMHCs because CMHCs are Medicare 


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providers only for the purpose of 

providing partial hospitalization 

services. We used CCRs from the most 

recently available hospital and CMHC 

cost reports to convert each provider’s 

line-item charges as reported on bills, to 

estimate the provider’s cost for a day of 

PHP services. Per diem costs were then 

computed by summing the line-item 

costs on each bill and dividing by the 

number of days on the bill. 

In a Program Memorandum issued on 

January 17, 2003 (Transmittal A–03–

004), we directed fiscal intermediaries 

to recalculate hospital and CMHC CCRs 

by April 30, 2003, using the most 

recently settled cost reports. Following 

the initial update of CCRs, fiscal 

intermediaries were further instructed 

to continue to update a provider’s CCR 

and enter revised CCRs into the 

outpatient provider specific file. 

Therefore, for CMHCs, we used CCRs 

from the outpatient provider specific 

file. 

In the CY 2005 OPPS update, the 

CMHC median per diem cost was $310 

and the hospital-based PHP median per 

diem cost was $215. No adjustments 

were determined to be necessary and, 

after scaling, the combined median per 

diem cost of $289 was reduced to 

$281.33. We believed that the reduction 

in the CMHC median per diem cost 

indicated that the use of updated CCRs 

had accounted for the previous increase 

in CMHC charges, and represented a 

more accurate estimate of CMHC per 

diem costs for PHP. 

For the CY 2006 OPPS final rule with 

comment period, we analyzed 12 

months of the most current claims data 

available for hospital and CMHC PHP 

services furnished between January 1, 

2004, and December 31, 2004. We also 

used the most currently available CCRs 

to estimate costs. The median per diem 

cost for CMHCs was $154, while the 

median per diem cost for hospital-based 

PHPs was $201. Based on the CY 2004 

claims data, the average charge per day 

for CMHCs was $760, considerably 

greater than hospital-based per day costs 

but significantly lower than what it was 

in CY 2003 ($1,184). We believed that 

a combination of reduced charges and 

slightly lower CCRs for CMHCs resulted 

in a significant decline in the CMHC 

median per diem cost between CY 2003 

and CY 2004. 

Following the methodology used for 

the CY 2005 OPPS update, the CY 2006 

OPPS update combined hospital-based 

and CMHC median per diem cost was 

$161, a decrease of 44 percent compared 

to the CY 2005 combined median per 

diem amount. We believed that this 

amount was too low to cover the cost for 

all PHPs. 

Therefore, as stated in the CY 2006 

OPPS final rule with comment period 

(70 FR 68548 and 68549), we considered 

the following three alternatives to our 

update methodology for the PHP APC 

for CY 2006 to mitigate this drastic 

reduction in payment for PHP services: 

(1) Base the PHP APC on hospital-based 

PHP data alone; (2) apply a different 

trimming methodology to CMHC costs 

in an effort to eliminate the effect of 

data for those CMHCs that appeared to 

have excessively increased their charges 

in order to receive outlier payments; 

and (3) apply a 15 percent reduction to 

the combined hospital-based and CMHC 

median per diem cost that was used to 

establish the CY 2005 PHP APC. (We 

refer readers to the CY 2006 OPPS final 

rule with comment period for a full 

discussion of the three alternatives (70 

FR 68548).) After carefully considering 

these three alternatives and all 

comments received on them, we 

adopted the third alternative for CY 

2006. We adopted this alternative 

because we believed and continue to 

believe that a reduction in the CY 2005 

median per diem cost would strike an 

appropriate balance between using the 

best available data and providing 

adequate payment for a program that 

often spans 5–6 hours a day. We believe 

that 15 percent is an appropriate 

reduction because it recognizes 

decreases in median per diem costs in 

both the hospital data and the CMHC 

data, and also reduces the risk of any 

adverse impact on access to these 

services that might result from a large 

single-year rate reduction. However, we 

adopted this policy as a transitional 

measure, and stated in the CY 2006 

OPPS final rule with comment period 

that we would continue to monitor 

CMHC costs and charges for these 

services and work with CMHCs to 

improve their reporting so that 

payments can be calculated based on 

better empirical data, consistent with 

the approach we have used to calculate 

payments in other areas of the OPPS (70 

FR 68548). 

To apply this methodology for CY 

2006, we reduced $289 (the CY 2005 

combined unscaled hospital-based and 

CMHC median per diem cost) by 15 

percent, resulting in a combined median 

per diem cost of $245.65 for CY 2006. 

2. Proposed PHP APC Update for CY 

2007 

For CY 2007, we are proposing to 

calculate the CY 2007 PHP per diem 

payment rate using the same update 

methodology that we adopted in CY 

2006. That is, we are proposing to apply 

an additional 15-percent reduction to 

the combined hospital-based and CMHC 

median per diem cost that was used to 

establish the CY 2006 per diem PHP 

payment. 

For CY 2007, we analyzed 12 months 

of data for hospital and CMHC PHP 

claims for services furnished between 

January 1, 2005 and December 31, 2005. 

We also used the most currently 

available CCRs to estimate costs. Using 

these CY 2005 claims data, the median 

per diem cost for CMHCs was $165 and 

the median per diem cost for hospitalbased PHPs was $209. Following the 

methodology used for the CY 2005 

update, the CY 2007 combined hospitalbased and CMHC median per diem cost 

is $172. 

While the combined hospital-based 

and CMHC median per diem cost is 

about $10 higher using the CY 2005 data 

compared to the CY 2004 data ($172 

compared to $161), we believe this 

amount is still too low to cover the cost 

for PHPs. We continue to believe that 

the policy we adopted for CY 2006—a 

15-percent reduction applied to the 

current median cost—provides an 

appropriate decrease in median per 

diem costs for both the hospital and 

CMHC data. Therefore, for CY 2007, we 

are proposing an additional 15 percent 

reduction to the combined hospitalbased and CMHC median per diem cost. 

We will continue to monitor and work 

with CMHCs to improve their reporting. 

If CMHC data continues to be a problem, 

we would consider using data from 

hospital-based PHPs only. 

To calculate the CY 2007 APC PHP 

per diem cost, we reduced $245.65 (the 

CY 2005 combined hospital-based and 

CMHC median per diem cost of $289 

reduced by 15 percent) by 15 percent, 

which resulted in a combined median 

per diem cost of $208.80. 

3. Proposed Separate Threshold for 

Outlier Payments to CMHCs 

In the November 7, 2003 final rule 

with comment period (68 FR 63469), we 

indicated that, given the difference in 

PHP charges between hospitals and 

CMHCs, we did not believe it was 

appropriate to make outlier payments to 

CMHCs using the outlier percentage 

target amount and threshold established 

for hospitals. There was a significant 

difference in the amount of outlier 

payments made to hospitals and CMHCs 

for PHP. In addition, further analysis 

indicated that using the same OPPS 

outlier threshold for both hospitals and 

CMHCs did not limit outlier payments 

to high cost cases and resulted in 

excessive outlier payments to CMHCs. 

Therefore, for CYs 2004, 2005, and 

2006, we established a separate outlier 

threshold for CMHCs. For CYs 2004 and 

2005, we designated a portion of the 


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estimated 2.0 percent outlier target 

amount specifically for CMHCs, 

consistent with the percentage of 

projected payments to CMHCs under the 

OPPS in each of those years, excluding 

outlier payments. For CY 2006, we set 

the estimated outlier target at 1.0 

percent and allocated a portion of that 

1.0 percent, 0.6 percent (or 0.006 

percent of total OPPS payments), to 

CMHCs for PHP services. The CY 2006 

CMHC outlier threshold is met when the 

cost of furnishing services by a CMHC 

exceeds 3.40 times the PHP APC 

payment amount. The CY 2006 OPPS 

outlier payment percentage is 50 

percent of the amount of costs in excess 

of the threshold. 

The separate outlier threshold for 

CMHCs became effective January 1, 

2004, and has resulted in more 

commensurate outlier payments. In CY 

2004, the separate outlier threshold for 

CMHCs resulted in $1.8 million in 

outlier payments to CMHCs. In CY 2005, 

the separate outlier threshold for 

CMHCs resulted in $0.5 million in 

outlier payments to CMHCs. In contrast, 

in CY 2003, more than $30 million was 

paid to CMHCs in outlier payments. We 

believe this difference in outlier 

payments indicates that the separate 

outlier threshold for CMHCs has been 

successful in keeping outlier payments 

to CMHCs in line with the percentage of 

OPPS payments made to CMHCs. 

As discussed in section II.B.2. of this 

preamble, the CY 2005 CMHC data 

produce median per diem costs too low 

to use for the CY 2007 partial 

hospitalization payment rate. Due to the 

continued volatility of the CMHC charge 

data, we are proposing to maintain the 

existing outlier threshold for CMHCs for 

CY 2007 at 3.40 times the APC payment 

amount and the CY 2007 outlier 

payment percentage applicable to costs 

in excess of the threshold at 50 percent. 

As noted in section II.G. of this 

preamble, for CY 2007, we are 

proposing to continue our policy of 

setting aside 1.0 percent of the aggregate 

total payments under the OPPS for 

outlier payments. We are proposing that 

a portion of that 1.0 percent, an amount 

equal to 0.25 percent of outlier 

payments and 0.0025 percent of total 

OPPS payments would be allocated to 

CMHCs for PHP service outliers. As 

discussed in section II.G. of this 

preamble, we again are proposing to set 

a dollar threshold in addition to an APC 

multiplier threshold for OPPS outlier 

payments. However, because the PHP is 

the only APC for which CMHCs may 

receive payment under the OPPS, we 

would not expect to redirect outlier 

payments by imposing a dollar 

threshold. Therefore, we are not 

proposing to set a dollar threshold for 

CMHC outliers. As noted above, we are 

proposing to set the outlier threshold for 

CMHCs for CY 2007 at 3.40 percent 

times the APC payment amount and the 

CY 2007 outlier payment percentage 

applicable to costs in excess of the 

threshold at 50 percent. 

CMS and the Office of the Inspector 

General are continuing to monitor the 

excessive outlier payments to CMHCs. 

C. Proposed Conversion Factor Update 

for CY 2007 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Conversion Factor’’ at the 

beginning of your comment.) 

Section 1833(t)(3)(C)(ii) of the Act 

requires us to update the conversion 

factor used to determine payment rates 

under the OPPS on an annual basis. 

Section 1833(t)(3)(C)(iv) of the Act 

provides that, for CY 2007, the update 

is equal to the hospital inpatient market 

basket percentage increase applicable to 

hospital discharges under section 

1886(b)(3)(B)(iii) of the Act. 

The forecast of the hospital market 

basket increase for FY 2007 published 

in the IPPS proposed rule on April 25, 

2006 is 3.4 percent (71 FR 24148). To set 

the OPPS proposed conversion factor for 

CY 2007, we increased the CY 2006 

conversion factor of $59.511, as 

specified in the November 10, 2005 final 

rule with comment period (70 FR 

68551), by 3.4 percent. 

In accordance with section 

1833(t)(9)(B) of the Act, we further 

adjusted the conversion factor for CY 

2006 to ensure that the revisions we are 

making to our updates for a revised 

wage index and expanded rural 

adjustment are made on a budget 

neutral basis. We calculated a budget 

neutrality factor of 0.999908021 for 

wage index changes by comparing total 

payments from our simulation model 

using the FY 2007 IPPS proposed wage 

index values to those payments using 

the current (FY 2006) IPPS wage index 

values. To reflect the inclusion of 

essential access community hospitals 

(EACHs) as rural SCHs (discussed in 

section II.F. of this preamble), we 

calculated an additional budget 

neutrality factor of 0.999883468 for the 

rural adjustment, including EACHs. For 

CY 2007, we estimate that allowed passthrough spending would equal 

approximately $43.2 million, which 

represents 0.13 percent of total OPPS 

projected spending for CY 2007. The 

proposed conversion factor also is 

adjusted by the difference between the 

0.17 percent pass-through dollars setaside in CY 2006 and the 0.13 percent 

estimate for CY 2007 pass-through 

spending. Finally, proposed payments 

for outliers remain at 1.0 percent of total 

payments for CY 2007. 

The proposed market basket increase 

update factor of 3.4 percent for CY 2007, 

the required wage index budget 

neutrality adjustment of approximately 

0.999908021, the return of 0.04 percent 

for the difference in the pass-through 

set-aside, and the proposed adjustment 

for the rural payment adjustment for 

rural SCHs, including rural EACHs, of 

0.999883468 result in a proposed 

conversion factor for CY 2007 of 

$61.551. 

D. Proposed Wage Index Changes for CY 

2007 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Wage Indices’’ at the 

beginning of your comment.) 

Section 1833(t)(2)(D) of the Act 

requires the Secretary to determine a 

wage adjustment factor to adjust, for 

geographic wage differences, the portion 

of the OPPS payment rate and the 

copayment standardized amount 

attributable to labor and labor-related 

cost. This adjustment must be made in 

a budget neutral manner. As we have 

done in prior years, we are proposing to 

adopt the IPPS wage indices and extend 

these wage indices to hospitals that 

participate in the OPPS but not the IPPS 

(referred to in this section as ‘‘nonIPPS’’ hospitals). 

As discussed in section II.A. of this 

preamble, we standardize 60 percent of 

estimated costs (labor-related costs) for 

geographic area wage variation using the 

IPPS wage indices that are calculated 

prior to adjustments for reclassification 

to remove the effects of differences in 

area wage levels in determining the 

OPPS payment rate and the copayment 

standardized amount. 

As published in the original OPPS 

April 7, 2000 final rule with comment 

period (65 FR 18545), OPPS has 

consistently adopted the final IPPS 

wage indices as the wage indices for 

adjusting the OPPS standard payment 

amounts for labor market differences. 

Thus, the wage index that applies to a 

particular hospital under the IPPS will 

also apply to that hospital under the 

OPPS. As initially explained in the 

September 8, 1998 OPPS proposed rule, 

we believed and continue to believe that 

using the IPPS wage index as the source 

of an adjustment factor for OPPS is 

reasonable and logical, given the 

inseparable, subordinate status of the 

hospital outpatient within the hospital 

overall. In accordance with section 

1886(d)(3)(E) of the Act, the IPPS wage 

index is updated annually. In this 

proposed rule, we are using the 


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proposed FY 2007 hospital IPPS wage 

indices published in the Federal 

Register on April 25, 2006, which 

include the wage indices proposed to be 

in effect through March 31, 2007, and 

those proposed to be in effect on or after 

April 1, 2007, to accommodate the 

expiring reclassification provisions 

under section 508 of Pub. L. 108–173, to 

determine the wage adjustments for the 

OPPS payment rate and the copayment 

standardized amount for CY 2007. 

However, in accordance with our 

established policy, we are proposing to 

use the FY 2007 final version of these 

wage indices to determine the wage 

adjustments for the OPPS payment rate 

and copayment standardized amount 

that we will publish in our final rule for 

CY 2007. 

On May 17, 2006 (71 FR 28644), in 

response to a court order in Bellevue 

Hosp. Ctr. v. Leavitt, we published a 

second IPPS proposed rule that would 

revise the methodology for calculating 

the occupational mix adjustment for FY 

2007. We proposed to replace in full the 

descriptions of the data and 

methodology that would be used in 

calculating the occupational mix 

adjustment discussed in the first FY 

2007 IPPS proposed rule. The second 

proposed rule also states that, because 

of the collection of new occupational 

mix data, we would publish the FY 

2007 occupational mix adjusted wage 

index tables and related impacts on the 

CMS Web site shortly after we publish 

the FY 2007 IPPS final rule, and in 

advance of October 1, 2006. The weights 

and factors would also be published on 

the CMS Web site after the FY 2007 

IPPS final rule, but in advance of 

October 1, 2006. (71 FR 28650). Thus, 

for purposes of determining OPPS wage 

indices, readers are also directed to refer 

to the wage index tables that are 

published after the FY 2007 IPPS final 

rule. 

We note that the FY 2007 IPPS wage 

indices continue to reflect a number of 

changes implemented in FY 2005 as a 

result of the revised Office of 

Management and Budget (OMB) 

standards for defining geographic 

statistical areas, the implementation of 

an occupational mix adjustment as part 

of the wage index, and new wage 

adjustments provided for under Pub. L. 

108–173. The following is a brief 

summary of the proposed changes in the 

FY 2005 IPPS wage indices, continued 

for FY 2007, and any adjustments that 

we are applying to the OPPS for CY 

2007. We refer the reader to the FY 2007 

IPPS proposed rule (71 FR 24074 

through 24091) for a detailed discussion 

of the proposed changes to the wage 

indices. Readers should refer to our 

proposed rule published May 17, 2006, 

for proposed changes to the 

occupational mix adjustment and 

related issues (71 FR 28644–28653). In 

this proposed rule, we are not reprinting 

the proposed FY 2007 IPPS wage 

indices. We also refer readers to the 

CMS Web site for the OPPS at http:// 

www.cms.hhs.gov/providers/hopps. At 

this Web site, the reader will find a link 

to the proposed FY 2007 IPPS wage 

indices tables. (However, as noted 

above, these tables may change as a 

result of the May 17, 2006 occupational 

mix proposed rule discussed above.) 

1. The proposed continued use of the 

Core Based Statistical Areas (CBSAs) 

issued by the OMB as revised standards 

for designating geographical statistical 

areas based on the 2000 Census data, to 

define labor market areas for hospitals 

for purposes of the IPPS wage index. 

The OMB revised standards were 

published in the Federal Register on 

December 27, 2000 (65 FR 82235), and 

OMB announced the new CBSAs on 

June 6, 2003, through an OMB bulletin. 

In the FY 2005 IPPS final rule, CMS 

adopted the new OMB definitions for 

wage index purposes. In the FY 2007 

IPPS proposed rule, we again stated that 

hospitals located in MSAs will be urban 

and hospitals that are located in 

Micropolitan Areas or outside CBSAs 

will be rural. To help alleviate the 

decreased payments for previously 

urban hospitals that became rural under 

the new geographical definitions, we 

allowed these hospitals to maintain for 

the 3-year period from FY 2005 through 

FY 2007, the wage index of the MSA 

where they previously had been located. 

To be consistent with the IPPS, we will 

continue the policy we began in CY 

2005 of applying the same urban-torural transition to non-IPPS hospitals 

paid under the OPPS. That is, we would 

maintain the wage index of the MSA 

where the hospital was previously 

located for purposes of determining a 

wage index for CY 2007. Beginning in 

FY 2008, the 3-year transition will end 

and these hospitals will receive their 

statewide rural wage index. However, 

hospitals paid under the IPPS will be 

eligible to apply for reclassification. 

For the occupational mix adjustment, 

we refer readers to CMS’s May 17, 2006 

occupational mix proposed rule 

discussed above. Under this proposed 

rule, wage indices would be adjusted 

100 percent for occupational mix. In 

addition, as stated above, CMS plans 

that wage index tables and other 

adjustment factors would be published 

after publication of the FY 2007 IPPS 

final rule, but prior to October 1, 2006. 

As noted above, for purposes of 

estimating an adjustment for the OPPS 

payment rates to accommodate 

geographic differences in labor costs in 

this proposed rule, we have used the 

wage indices identified in the FY 2007 

IPPS proposed rule. For the CY 2007 

OPPS final rule, we plan to use the 

revised FY 2007 IPPS wage indices that 

will be fully adjusted for differences in 

occupational mix using the new survey 

data and available after October 1, 2006. 

In all cases, we will use the final FY 

2007 IPPS wage indices, which include 

the wage indices to be in effect through 

March 31, 2007, and those to be in effect 

on or after April 1, 2007, with any 

subsequent corrections, for calculating 

OPPS payment in CY 2007. 

2. The reclassifications of hospitals to 

geographic areas for purposes of the 

wage index. For purposes of the OPPS 

wage index, we are proposing to adopt 

all of the IPPS reclassifications for FY 

2007, including reclassifications that the 

Medicare Geographic Classification 

Review Board (MGCRB) approved under 

the one-time appeal process for 

hospitals under section 508 of Pub. L. 

108–173. We note that section 508 

reclassifications will terminate March 

31, 2007, and that this expiration, along 

with the calendar year operating period 

of OPPS, impacts the calculation of the 

OPPS payment and the budget 

neutrality adjustment for the wage 

index. In the FY 2007 IPPS proposed 

rule (71 FR 24085 through 24087), we 

proposed procedural rules for hospitals 

that wished to reclassify for the second 

half of FY 2007 (April 1, 2007, through 

September 30, 2007) under section 

1886(d)(10) of the Act. These rules 

essentially provided procedures for 

some hospitals to retain section 508 

reclassifications for the first half of FY 

2007 and also be eligible to maintain an 

approved reclassification under section 

1886(d)(10) for the second half of FY 

2007. Rather than calculating one wage 

index that reflected all final 

reclassification adjustments, we 

proposed two separate wage indices for 

FY 2007, one to be in effect October 1 

through March 31, 2007, and one to be 

in effect April 1 through September 30, 

2007. 

These procedural rules also impact a 

hospital’s eligibility to receive the outmigration wage adjustment, discussed 

in greater detail in section III.I. of the FY 

2007 IPPS proposed rule (71 FR 24087) 

and under section II.D.4. of this 

preamble. A hospital cannot receive an 

out-migration wage adjustment if it is 

reclassified under section 1886(d)(10) of 

the Act. Hospitals declining 

reclassification status for any part of the 

year become eligible to receive the outmigration wage adjustment if they are 

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Because the OPPS operates on a 

calendar year (January 1 through 

December 31) and not a fiscal year, the 

expiring reclassification status under 

section 508 of Pub. L. 108–173 results 

in different wage indices for OPPS for 

the first quarter of CY 2007 (January 1, 

2007, through March 31, 2007) and the 

last three quarters of CY 2007 (April 1, 

2007, through December 31, 2007). 

3. The out-migration wage adjustment 

to the wage index. In FY 2007 IPPS 

proposed rule (71 FR 24087), we 

discussed the out-migration adjustment 

under section 505 of Pub. L. 109–173 for 

counties under this adjustment. 

Hospitals paid under the IPPS located in 

the qualifying section 505 ‘‘outmigration’’ counties receive a wage 

index increase unless they have already 

been otherwise reclassified. (See the 

IPPS FY 2007 proposed rule for further 

information on out-migration.) For 

OPPS purposes, we propose to continue 

our policy from CY 2006 to allow nonIPPS hospitals paid under the OPPS to 

qualify for out-migration adjustment if 

they are located in a section 505 outmigration county. Because non-IPPS 

hospitals cannot reclassify, they are 

eligible for the out-migration wage 

adjustment. Tables identifying counties 

eligible for the out-migration adjustment 

will be published after the FY 2007 IPPS 

final rule and CMS plans to publish 

them in advance of October 1, 2006. 

These tables will reflect updated county 

listing to reflect changes to the 

occupation mix adjustment made in 

response to Bellevue court case 

discussed above. Because we are 

proposing to adopt the final FY 2007 

IPPS wage index, we will adopt any 

changes in a hospital’s classification 

status that would make them either 

eligible or ineligible for the outmigration wage adjustment both through 

March 31, 2007, and on or after April 1, 

2007. 

With the exception of reclassifications 

resulting from the implementation of 

the one-time appeal process under 

section 508 of Pub. L. 108–173, all 

changes to the wage index resulting 

from geographic labor market area 

reclassifications or other adjustments 

must be incorporated in a budget 

neutral manner. Accordingly, in 

calculating the OPPS budget neutrality 

estimates for CY 2007, in this proposed 

rule, we have included the wage index 

changes that would result from MGCRB 

reclassifications, implementation of 

section 505 of Pub. L. 108–173, and 

other refinements made in the FY 2007 

IPPS proposed rule, such as the hold 

harmless provision for hospitals 

changing status from urban to rural 

under the new CBSA geographic 

statistical area definitions. However, 

section 508 sets aside $900 million to 

implement the section 508 

reclassifications. We considered the 

increased Medicare payments that the 

section 508 reclassifications would 

create in both the IPPS and OPPS when 

we determined the impact of the onetime appeal process. Because the 

increased OPPS payments already count 

against the $900 million limit, we did 

not consider these reclassifications 

when we calculated the proposed OPPS 

budget neutrality adjustment. 

Under the procedural rules described 

under section II.D.3. of this proposed 

rule above and in section III.H.5. of the 

FY 2007 IPPS proposed rule (71 FR 

24085) regarding expiring section 508 

reclassifications, different wage indices 

may be in effect for the first quarter of 

the calendar year and the last three 

quarters of the calendar year. These 

rules have implications for budget 

neutrality adjustments. Any additional 

payment attributable to reclassifications 

due to section 508 between January 1 

and April 1, 2007, must be excluded 

from a budget neutrality adjustment, 

and all other adjustments to the wage 

index are subject to budget neutrality. 

Rather than calculating two different 

conversion factors, with different budget 

neutrality adjustments, we are 

proposing to calculate one budget 

neutrality adjustment that reflects the 

combined adjustments required for the 

first quarter and last three quarters of 

the calendar year, respectively. We 

followed the same approach in the FY 

2007 IPPS proposed rule (71 FR 24087). 

E. Proposed Statewide Average Default 

CCRs 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Cost-to-Charge Ratios’’

at the beginning of your comment.) 

CMS uses CCRs to determine outlier 

payments, payments for pass-through 

devices, and monthly interim 

transitional corridor payments under 

the OPPS. Some hospitals do not have 

a valid CCR. These hospitals include, 

but are not limited to, hospitals that are 

new and have not yet submitted a cost 

report, hospitals that have a CCR that 

falls outside predetermined floor and 

ceiling thresholds for a valid CCR, or 

hospitals that have recently given up 

their all-inclusive rate status. Last year, 

we updated the default urban and rural 

CCRs for CY 2006 in our final rule, 

published on November 10, 2005 (70 FR 

68553 through 68555). In this proposed 

rule, we are proposing to update the 

default ratios for CY 2007 using the 

most recent cost report data. 

We calculated the statewide default 

CCRs using the same overall CCRs that 

we use to adjust charges to costs on 

claims data. Please refer to section 

II.A.1.c. of this preamble for a 

discussion of our proposed revision to 

the overall CCR calculation. Table 4 lists 

the proposed CY 2007 default urban and 

rural CCRs by State and compares them 

to last year’s default CCRs. These CCRs 

are the ratio of total costs to total 

charges from each provider’s most 

recently submitted cost report, for those 

cost centers relevant to outpatient 

services weighted by Medicare Part B 

charges. We also adjusted these ratios to 

reflect final settled status by applying 

the differential between settled to 

submitted costs and charges from the 

most recent pair of settled to submitted 

cost reports. 

For this proposed rule, 81.79 percent 

of the submitted cost reports 

represented data for CY 2004. We only 

used valid CCRs to calculate these 

default ratios. That is, we removed the 

CCRs for all-inclusive hospitals, CAHs, 

and hospitals in Guam and the U.S. 

Virgin Islands because these entities are 

not paid under the OPPS, or in the case 

of all-inclusive hospitals, because their 

CCRs are suspect. We further identified 

and removed any obvious error CCRs 

and trimmed any outliers. We limited 

the hospitals used in the calculation of 

the default CCRs to those hospitals that 

billed for services under the OPPS 

during CY 2004. 

Finally, we calculated an overall 

average CCR, weighted by a measure of 

volume for CY 2004, for each State 

except Maryland. This measure of 

volume is the total lines on claims and 

is the same one that we use in our 

impact tables. For Maryland, we used an 

overall weighted average CCR for all 

hospitals in the Nation as a substitute 

for Maryland CCRs, which appear in 

Table 4. Very few providers in Maryland 

are eligible to receive payment under 

the OPPS, which limits the data 

available to calculate an accurate and 

representative CCR. The observed 

differences between last year’s default 

statewide CCRs and the proposed CCRs 

are a combination of the general decline 

in the ratio between costs and charges 

widely observed in the cost report data 

and the change in the proposed overall 

CCR calculation. 

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BILLING CODE 4120–01–C 

As stated above, CMS uses default 

statewide CCRs for several groups of 

hospitals, including, but not limited to, 

hospitals that are new and have not yet 

submitted a cost report, hospitals that 

have a CCR that falls outside 

predetermined floor and ceiling 

thresholds for a valid CCR, and 

hospitals that have recently given up 

their all-inclusive rate status. Current 

OPPS policy also requires hospitals that 

experience a change of ownership, but 

that do not accept assignment of the 

previous hospital’s provider agreement, 

to use the previous provider’s CCR. 

For CY 2007, we are proposing to 

apply this treatment of using the default 

statewide CCR to include an entity that 

has not accepted assignment of an 

existing hospital’s provider agreement 

in accordance with 42 CFR 489.18, and 

that has not yet submitted its first 

Medicare cost report. We are proposing 

that this policy be effective for hospitals 

experiencing a change of ownership on 

or after January 1, 2007. We believe that 

a hospital that has not accepted 

assignment of an existing hospital’s 

provider agreement is similar to a new 

hospital that will establish its own costs 

and charges. We believe that the 

hospital that has chosen not to accept 

assignment may have different costs and 

charges than the existing hospital. 

Furthermore, we believe that the 

hospital should be provided time to 

establish its own costs and charges. 

Therefore, we are proposing to use the 

default statewide CCR to determine 

cost-based payments until the hospital 

has submitted its first Medicare cost 

report. 

F. OPPS Payments to Certain Rural 

Hospitals 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Rural Hospitals Hold 

Harmless Transitional Payments’’ at the 

beginning of your comment.) 

1. Hold Harmless Transitional Payment 

Changes Made by Pub. L. 109–171 

(DRA) 

When the OPPS was implemented, 

every provider was eligible to receive an 

additional payment adjustment 

(transitional corridor payment) if the 

payments it received for covered OPD 

services under the OPPS were less than 

the payments it would have received for 

the same services under the prior 

reasonable cost-based system. Section 

1833(t)(7) of the Act provides that the 

transitional corridor payments are 

temporary payments for most providers, 

with two exceptions, to ease their 

transition from the prior reasonable 

cost-based payment system to the OPPS 

system. Cancer hospitals and children’s 

hospitals receive the transitional 

corridor payments on a permanent 

basis. Section 1833(t)(7)(D)(i) of the Act 

originally provided for transitional 

corridor payments to rural hospitals 

with 100 or fewer beds for covered OPD 

services furnished before January 1, 

2004. However, section 411 of Pub. L. 

108–173 amended section 

1833(t)(7)(D)(i) of the Act to extend 

these payments through December 31, 

2005, for rural hospitals with 100 or 

fewer beds. Section 411 also extended 

the transitional corridor payments to 

sole community hospitals (SCHs) 

located in rural areas for services 

furnished during the period that begins 

with the provider’s first cost reporting 

period beginning on or after January 1, 

2004, and ends on December 31, 2005. 

Accordingly, the authority for making 

transitional corridor payments under 

section 1833(t)(7)(D)(i) of the Act, as 

amended by section 411 of Pub. L. 108–

173, expired for rural hospitals having 

100 or fewer beds and SCHs located in 

rural areas on December 31, 2005. 

Section 5105 of Pub. L. 109–171 

reinstituted the hold harmless 

transitional outpatient payments (TOPs) 

for covered OPD services furnished on 

or after January 1, 2006, and before 

January 1, 2009, for rural hospitals 

having 100 or fewer beds that are not 

SCHs. When the OPPS payment is less 

than the payment the provider would 

have received under the previous 

reasonable cost-based system, the 

amount of payment is increased by 95 

percent of the amount of the difference 

between those two payment systems for 

CY 2006, by 90 percent of the amount 

of that difference for CY 2007, and by 

85 percent of the amount of that 

difference for CY 2008. 

For CY 2006, we have implemented 

section 5106 of Pub. L. 109–171 through 

Transmittal 877, issued on February 24, 

2006. We did not specifically address 

whether TOPs payments apply to 

EACHs, which are considered to be 

SCHs under section 

1886(d)(5)(D)(iii)(III) of the Act. 

Accordingly, under the statute, EACHs 

are treated as SCHs. Therefore, we 

believe that EACHs are not eligible for 

TOPs payment under Pub. L. 109–171. 

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to reflect the requirements of Pub. L. 

109–171. 

2. Proposed Adjustment for Rural SCHs 

Implemented in CY 2006 Related to 

Pub. L. 108–173 (MMA) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Rural SCH Payments’’ at 

the beginning of your comment.) 

In the CY 2006 OPPS final rule with 

comment period (70 FR 68556), we 

finalized a payment increase for rural 

SCHs of 7.1 percent for all services and 

procedures paid under the OPPS, 

excluding drugs, biologicals, 

brachytherapy seeds, and services paid 

under pass-through payment policy in 

accordance with section 1833(t)(13)(B) 

of the Act, as added by section 411 of 

Pub. L. 108–173. Section 411 gave the 

Secretary the authority to make an 

adjustment to OPPS payments for rural 

hospitals effective January 1, 2006 if 

justified by a study of the difference in 

costs by APC between hospitals in rural 

and urban areas. Our analysis showed a 

difference in costs only for rural SCHs 

and we implemented a payment 

adjustment for those hospitals beginning 

January 1, 2006. 

We recently became aware that we 

did not specifically address whether the 

adjustment applies to EACHs, which are 

considered to be SCHs pursuant to 

section 1886(d)(5)(D)(iii)(III) of the Act. 

Thus, under the statute, EACHs are 

treated as SCHs. Currently, fewer than 

10 hospitals are classified as EACHs. As 

of CY 1998, under section 4201(c) of 

Pub. L. 105–33, a hospital can no longer 

become newly classified as an EACH. 

Therefore, for purposes of receiving this 

rural adjustment, we are clarifying that 

EACHs are treated as SCHs for purposes 

of receiving this adjustment, assuming 

these entities otherwise meet the rural 

adjustment criteria. 

This adjustment is budget neutral and 

applied before calculating outliers and 

coinsurance. We also stated that we 

would not reestablish the adjustment 

amount on an annual basis, but that we 

might review the adjustment in the 

future and, if appropriate, would revise 

the adjustment. For CY 2007, we are 

proposing to continue our current 

policy of a budget neutral 7.1 percent 

payment increase for rural SCHs for 

specified services. 

G. Proposed CY 2007 Hospital 

Outpatient Outlier Payments 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Outlier Payments’’ at the 

beginning of your comment.) 

Currently, the OPPS pays outlier 

payments on a service-by-service basis. 

For CY 2006, the outlier threshold is 

met when the cost of furnishing a 

service or procedure by a hospital 

exceeds 1.75 times the APC payment 

amount and exceeds the APC payment 

rate plus a $1,250 fixed-dollar 

threshold. We introduced a fixed-dollar 

threshold in CY 2005 in addition to the 

traditional multiple threshold in order 

to better target outliers to those high 

cost and complex procedures where a 

very costly service could present a 

hospital with significant financial loss. 

If a provider meets both of these 

conditions, the multiple threshold and 

the fixed-dollar threshold, the outlier 

payment is calculated as 50 percent of 

the amount by which the cost of 

furnishing the service exceeds 1.75 

times the APC payment rate. For a 

discussion on CMHC outliers, see 

section II.B.3. of the preamble to this 

proposed rule. 

As explained in our CY 2006 OPPS 

final rule with comment period (70 FR 

68561), we set our projected target for 

aggregate outlier payments at 1.0 

percent of aggregate total payments 

under the OPPS. Our outlier thresholds 

were set so that estimated CY 2006 

aggregate outlier payments would equal 

1.0 percent of aggregate total payments 

under the OPPS. In our CY 2006 OPPS 

final rule with comment period (70 FR 

68563), we also published total outlier 

payments as a percent of total 

expenditures for past years. At this time, 

we do not have a complete set of CY 

2005 claims in order to produce this 

number for CY 2005. We will report on 

CY 2005 outlier payments in our CY 

2007 OPPS final rule. 

For CY 2007, we are proposing to 

continue our policy of setting aside 1.0 

percent of aggregate total payments 

under the OPPS for outlier payments. A 

portion of that 1.0, an amount equal to 

0.25 percent of outlier payments and 

0.0025 percent of total OPPS payments 

would be allocated to CMHCs for partial 

hospitalization program service outliers. 

In order to ensure that estimated CY 

2007 aggregate outlier payments would 

equal 1.0 percent of estimated aggregate 

total payments under the OPPS, we are 

proposing that the outlier threshold be 

set so that outlier payments are triggered 

when the cost of furnishing a service or 

procedure by a hospital exceeds 1.75 

times the APC payment amount and 

exceeds the APC payment rate plus a 

$1,825 fixed-dollar threshold. 

We calculated the fixed-dollar 

threshold for this proposed rule using 

the same methodology as we did in CY 

2006 except we used the revised overall 

CCR calculation discussed in section 

II.A.1.c. of this preamble. As discussed 

in section II.A.1.c. of this preamble, we 

discovered that the calculation of the 

overall CCR that the fiscal 

intermediaries are using to determine 

outlier payment and payment for 

services paid at charges reduced to cost 

differs from the overall CCR that we 

traditionally use to model the outlier 

thresholds. We discovered this during 

our calculations of the outlier threshold 

for our CY 2006 final rule with 

comment period, and we indicated in 

our preamble discussion for that rule, 

that we may revisit the threshold 

estimate in light of identified 

differences in the overall CCR 

calculation. Because, on average, the 

overall CCR calculation used by the 

fiscal intermediaries results in higher 

CCRs than those estimated using our 

‘‘traditional’’ CCR sets, the outlier 

threshold is too low. The OPPS impact 

table in section XXVII. of this preamble 

demonstrates an estimated payment 

differential of 0.25 percent of total 

spending for hospital outlier payments 

in CY 2006 because of the differences in 

overall CCR calculations. The revised 

overall CCR calculation that we are 

proposing for CY 2007 aligns the two 

CCR calculations by removing allied 

and nursing health costs for those 

hospitals with paramedical education 

programs from the fiscal intermediary’s 

CCR calculation and weighting our 

‘‘traditional’’ calculation by total 

Medicare Part B charges. We expected 

this proposed change in the overall CCR 

calculation to raise the outlier 

threshold. 

The claims that we use to model each 

OPPS lag by 2 years. For this proposed 

rule, we used CY 2005 claims to model 

the CY 2007 OPPS. In order to estimate 

CY 2007 outlier payments for this 

proposed rule, we inflated the charges 

on the CY 2005 claims using the same 

inflation factor of 1.1515 that we used 

to estimate the IPPS fixed-dollar outlier 

threshold for the IPPS FY 2007 

proposed rule. For 1 year, the inflation 

factor is 1.0757. The methodology for 

determining this charge inflation factor 

was discussed in the FY 2007 IPPS 

proposed rule (71 FR 24150). As we 

stated in our CY 2005 final rule with 

comment period, we believe that the use 

of this charge inflation factor is 

appropriate for OPPS because, with the 

exception of the routine service cost 

centers, hospitals use the same cost 

centers to capture costs and charges 

across inpatient and outpatient services 

(69 FR 65845, November 15, 2004). As 

also noted in the FY 2006 IPPS final 

rule, we believe that a charge inflation 

factor is more appropriate than an 

adjustment to costs because this 

methodology closely captures how 


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actual outlier payments are made and 

calculated (70 FR 47495, August 12, 

2005). We then applied the revised 

overall CCR that we calculated from 

each hospital’s most recent cost report 

(CMS–2552–96) and, if the cost report 

was not settled, we adjusted it by a 

settled-to-submitted ratio. We simulated 

aggregated outlier payments using these 

costs for several different fixed-dollar 

thresholds holding the 1.75 multiple 

constant until the total outlier payments 

equaled 1.0 percent of aggregated total 

OPPS payments. We estimate that a 

threshold of $1,825 combined with the 

multiple threshold of 1.75 times the 

APC payment rate would allocate 1.0 

percent of aggregated total OPPS 

payments to outlier payments. 

For CMHCs, in CY 2007 we project 

the outlier threshold is met when the 

cost of furnishing a service or procedure 

by a CMHC exceeds 3.40 times the APC 

payment rate. If a CMHC provider meets 

this condition, the outlier payment is 

calculated as 50 percent of the amount 

by which the cost exceeds 3.40 times 

the APC payment rate. We are proposing 

to continue the same threshold policy 

for CY 2007 as we have established for 

CY 2006. An explanation for this 

proposed policy is discussed in section 

II.B.3. the preamble of this proposed 

rule. 

The following is an example of an 

outlier calculation for CY 2007 under 

our proposed policy. A hospital charges 

$20,000 for a procedure. The wage 

adjusted, and rural adjusted, if 

applicable, APC payment for the 

procedure is $3,500. Using the 

provider’s CCR of 0.35, the estimated 

cost to the hospital is $7,000 (0.35 × 

$20,000). To determine whether this 

provider is eligible for outlier payments 

for this procedure, the provider must 

determine whether the cost for the 

service exceeds both the APC outlier 

cost threshold (1.75 × APC payment) 

and the fixed-dollar threshold ($1,825 + 

APC payment). In this example, the 

provider meets both criteria: 

(1) $7,000 exceeds $6,125 (1.75 × 

$3,500) 

(2) $7,000 exceeds $5,325 ($3,500 + 

$1,825) 

To calculate the outlier payment, 

which is 50 percent of the amount by 

which the cost of furnishing the service 

exceeds 1.75 times the APC rate, 

subtract $6,125 (1.75 × $3,500) from 

$7,000 (resulting in $825). The provider 

is eligible for 50 percent of the 

difference, in this case $437.50 ($825/2). 

The formula is (cost ¥ (1.75 × APC 

payment rate))/2. 

H. Calculation of the Proposed OPPS 

National Unadjusted Medicare Payment 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: National Unadjusted 

Medicare Payment’’ at the beginning of 

your comment.) 

The basic methodology for 

determining prospective payment rates 

for OPD services under the OPPS is set 

forth in existing regulations at § 419.31 

and § 419.32. The payment rate for 

services and procedures for which 

payment is made under the OPPS is the 

product of the conversion factor 

calculated in accordance with section 

II.C. of this proposed rule and the 

relative weight determined under 

section II.A. of this proposed rule. 

Therefore, the national unadjusted 

payment rate for APCs contained in 

Addendum A to this proposed rule and 

for HCPCS codes to which payment 

under the OPPS has been assigned in 

Addendum B to this proposed rule 

(Addendum B is provided as a 

convenience for readers) was calculated 

by multiplying the proposed CY 2007 

scaled weight for the APC by the 

proposed CY 2007 conversion factor. 

However, to determine the payment 

that will be made in a calendar year 

under the OPPS to a specific hospital for 

an APC for a service other than a drug, 

in a circumstance in which the multiple 

procedure discount does not apply, we 

take the following steps: 

Step 1. Calculate 60 percent (the 

labor-related portion) of the national 

unadjusted payment rate. Since the 

initial implementation of the OPPS, we 

have used 60 percent to represent our 

estimate of that portion of costs 

attributable, on average, to labor. (Refer 

to the April 7, 2000 final rule with 

comment period (65 FR 18496 through 

18497) for a detailed discussion of how 

we derived this percentage.) 

Step 2. Determine the wage index area 

in which the hospital is located and 

identify the wage index level that 

applies to the specific hospital. The 

wage index values assigned to each area 

reflect the new geographic statistical 

areas as a result of revised OMB 

standards (urban and rural) to which 

hospitals are assigned for FY 2007 

under the IPPS, reclassifications 

through the Medicare Classification 

Geographic Review Board, section 

1866(d)(8)(B) ‘‘Lugar’’ hospitals, and 

section 401 of Pub. L. 108–173, and the 

reclassifications of hospitals under the 

one-time appeals process under section 

508 of Pub. L. 108–173. The wage index 

values include the occupational mix 

adjustment described in section II.D. of 

this proposed rule that was developed 

for the proposed FY 2007 IPPS payment 

rates. We note that the original proposal 

for calculating the FY 2007 IPPS wage 

index has been recently changed. (Refer 

to the May 17, 2006 FY 2007 IPPS 

proposed rule, 71 FR 28644).) Final FY 

2007 IPPS wage indices will be adjusted 

100 percent for differences in 

occupational mix. Although we have 

not incorporated those changes in this 

proposed rule due to the availability of 

new survey data, as is our practice, we 

propose to adopt changes made to the 

FY 2007 IPPS wage index values after 

they have been finalized. 

Step 3. Adjust the wage index of 

hospitals located in certain qualifying 

counties that have a relatively high 

percentage of hospital employees who 

reside in the county, but who work in 

a different county with a higher wage 

index, in accordance with section 505 of 

Pub. L. 108–173. Addendum L contains 

the qualifying counties and the 

proposed wage index increase 

developed for the FY 2007 IPPS. This 

step is to be followed only if the 

hospital has chosen not to accept 

reclassification under Step 2 above. 

Step 4. Multiply the applicable wage 

index determined under Steps 2 and 3 

by the amount determined under Step 1 

that represents the labor-related portion 

of the national unadjusted payment rate. 

Step 5. Calculate 40 percent (the 

nonlabor-related portion) of the national 

unadjusted payment rate and add that 

amount to the resulting product of Step 

4. The result is the wage index adjusted 

payment rate for the relevant wage 

index area. 

Step 6. If a provider is a SCH, as 

defined in § 419.92, and located in a 

rural area, as defined in § 412.63(b), or 

is treated as being located in a rural area 

under § 412.103 of the Act, multiply the 

wage index adjusted payment rate by 

1.071 to calculate the total payment. 

I. Proposed Beneficiary Copayments for 

CY 2007 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Beneficiary 

Copayments’’ at the beginning of your 

comment.) 

1. Background 

Section 1833(t)(3)(B) of the Act 

requires the Secretary to set rules for 

determining copayment amounts to be 

paid by beneficiaries for covered OPD 

services. Section 1833(t)(8)(C)(ii) of the 

Act specifies that the Secretary must 

reduce the national unadjusted 

copayment amount for a covered OPD 

service (or group of such services) 

furnished in a year in a manner so that 

the effective copayment rate 


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(determined on a national unadjusted 

basis) for that service in the year does 

not exceed specified percentages. For all 

services paid under the OPPS in CY 

2007, and in calendar years thereafter, 

the specified percentage is 40 percent of 

the APC payment rate (section 

1833(t)(8)(C)(ii)(V) of the Act). Section 

1833(t)(3)(B)(ii) of the Act provides that, 

for a covered OPD service (or group of 

such services) furnished in a year, the 

national unadjusted coinsurance 

amount cannot be less than 20 percent 

of the OPD fee schedule amount. 

2. Proposed Copayment for CY 2007 

For CY 2007, we are proposing to 

determine copayment amounts for new 

and revised APCs using the same 

methodology that we implemented for 

CY 2004 (Refer to the November 7, 2003 

OPPS final rule with comment period, 

68 FR 63458.) The proposed unadjusted 

copayment amounts for services payable 

under the OPPS that would be effective 

January 1, 2007, are shown in 

Addendum A and Addendum B of this 

proposed rule. 

3. Calculation of a Proposed Adjusted 

Copayment Amount for an APC Group 

for CY 2007 

To calculate the OPPS adjusted 

copayment amount for an APC group, 

take the following steps: 

Step 1. Calculate the beneficiary 

payment percentage for the APC by 

dividing the APC’s national unadjusted 

copayment by its payment rate. For 

example, using APC 0001, $7.00 is 23 

percent of $30.14. 

Step 2. Calculate the wage adjusted 

payment rate for the APC, for the 

provider in question, as indicated in 

section II.H. of this preamble. Calculate 

the rural adjustment for eligible 

providers as indicated in section II.H. of 

this preamble. 

Step 3. Multiply the percentage 

calculated in Step 1 by the payment rate 

calculated in Step 2. The result is the 

wage-adjusted copayment amount for 

the APC. 

III. Proposed OPPS Ambulatory 

Payment Classification (APC) Group 

Policies 

A. Proposed Treatment of New HCPCS 

and CPT Codes 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: New HCPCS and CPT 

Codes’’ at the beginning of your 

comment.) 

1. Proposed Treatment of New HCPCS 

Codes Included in the Second and Third 

Quarterly OPPS Updates for CY 2006 

During the second and third quarters 

of CY 2006, we created a total of four 

new Level II HCPCS codes that were not 

addressed in the November 10, 2005 

final rule with comment period that 

updated the CY 2006 OPPS. We have 

designated the payment status of those 

codes and added them either through 

the April update (Transmittal 896, dated 

March 24, 2006) or the July update of 

the CY 2006 OPPS (Transmittal 970, 

dated May 30, 2006). In this proposed 

rule, we are soliciting public comments 

on the status indicators and APC 

assignments of these services, which are 

listed in Table 5. Because of the timing 

of this proposed rule, those codes 

implemented through the July 2006 

OPPS update are not included in 

Addendum B of this proposed rule, 

while those codes based upon the April 

2006 OPPS update are included in 

Addendum B. We intend to finalize the 

assignments for all of these services in 

the OPPS CY 2007 final rule. 

TABLE 5.—NEW HCPCS CODES IMPLEMENTED IN APRIL OR JULY 2006 

HCPCS code Description 

Assigned 

status indicator Assigned APC Implementation 

date 

C9227 .............................. Injection, micafungin sodium, per 1 mg ......................................... G 9227 April 1, 2006. 

C9228 .............................. Injection, tigecycline, per 1 mg ....................................................... G 9228 April 1, 2006. 

C9229 .............................. Injection ibandronate sodium ......................................................... G 9229 July 1, 2006. 

C9230 .............................. Injection, abatacept ........................................................................ G 9230 July 1, 2006. 

2. Proposed Treatment of New CY 2007 

Category I and III CPT Codes and Level 

II HCPCS Codes 

As has been our practice in the past, 

we implement new Category I and III 

CPT codes and new Level II HCPCS 

codes, which are released in the fall of 

each year for annual updating, effective 

January 1 in the final rule updating the 

OPPS for the following calendar year. 

These codes are flagged with Comment 

Indicator ‘‘NI’’ in Addendum B of the 

OPPS final rule to indicate that we are 

assigning them an interim payment 

status which is subject to public 

comment following publication of the 

final rule that implements the annual 

OPPS update. (See the discussion 

immediately below concerning our 

modified policy for implementing new 

Category I and III mid-year CPT codes.) 

We are proposing to continue this 

recognition and process for CY 2007. 

New Category I and III CPT codes and 

new Level II HCPCS codes, effective 

January 1, 2007, will be designated in 

Addendum B of the CY 2007 OPPS final 

rule with Comment Indicator ‘‘NI.’’ The 

status indicator, the APC assignment, or 

both for all such codes flagged with 

Comment Indicator ‘‘NI,’’ will be open 

to public comment. We will respond to 

all comments received in a subsequent 

final rule. 

3. Proposed Treatment of New Mid-Year 

CPT Codes 

Twice each year, the AMA issues 

Category III CPT codes, which the AMA 

defines as temporary codes for emerging 

technology, services, and procedures. 

(In addition, AMA issues mid-year 

Category I CPT codes for vaccines for 

which FDA approval is imminent, to 

ensure timely availability of a code.) 

The AMA establishes these codes to 

allow collection of data specific to the 

service described by the code, as these 

services could otherwise only be 

reported using a Category I CPT unlisted 

code. The AMA releases Category III 

CPT codes in January, for 

implementation beginning the following 

July, and in July, for implementation 

beginning the following January. Prior 

to CY 2006, we treated new Category III 

CPT codes implemented in July of the 

previous year or January of the OPPS 

update year in the same manner that 

new Category I CPT codes and new 

Level II HCPCS codes implemented in 

January of the OPPS update year are 

treated; that is, we provided APC and 

status indicator assignments or both in 

the final rule updating the OPPS for the 

following calendar year. New Category I 

and Category III CPT codes, as well as 

new Level II HCPCS codes, were flagged 

with Comment Indicator ‘‘NI’’ in 

Addendum B of the final rule to 

indicate that we were assigning them an 


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interim payment status which was 

subject to public comment following 

publication of the final rule that 

implemented the annual OPPS update. 

As stated in the CY 2006 OPPS final 

rule with comment period (70 FR 

68567), we modified our process for 

implementing the Category III codes that 

the AMA releases each January for 

implementation in July to ensure timely 

collection of data pertinent to the 

services described by the codes; to 

ensure patient access to the services the 

codes describe; and to eliminate 

potential redundancy between Category 

III CPT codes and some of the C-codes, 

which are payable under the OPPS and 

created by us in response to 

applications for new technology 

services. Therefore, beginning on July 1, 

2006, we implemented in the OPPS 

seven Category III CPT codes that the 

AMA released in January 2006 for 

implementation in July 2006. The codes 

are shown in Table 6. These codes are 

not included in Addendum B of this 

proposed rule, which is based upon the 

April 2006 OPPS update. In this 

proposed rule, we are soliciting public 

comments on the status indicators and, 

if applicable, the APC assignments of 

these services. We intend to finalize the 

assignments of these Category III CPT 

codes implemented in July 2006 in the 

CY 2007 OPPS final rule. 

TABLE 6.—CATEGORY III CPT CODES IMPLEMENTED IN JULY 2006 

HCPCS code Long descriptor Status indicator APC 

0155T ....................................... Laparoscopy, surgical, implantation or replacement of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity).T 0130 

0156T ....................................... Laparoscopy, surgical, revision or removal of gastric stimulation electrodes, 

lesser curvature (i.e., morbid obesity).

T 0130 

0157T ....................................... Laparotomy, implantation or replacement of gastric stimulation electrodes, 

lesser curvature (i.e., morbid obesity).

C ........................

0158T ....................................... Laparotomy, revision or removal of gastric stimulation electrodes, lesser curvature (i.e., morbid obesity).C ........................

0159T ....................................... Computer aided detection, including computer algorithm analysis of MRI 

image data for lesion detection/characterization, pharmacokinetic analysis, 

with further physician review for interpretation, breast MRI.

N ........................

0160T ....................................... Therapeutic repetitive transcranial magnetic stimulation treatment planning .... X 0340 

0161T ....................................... Therapeutic repetitive transcranial magnetic stimulation treatment delivery and 

management, per session.

X 0340 

Some of the new Category III CPT 

codes describe services that we have 

determined to be similar in clinical 

characteristics and resource use to 

HCPCS codes in an existing APC. In 

these instances, we may assign the 

Category III CPT code to the appropriate 

clinical APC. Other Category III CPT 

codes describe services that we have 

determined are not compatible with an 

existing clinical APC, yet are 

appropriately provided in the hospital 

outpatient setting. In these cases, we 

may assign the Category III CPT code to 

what we estimate is an appropriately 

priced New Technology APC. In other 

cases, we may assign a Category III CPT 

code one of several nonseparately 

payable status indicators, including N, 

C, B, or E, which we believe is 

appropriate for the specific code. We 

expect that we will have received 

applications for new technology status 

for some of the services described by 

new Category III CPT codes, which may 

assist us in determining appropriate 

APC assignments. If the AMA 

establishes a Category III CPT code for 

a service for which an application has 

been submitted to CMS for new 

technology status, CMS may not have to 

issue a temporary Level II HCPCS code 

to describe the service, as has often been 

the case in the past when Category III 

CPT codes were only recognized by the 

OPPS on an annual basis. 

Therefore, for CY 2007, we are 

proposing to include in Addendum B of 

the OPPS CY 2007 final rule the new 

Category III CPT codes and the new 

Category I CPT codes for vaccines 

released in January 2006 for 

implementation on July 1, 2006 

(through the OPPS quarterly update 

process) and the Category III and 

vaccine Category I CPT codes released 

in July 2006 for implementation on 

January 1, 2007. However, only those 

new Category III codes and the new 

vaccine codes implemented effective 

January 1, 2007, will be flagged with 

Comment Indicator ‘‘NI’’ in Addendum 

B of the CY 2007 final rule to indicate 

that we are assigning them an interim 

payment status which is subject to 

public comment. As discussed earlier, 

Category III codes and Category I 

vaccine codes implemented in July 

2006, which are listed in Table 6, are 

subject to comment through this 

proposed rule and their status will be 

made final in the CY 2007 OPPS final 

rule. 

B. Proposed Changes—Variations 

Within APCs 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: 2 Times Rule’’ at the 

beginning of your comment.) 

1. Background 

Section 1833(t)(2)(A) of the Act 

requires the Secretary to develop a 

classification system for covered 

hospital outpatient services. Section 

1833(t)(2)(B) of the Act provides that 

this classification system may be 

composed of groups of services, so that 

services within each group are 

comparable clinically and with respect 

to the use of resources. In accordance 

with these provisions, we developed a 

grouping classification system, referred 

to as the Ambulatory Payment 

Classification Groups (or APCs), as set 

forth in § 419.31 of the regulations. We 

use Level I and Level II HCPCS codes 

and descriptors to identify and group 

the services within each APC. The APCs 

are organized such that each group is 

homogeneous both clinically and in 

terms of resource use. Using this 

classification system, we have 

established distinct groups of surgical, 

diagnostic, and partial hospitalization 

services, as well as medical visits. We 

also have developed separate APC 

groups for certain medical devices, 

drugs, biologicals, 

radiopharmaceuticals, and 

brachytherapy devices. 

We have packaged into each 

procedure or service within an APC 

group the costs associated with those 

items or services that are directly related 

and integral to performing a procedure 


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or furnishing a service. Therefore, we do 

not make separate payment for packaged 

items or services. For example, 

packaged items and services include: (1) 

Use of an operating, treatment, or 

procedure room; (2) use of a recovery 

room; (3) most observation services; (4) 

anesthesia; (5) medical/surgical 

supplies; (6) pharmaceuticals (other 

than those for which separate payment 

may be allowed under the provisions 

discussed in section V of this preamble); 

and (7) incidental services such as 

venipuncture. Our packaging 

methodology is discussed in section 

II.A. of this proposed rule. 

Under the OPPS, we pay for hospital 

outpatient services on a rate-per-service 

basis that varies according to the APC 

group to which the service is assigned. 

Each APC weight represents the hospital 

median cost of the services included in 

that APC relative to the hospital median 

cost of the services included in APC 

0606. The APC weights are scaled to 

APC 0606 because we are proposing it 

to be the middle level clinic visit APC 

(that is, where the Level III Clinic Visit 

HCPCS code of five proposed levels of 

clinic visits is assigned), and because 

middle level clinic visits are among the 

most frequently furnished services in 

the outpatient hospital setting. See 

section II.A.3. of this preamble for a 

complete discussion of the reasons for 

choosing APC 0606 as the basis for 

scaling the APC relative weights. 

Section 1833(t)(9)(A) of the Act 

requires the Secretary to review the 

components of the OPPS not less than 

annually and to revise the groups and 

relative payment weights and make 

other adjustments to take into account 

changes in medical practice, changes in 

technology, and the addition of new 

services, new cost data, and other 

relevant information and factors. 

Section 1833(t)(9)(A) of the Act, as 

amended by section 201(h) of the BBRA 

of 1999, also requires the Secretary, 

beginning in CY 2001, to consult with 

an outside panel of experts to review the 

APC groups and the relative payment 

weights (the APC Panel 

recommendations for specific services 

for CY 2007 OPPS and our responses to 

them are discussed in section III.D. of 

this preamble). 

Finally, as discussed earlier, section 

1833(t)(2) of the Act provides that, 

subject to certain exceptions, the items 

and services within an APC group 

cannot be considered comparable with 

respect to the use of resources if the 

highest median (or mean cost, if elected 

by the Secretary) for an item or service 

in the group is more than 2 times greater 

than the lowest median cost for an item 

or service within the same group 

(referred to as the ‘‘2 times rule’’). We 

use the median cost of the item or 

service in implementing this provision. 

The statute authorizes the Secretary to 

make exceptions to the 2 times rule in 

unusual cases, such as low-volume 

items and services. 

2. Application of the 2 Times Rule 

In accordance with section 1833(t)(2) 

of the Act and § 419.31 of the 

regulations, we annually review the 

items and services within an APC group 

to determine, with respect to 

comparability of the use of resources, if 

the median of the highest cost item or 

service within an APC group is more 

than 2 times greater than the median of 

the lowest cost item or service within 

that same group (‘‘2 times rule’’). We 

make exceptions to this limit on the 

variation of costs within each APC 

group in unusual cases such as lowvolume items and services. 

During the APC Panel’s March 1–2, 

2006 meeting, we presented median cost 

and utilization data for services 

furnished during the period of January 

1, 2005, through September 30, 2005, 

about which we had concerns or about 

which the public had raised concerns 

regarding their APC assignments, status 

indicator assignments, or payment rates. 

The discussions of service-specific 

issues, the APC Panel recommendations 

if any, and our proposals for CY 2007 

are contained in section III.D. of this 

preamble. 

In addition to the assignment of 

specific services to APCs which we 

discussed with the APC Panel, we also 

identified APCs with 2 times violations 

that were not specifically discussed 

with the APC Panel but for which we 

are proposing changes to their HCPCS 

codes’ APC assignments in Addendum 

B of this proposed rule. In these cases, 

to eliminate a 2 times violation, we 

reassigned the codes to APCs that 

contained services that were similar 

with regard to both resource use and 

clinical homogeneity. We also are 

proposing changes to the status 

indicators for some codes that are not 

specifically and separately discussed in 

this proposed rule. In these cases, we 

changed the status indicators for some 

codes because we thought that another 

status indicator more accurately 

describes their payment status from an 

OPPS perspective based on our CY 2007 

proposed policies. 

Addendum B of this proposed rule 

identifies with a comment indicator 

‘‘CH’’ those HCPCS codes for which we 

are proposing a change to the APC 

assignment or status indicator as 

assigned in the January 2006 Addendum 

B. These proposed reassignments of 

APC or status indicator are subject to 

public comment under this proposed 

rule. 

3. Exceptions to the 2 Times Rule 

As discussed earlier, we may make 

exceptions to the 2 times limit on the 

variation of costs within each APC 

group in unusual cases such as lowvolume items and services. Taking into 

account the APC changes that we are 

proposing for CY 2007 based on the 

APC Panel recommendations discussed 

in section III.D. of this preamble, the 

proposed changes to status indicators 

and APC assignments as identified in 

Addendum B, and the use of CY 2005 

claims data to calculate the median 

costs of procedures classified in the 

APCs, we reviewed all the APCs to 

determine which APCs would not 

satisfy the 2 times rule. We used the 

following criteria to decide whether to 

propose exceptions to the 2 times rule 

for affected APCs: 

• Resource homogeneity 

• Clinical homogeneity 

• Hospital concentration 

• Frequency of service (volume) 

• Opportunity for upcoding and code 

fragments. 

For a detailed discussion of these 

criteria, refer to the April 7, 2000 OPPS 

final rule with comment period (65 FR 

18457). 

Table 7 lists the APCs that we are 

proposing to exempt from the 2 times 

rule based on the criteria cited above. 

For cases in which a recommendation 

by the APC Panel appeared to result in 

or allow a violation of the 2 times rule, 

we generally accepted the APC Panel’s 

recommendation because those 

recommendations were based on 

explicit consideration of resource use, 

clinical homogeneity, hospital 

specialization, and the quality of the 

data used to determine the APC 

payment rates that we are proposing for 

CY 2007. The median costs for hospital 

outpatient services for these and all 

other APCs which were used in 

development of this proposed rule can 

be found on the CMS Web site: http:// 

www.cms.hhs.gov. 


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TABLE 7.—PROPOSED APC EXCEPTIONS TO THE 2 TIMES RULE FOR CY 2007 

APC APC description 

0007 ................................................ Level II Incision & Drainage. 

0010 ................................................ Level I Destruction of Lesion. 

0019 ................................................ Level I Excision/Biopsy. 

0024 ................................................ Level I Skin Repair. 

0031 ................................................ Smoking Cessation Services. 

0040 ................................................ Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve. 

0043 ................................................ Closed Treatment Fracture Finger/Toe/Trunk. 

0058 ................................................ Level I Strapping and Cast Application. 

0060 ................................................ Manipulation Therapy. 

0081 ................................................ Non-Coronary Angioplasty or Atherectomy. 

0085 ................................................ Level II Electrophysiologic Evaluation. 

0093 ................................................ Vascular Reconstruction/Fistula Repair without Device. 

0105 ................................................ Revision/Removal of Pacemakers, AICD, or Vascular. 

0111 ................................................ Blood Product Exchange. 

0112 ................................................ Apheresis, Photopheresis, and Plasmapheresis. 

0204 ................................................ Level I Nerve Injections. 

0235 ................................................ Level I Posterior Segment Eye Procedures. 

0245 ................................................ Level I Cataract Procedures without IOL Insert. 

0251 ................................................ Level I ENT Procedures. 

0252 ................................................ Level II ENT Procedures. 

0274 ................................................ Myelography. 

0303 ................................................ Treatment Device Construction. 

0307 ................................................ Myocardial Positron Emission Tomography (PET) Imaging. 

0312 ................................................ Radioelement Applications. 

0323 ................................................ Extended Individual Psychotherapy. 

0330 ................................................ Dental Procedures. 

0409 ................................................ Red Blood Cell Tests. 

0418 ................................................ Insertion of Left Ventricular Pacing Elect. 

0432 ................................................ Health and Behavior Services. 

0437 ................................................ Level II Drug Administration. 

0604 ................................................ Level I Clinic Visits. 

0664 ................................................ Level I Proton Beam Radiation Therapy. 

C. New Technology APCs 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘New Technology APCs’’ at the 

beginning of your comment.) 

1. Introduction 

In the November 30, 2001 final rule 

(66 FR 59903), we finalized changes to 

the time period a service was eligible for 

payment under a New Technology APC. 

Beginning in CY 2002, we retain 

services within New Technology APC 

groups until we gather sufficient claims 

data to enable us to assign the service 

to a clinically appropriate APC. This 

policy allows us to move a service from 

a New Technology APC in less than 2 

years if sufficient data are available. It 

also allows us to retain a service in a 

New Technology APC for more than 3 

years if sufficient data upon which to 

base a decision for reassignment have 

not been collected. We note that the cost 

bands for new technology APCs range 

from $0 to $50 in increments of $10, 

from $50 to $100 in an increment of 

$50, from $100 through $2,000 in 

intervals of $100, and from $2,000 

through $6,000 in intervals of $500. 

These intervals, which are in two 

parallel sets of New Technology APCs, 

one with status indicator ‘‘S’’ and the 

other with status indicator ‘‘T,’’ allow us 

to price new technology services more 

appropriately and consistently. 

Every year we receive many requests 

for higher payment amounts for specific 

procedures under the OPPS because 

they require the use of expensive 

equipment. We are taking this 

opportunity to reiterate our response in 

general to the issue of hospitals’ capital 

expenditures as they relate to the OPPS 

and Medicare. 

Under the OPPS, one of our goals is 

to make payments that are appropriate 

for the services that are necessary for 

treatment of Medicare beneficiaries. The 

OPPS like other Medicare payment 

systems is budget neutral and so, 

although we do not pay full hospital 

costs for procedures, we believe that our 

payment rates generally reflect the costs 

that are associated with providing care 

to Medicare beneficiaries in costefficient settings. Further, we believe 

that our rates are adequate to assure 

access to services for most beneficiaries. 

For many emerging technologies there 

is a transitional period during which 

utilization may be low, often because 

providers are first learning about the 

techniques and their clinical utility. 

Quite often, the requests for higher 

payment amounts are for new 

procedures in that transitional phase. 

These requests, and their accompanying 

estimates for expected Medicare 

beneficiary or total patient utilization, 

often reflect very low rates of patient 

use, resulting in high per use costs for 

which requesters believe Medicare 

should make full payment. Medicare 

does not, and we believe should not, 

assume responsibility for more than its 

share of the costs of procedures based 

on Medicare beneficiary projected 

utilization and does not set its payment 

rates based on initial projections of low 

utilization for services that require 

expensive capital equipment. For the 

OPPS, we rely on hospitals to make 

their business decisions regarding 

acquisition of high cost capital 

equipment taking into consideration 

their knowledge about their entire 

patient base (Medicare beneficiaries 

included) and an understanding of 

Medicare’s and other payers’ payment 

policies. 

We note that in a budget neutral 

environment, payments may not fully 

cover hospitals’ costs, including those 

for the purchase and maintenance of 

capital equipment. We rely on providers 

to make their decisions regarding the 

acquisition of high cost equipment with 

the understanding that the Medicare 


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program must be careful to establish its 

initial payment rates for new services 

that lack hospital claims data based on 

realistic utilization projections for all 

such services delivered in cost-efficient 

hospital outpatient settings. As the 

OPPS acquires claims data regarding 

hospital costs associated with new 

procedures, we will regularly examine 

the claims data and any available new 

information regarding the clinical 

aspects of new procedures to confirm 

that our OPPS payments remain 

appropriate for procedures as they 

transition into mainstream medical 

practice. 

2. Proposed Movement of Procedures 

From New Technology APCs to Clinical 

APCs 

As we explained in the November 30, 

2001 final rule (66 FR 59897), we 

generally keep a procedure in the New 

Technology APC to which it is initially 

assigned until we have collected data 

sufficient to enable us to move the 

procedure to a clinically appropriate 

APC. However, in cases where we find 

that our original New Technology APC 

assignment was based on inaccurate or 

inadequate information, or where the 

New Technology APCs are restructured, 

we may, based on more recent resource 

utilization information (including 

claims data) or the availability of refined 

New Technology APC bands, reassign 

the procedure or service to a different 

New Technology APC that most 

appropriately reflects its cost. 

The procedures presented below 

represent services assigned to New 

Technology APCs for CY 2006 for which 

we believe we have sufficient data to 

reassign them to clinically appropriate 

APCs for CY 2007. Therefore, we are 

proposing to reassign them to clinically 

appropriate APCs as indicated 

specifically in our discussion and in 

Table 10. 

a. Nonmyocardial Positron Emission 

Tomography (PET) Scans 

Positron emission tomography (PET) 

is a noninvasive diagnostic imaging 

procedure that assesses the level of 

metabolic activity and perfusion in 

various organ systems of the human 

body. PET serves an important role in 

the clinical care of many Medicare 

beneficiaries. We recognize that PET is 

a useful technology in many instances 

and want to ensure that the technology 

remains available to Medicare 

beneficiaries when medically necessary. 

Since August 2000, nonmyocardial PET 

procedures have been assigned to a New 

Technology APC in the OPPS. As a 

result of our collection of 5 full years 

worth of hospital claims data, we 

believe that we have sufficient data to 

assign nonmyocardial PET scans to a 

clinically appropriate APC for CY 2007. 

Note that we assign a service to a New 

Technology APC only when we do not 

have adequate claims data upon which 

to determine the median cost of 

performing the procedure, and we 

expect that the service’s clinical or 

resource characteristics will differ from 

all other procedures already assigned to 

clinical APCs. Each New Technology 

APC represents a particular cost band 

(for example, $1,400–1,500), and we 

assign procedures to these APCs based 

on our analysis of the procedures’ costs. 

Payment for items assigned to a New 

Technology APC is the midpoint of the 

band (for example, $1,450). We move a 

service from a New Technology APC to 

a clinical APC when we have adequate 

claims data upon which to base its 

future payment rate. In the case of 

nonmyocardial PET services, we believe 

that we now have sufficient data to 

assign them to a clinically appropriate 

APC. 

We last proposed changes in 

payments for nonmyocardial PET 

procedures for CY 2005. At that time, 

while we had large numbers of single 

claims reflecting that the median cost of 

PET procedures was substantially lower 

than their CY 2004 payment rate of 

$1,450, we had some concerns that 

abruptly lowering the payment rate for 

nonmyocardial PET scans could hinder 

access to this technology. Therefore, we 

proposed three options to develop the 

CY 2005 payment rate for these 

procedures in the August 16, 2004 

proposed rule (69 FR 50468). 

Specifically, we proposed the following 

options and invited comments on each 

of the options. 

• Option 1: Continue in CY 2005 the 

CY 2004 assignment of the scans to New 

Technology APC 1516 prior to assigning 

to a clinical APC. 

• Option 2: Assign the PET scans to 

a clinically appropriate APC priced 

according to the median cost of the 

scans based on CY 2003 claims data. 

Under this option, we would assign PET 

scans to APC 0420, PET imaging. 

• Option 3: Transition assignment to 

a clinical APC in CY 2006 by setting 

payment in CY 2005 based on a 50/50 

blend of the median cost of PET scans 

and their CY 2004 New Technology 

payment rate. We would assign the 

scans to New Technology APC 1513 for 

a blended transition payment. 

Based on comments received, we 

decided to set the CY 2005 payment rate 

for nonmyocardial PET scans based on 

option 3 at $1,150. We further stated in 

the November 15, 2004 final rule with 

comment period (69 FR 65716) that we 

believed there were sufficient claims 

data to assign nonmyocardial PET scans 

to a single clinical APC. However, to 

minimize any potential impact that a 

payment reduction resulting from this 

move might have had on beneficiary 

access to this technology, we set the CY 

2005 OPPS payment rate for 

nonmyocardial PET scans based on a 

50/50 blend of their median cost based 

on CY 2003 claims data and the 

payment rate of the CY 2004 New 

Technology APC to which they were 

assigned. Therefore, nonmyocardial PET 

scans were assigned to New Technology 

APC 1513 (New Technology—Level XIV 

($1,000-$1,200) for a blended payment 

rate of $1,150 in CY 2005. In CY 2005, 

in the context of an expansion in 

Medicare coverage for PET procedures, 

we also simplified coding for PET 

services by instructing hospitals to bill 

several more general CPT codes in place 

of numerous disease-specific G-codes. 

We continued with these coding and 

payment methodologies in CY 2006. 

For CY 2007, we are proposing the 

assignment of nonmyocardial PET 

procedures to a clinically appropriate 

APC as we have several years of robust 

and stable claims data upon which to 

determine the median cost of 

performing these procedures. Based on 

analysis of our claims data, the median 

costs for nonmyocardial PET scans have 

ranged between approximately $852 and 

$924 for claims submitted from CY 2002 

through CY 2005, yet our payment rates 

have been significantly higher than the 

median costs throughout this same time 

period. We have observed significant 

growth in the number of nonmyocardial 

PET scans performed on Medicare 

beneficiaries, from about 48,000 in CY 

2002, to 68,000 in CY 2003, and once 

again to 121,000 in CY 2004, the year 

when we first reduced the OPPS 

nonmyocardial PET scan payment rates 

from $1,450 to $1,150. For the CY 2007 

proposed rule, we have about 45,000 

single PET claims from CY 2005, 

yielding a stable median cost for PET 

procedures of about $867. Although the 

CY 2005 claims data are not yet 

complete, the apparent decline in 

numbers of claims for nonmyocardial 

PET scans alone in the CY 2005 claims 

data is likely related to the large number 

of claims for PET/CT scans now 

observed in CY 2005, when codes for 

that combined service were first 

available for billing. In fact, the total 

number of PET scans provided to 

Medicare beneficiaries in CY 2005, 

defined as PET scans and PET/CT scans, 

continued to climb to almost 128,000 

based upon the CY 2005 claims data 

available for this proposed rule, in 


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comparison to final claims for CY 2004 

of approximately 121,000 for PET scans. 

Therefore, we are proposing to assign 

nonmyocardial PET scans, in particular, 

CPT codes 78608, 78811, 78812, and 

78813, to new APC 0308 

(Nonmyocardial PET Imaging) with a 

median cost of $865.30 for CY 2007. We 

are confident, in the face of our stable 

median costs for nonmyocardial PET 

scans over the past 4 years, that their 

additional 2-year period of receiving 

New Technology APC payments at the 

blended rate of $1,150 for CY 2005 and 

CY 2006 as we transitioned the services 

to a clinical APC should ensure 

continued availability of this technology 

now that its services will be paid 

through a clinical APC for CY 2007, like 

most other OPPS services. 

b. PET/Computed Tomography (CT) 

Scans 

Since August 2000, we have paid 

separately for PET and CT scans. In CY 

2004, the payment rate for 

nonmyocardial PET scans was $1,450, 

while it was $193 for typical diagnostic 

CT scans. Prior to CY 2005, 

nonmyocardial PET and the PET portion 

of PET/CT scans were described by Gcodes for billing to Medicare. Several 

commenters to the November 15, 2004 

final rule with comment period (69 FR 

65682) urged that we replace the Gcodes for nonmyocardial PET and PET/ 

CT scan procedures with the established 

CPT codes. These commenters stated 

that movement to the established CPT 

codes would greatly reduce the burden 

on hospitals of tracking and billing the 

G-codes which are not recognized by 

other payers and would allow for more 

uniform hospital billing of these scans. 

We agreed with the commenters that 

movement from the G-codes to the 

established CPT codes for 

nonmyocardial PET and PET/CT scans 

would allow for more uniform billing of 

these scans. As a result of a Medicare 

national coverage determination 

(Publication 100–3, Medicare Claims 

Processing Manual section 220.6) that 

was made effective January 28, 2005, we 

discontinued numerous G-codes that 

described myocardial PET and 

nonmyocardial PET procedures and 

replaced them with the established CPT 

codes. The CY 2005 payment rate for 

concurrent PET/CT scans using the CPT 

codes 78814, 78815, and 78816 was 

$1,250, which was $100 higher than the 

payment rate for PET scans alone. These 

PET/CT CPT codes were placed in New 

Technology APC 1514 (New 

Technology—Level XIV, $1,200–$1,300) 

for CY 2005. We continued with these 

coding and payment methodologies in 

CY 2006. 

For CY 2007, we are proposing the 

assignment of concurrent PET/CT scans, 

specifically CPT codes 78814, 78815, 

and 78816, to a clinically appropriate 

APC because we believe we have 

adequate claims data from CY 2005 

upon which to determine the median 

cost of performing these procedures. 

Based on our analysis of CY 2005 single 

claims, the median cost of PET/CT scans 

is $865 from over almost 64,000 single 

claims. Comparison of the median cost 

of nonmyocardial PET procedures of 

$867 with the median cost of concurrent 

PET/CT scans demonstrates that the 

median costs of PET scans with or 

without concurrent CT scans for 

attenuation correction and anatomical 

localization are about the same. This 

result is not unexpected because many 

newer PET scanners also have the 

capability of rapidly acquiring CT 

images for attenuation correction and 

anatomical localization, sometimes with 

simultaneous image acquisition. 

To explore the possibility that the 

similarity in median costs for PET and 

PET/CT procedures could be related to 

different groups of hospitals billing the 

two types of PET services based on their 

available equipment, rather than the 

true comparability of hospital resources 

required for the two types of services, 

we analyzed claims from a subset of 

hospitals billing both PET and PET/CT 

scans in CY 2005. This analysis looked 

at 362 providers who billed a PET 

HCPCS code and a PET/CT CPT code at 

least one time each during CY 2005. The 

median cost from this subset of claims 

for nonmyocardial PET scans was $890, 

in comparison with $863 for the PET/CT 

scans. Thus, we observed the same close 

relationship between median costs of 

PET and PET/CT procedures from 

hospitals billing both sets of services as 

we did for all OPPS CY 2005 claims 

available for this proposed rule for these 

scans. We believe that our claims data 

accurately reflect the comparable 

hospital resources required to provide 

PET and PET/CT procedures, and the 

scans have obvious clinical similarity as 

well. Therefore, for CY 2007 we are 

proposing to assign the CPT codes for 

PET/CT scans, along with the CPT codes 

for PET scans, to the same new APC 

0308 (Nonmyocardial PET Imaging) 

with a median cost of $865.30. 

We note that we have been paying 

separately for fluorodeoxyglucose 

(FDG), the radiopharmaceutical 

described by HCPCS code A9552 (F18 

fdg), that is commonly administered 

during nonmyocardial PET and PET/CT 

procedures. For CY 2007, we are 

proposing to continue paying separately 

for FDG, according to the methodology 

described in section V. (Proposed OPPS 

Payment Changes for Drugs, Biologicals, 

and Radiopharmaceuticals) of the 

preamble of this proposed rule. 

c. Stereotactic Radiosurgery (SRS) 

Treatment Delivery Services 

For the past several years, we have 

collected hospital costs associated with 

the planning and delivery of stereotactic 

radiosurgery services (hereafter referred 

to as SRS). As new technology emerged 

in the field of SRS, public commenters 

urged us to recognize cost differences 

associated with the various methods of 

SRS planning and delivery. Beginning 

in CY 2001, we established G-codes to 

capture any such cost variations 

associated with the various methods of 

planning and delivery of SRS. For CY 

2004, based on comments received 

regarding the G-codes used for SRS, we 

made some modifications to the coding 

(68 FR 63431 and 63432). First, we 

received comments regarding the 

descriptors for HCPCS codes G0173 and 

G0251, indicating that these codes did 

not distinguish image-guided robotic 

SRS systems from other forms of linear 

accelerator-based SRS systems to 

account for the cost variation in 

delivering these services. In response, 

for CY 2004 we created two new Gcodes (G0339 and G0340) to describe 

complete and fractionated image-guided 

robotic linear accelerator-based SRS 

treatment. We placed HCPCS code 

G0339 in APC 1528 at a payment rate 

of $5,250, and HCPCS code G0340 in 

APC 1525 at a payment rate of $3,750. 

Second, we received comments on 

HCPCS code G0242 which requested 

that we modify the code descriptor to 

avoid confusion and misuse of the code, 

and also to appropriately describe 

treatment planning for both linear 

accelerator-based and Cobalt 60-based 

SRS treatments. In response, for CY 

2004, we created HCPCS code G0338 to 

distinguish linear accelerator-based SRS 

treatment planning from Cobalt 60- 

based SRS treatment planning. We 

placed HCPCS code G0338 in APC 1516 

at a payment rate of $1,450. 

In CY 2005, there were no changes to 

the coding or New Technology APC 

payment rates for the SRS planning or 

treatment delivery codes from CY 2004. 

We stated in the CY 2005 OPPS final 

rule with comment period (69 FR 

65711) that any SRS code changes 

would be premature without cost data to 

support a code restructuring. Therefore, 

we maintained HCPCS codes G0173, 

G0242, G0243, G0251, G0338, G0339, 

and G0340 in their respective New 

Technology APCs for CY 2005. We 

further stated that until we had 

completed an analysis of claims for 

these procedure codes, we would 


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continue to maintain HCPCS codes 

G0173, G0242, G0243, G0251, G0338, 

G0339, and G0340 in their respective 

New Technology APCs for CY 2005 as 

we considered the adoption of CPT 

codes to describe all SRS procedures for 

CY 2006. 

At its February 2005 meeting, the APC 

Panel discussed the clinical and 

resource cost similarities between 

planning for Cobalt 60-based and linear 

accelerator-based SRS. The APC Panel 

also discussed the use of CPT codes 

instead of specific G-codes to describe 

the services involved in SRS planning, 

noting the clinical similarities in 

radiation treatment planning regardless 

of the mode of treatment delivery. Given 

the APC Panel’s thoughts about the 

possible need for CMS to separately 

track planning for SRS, the APC Panel 

eventually recommended that we create 

a single HCPCS code to encompass both 

Cobalt 60-based and linear acceleratorbased SRS planning. Because we had no 

programmatic need to separately track 

SRS planning services, in the CY 2006 

OPPS final rule with comment period 

(70 FR 68585) we discontinued HCPCS 

codes G0242 and G0338 for the 

reporting of charges for SRS planning 

and instructed hospitals to bill charges 

for SRS planning, regardless of the 

mode of treatment delivery, using all of 

the available CPT codes that most 

accurately reflect the services provided. 

Furthermore, the APC Panel 

recommended that we make no changes 

to the coding or APC placement of SRS 

treatment delivery HCPCS codes G0173, 

G0243, G0251, G0339, and G0340 for CY 

2006. In addition, presenters to the APC 

Panel described ongoing deliberations 

among interested professional societies 

around the descriptions and coding for 

SRS. The APC Panel and presenters 

suggested that we wait for the outcome 

of these deliberations before making any 

significant changes to SRS delivery 

coding or payment rates. To date, we 

have received no report from 

participating professional societies as to 

the outcome of such deliberations. 

In response to comments for CY 2006 

regarding the mature technology and 

stable median costs associated with 

Cobalt 60-based SRS treatment delivery 

described by G0243, we reassigned 

G0243 from a New Technology APC to 

new clinical APC 0127 (Stereotactic 

Radiosurgery) with a payment rate of 

$7,305 established based on the CY 

2004 median cost of G0243. We made 

no changes for CY 2006 to the New 

Technology APC assignments of the 

other four SRS treatment codes, 

specifically, G0173, G0251, G0339, and 

G0340. 

Since we first established the full 

group of SRS treatment delivery codes 

in CY 2004, we now have 2 years of 

hospital claims data reflecting the costs 

of each of these services. Based on 

analysis of our claims data from CY 

2004 and CY 2005, the median costs for 

linear accelerator-based SRS treatment 

delivery procedures as described by 

HCPCS codes G0173, G0251, G0339, 

and G0340 have been stable and 

generally lower than our New 

Technology APC payment rates in effect 

from CY 2004 through CY 2006. 

Specifically, the payment rate for 

HCPCS code G0173, a complete course 

of non-image guided, non-robotic linear 

accelerator-based SRS treatment, has 

been set at $5,250, yet our claims data 

indicate a median cost of $2,802 from 

CY 2004 claims and $3,665 from CY 

2005 claims, based upon hundreds of 

single claims from each year. For 

HCPCS code G0251, fractionated nonimage guided, non-robotic linear 

accelerator-based SRS treatment, the 

corresponding median costs have been 

$1,028 and $1,386 based upon over 

1,000 single claims from each year, and 

relatively consistent with the 

procedure’s New Technology APC 

payment of $1,150. With respect to the 

complete course of therapy in one 

session or first fraction of image-guided, 

robotic linear accelerator-based SRS, 

described by HCPCS code G0339, its 

median costs have been $4,917 and 

$4,809 for CY 2004 and CY 2005 

respectively, based upon over 500 single 

bills in each year, in comparison with 

the procedure’s payment rate of $5,250 

for those years. Lastly, the median costs 

of HCPCS code G0340, the second 

through fifth sessions of image-guided, 

robotic linear accelerator-based SRS 

treatment, have been $2,502 for CY 2004 

and $2,917 for CY 2005 as determined 

by over 1,000 single bills during each 

year, significantly lower than its 

payment rate of $3,750. Unquestionably, 

the claims data from CY 2004 and CY 

2005 for linear accelerator-based SRS 

treatment delivery services reveal highly 

stable median costs from year to year 

based on significant claims volume. 

Based on the above findings, we 

believe that we have adequate claims 

data to assign the SRS treatment 

delivery procedures to clinically 

appropriate APCs, and we believe that 

such movement is appropriate. For CY 

2007, we are proposing to create several 

new SRS clinical APCs of different 

levels to assign the HCPCS codes 

describing linear accelerator-based SRS 

treatment, G0173, G0251, G0339, and 

G0340, based on their clinical and 

hospital resource similarities and 

differences. In particular, we are 

proposing to assign HCPCS codes G0339 

and G0173 to the same Level III SRS 

APC, because we believe these codes 

that describe the complete or first 

fraction of all types of linear acceleratorbased SRS treatments have substantial 

hospital resource and clinical similarity, 

as observed in their median costs and 

recognized previously in their 

equivalent New Technology APC 

payments. The codes describing 

subsequent fractions of image-guided, 

robotic and non-image guided, nonrobotic linear accelerator-based SRS 

treatments will each be assigned to their 

own clinical APCs, as they demonstrate 

significant differences in resource 

utilization as reflected in their median 

costs. Their previous assignments to 

different New Technology APCs 

anticipated these resource distinctions. 

We are proposing to continue our 

assignment of HCPCS code G0243 for 

Cobalt 60-based SRS treatment delivery 

to clinical APC 0127, renamed Level IV 

Stereotactic Radiosurgery. Our proposed 

reassignments of SRS services from New 

Technology APCs to clinical APCs are 

listed in Table 8 below. 

TABLE 8.—PROPOSED APC REASSIGNMENT FOR SRS TREATMENT DELIVERY SERVICES FOR CY 2007 

HCPCS 

code Short descriptor CY 2006 SI CY 2006 APC 

CY 2006 

payment 

rate 

Proposed CY 

2007 SI 

Proposed 

CY 2007 

APC 

Proposed CY 

2007 APC median cost 

G0173 .... Linear acc stereo radsur com .............. S 1528 $5,250.00 S 0067 $4,059.61 

G0251 .... Linear acc based stereo radio ............. S 1513 1,150.00 S 0065 1,386.20 

G0339 .... Robot lin-radsurg com, first .................. S 1528 5,250.00 S 0067 4,059.61 

G0340 .... Robot lin-radsurg fractx 2–5 ................ S 1525 3,750.00 S 0066 2,916.68 


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d. Magnetoencephalography (MEG) 

Services 

Magnetoencephalography (MEG) is a 

non-invasive diagnostic tool that assists 

surgeons presurgery by measuring and 

mapping brain activity. It may be used 

for epilepsy and brain tumor patients. 

Since CY 2002, the MEG procedures 

described by CPT codes 95965 (Meg, 

spontaneous), 95966 (Meg, evoked, 

single), and 95967 (Meg, evoked, each 

additional) have been assigned to New 

Technology APCs. In the July 25, 2005 

proposed rule (70 FR 42709), we 

proposed to reassign MEG procedures to 

clinical APC 0430 using CY 2004 claims 

data to establish median costs on which 

the CY 2006 payment rates would be 

based. This proposal involved the 

reassignment of the three MEG 

procedures, specifically CPT codes 

95965, 95966, and 95967, from three 

separate New Technology APCs into one 

new clinical APC with a status indicator 

of ‘‘T.’’ Commenters to this proposal 

believed that their assignment to 

clinical APC 0430 would be 

inappropriate because the proposed 

payment level of $674 was inadequate 

to cover the costs of the procedures, and 

because the procedures should not be 

assigned to only one level as their 

required hospital resources differ 

significantly. They further stated that 

our data did not represent the true costs 

of the procedures because MEG 

procedures are performed on very few 

Medicare patients. 

Analysis of our hospital data for 

claims submitted from CY 2002 through 

CY 2005 indicates that these procedures 

are rarely performed on Medicare 

beneficiaries. For claims submitted from 

CY 2002 through CY 2005, our single 

claims data show that there were 

annually only between 2 and 23 claims 

submitted for CPT code 95965, 3 and 7 

claims for CPT code 95966, and only 1 

for CPT code 95967. Additionally, the 

hospital claims median costs for these 

codes have varied widely, perhaps due 

to our small volume of claims. The 

median cost for CPT code 95965 has 

ranged from $332 using CY 2002 claims 

to $3,166 based upon CY 2005 claims. 

The median cost for CPT code 95966 

has varied widely from CY 2002 to CY 

2005. For single claims submitted 

during CY 2002, the median cost was 

$1,949, while it was $507 for CY 2003, 

$1,435 for CY 2004, and $701 from 3 

single claims for CY 2005. The median 

cost for CPT code 95967 based upon 1 

single claim from CY 2005 claims is 

$217. We have no hospital median cost 

data for CPT code 95967 prior to CY 

2005. 

In the November 10, 2005 final rule 

with comment period (70 FR 68579), we 

stated that we carefully considered our 

claims data, information provided by 

the commenters, and the APC Panel 

recommendation for CY 2006 that we 

retain the MEG procedures in New 

Technology APCs. As a result of this 

analysis, we determined that using a 50/ 

50 blend of the code specific median 

costs from our most recent CY 2004 

hospital claims data and the CY 2005 

New Technology APC code-specific 

payments amounts as the basis for 

assignment of the procedures for CY 

2006 would be an appropriate way to 

recognize both the current payment 

rates for the procedures, which were 

originally based on the theoretical costs 

to hospitals of providing MEG services, 

and the median costs based upon our 

hospital claims data regarding actual 

MEG services provided to Medicare 

beneficiaries by hospitals. Therefore, 

CPT codes 95965, 95966, and 95967 

were assigned to different New 

Technology APCs for CY 2006 based on 

this blended methodology, with 

payment rates of $2,750, $1,250, and 

$850 respectively. 

At the March 2006 APC Panel 

meeting, the Panel recommended that 

CMS move CPT codes 95965 (MEG, 

spontaneous), 95966 (MEG, evoked, 

single), and 95967 (MEG, evoked, each 

additional) from their CY 2006 New 

Technology APCs which were assigned 

based on the blended methodology 

described above to clinical APC(s) for 

CY 2007. Following that meeting, 

interested parties have provided us with 

CY 2005 charge and cost information 

from six hospitals that provided MEG 

services. These external data show wide 

variation in hospitals’ costs and charges 

for MEG procedures, with generally 

higher values for CPT code 95965 and 

lower values for CPT codes 95966 and 

95967 but no consistent proportionate 

relationship among those costs and 

charges. In some cases, the charges and 

costs for CPT codes 95966 and 95967 

are quite similar for the two related 

services, one of which describes MEG 

for a single modality of evoked magnetic 

fields and the other that describes MEG 

for each additional modality of evoked 

magnetic fields. The individual hospital 

cost and charge data for specific services 

demonstrate significant variations of up 

to six fold across the hospitals, with an 

apparent inverse relationship between 

the numbers of services provided and 

the costs of the procedures. This finding 

is not unexpected, given the 

dependence of MEG procedures on the 

use of expensive capital equipment. As 

we have previously stated, our OPPS 

payment rates generally reflect the costs 

that are associated with providing care 

to Medicare beneficiaries in costefficient settings. For emerging 

technologies, we establish payment 

rates for new services that lack hospital 

claims data based on realistic utilization 

projections for all such services 

delivered in cost-efficient hospital 

outpatient settings. Given that we now 

have 4 years of hospital claims data for 

MEG procedures, because MEG is no 

longer a new technology, we do not 

believe these external data from 6 

hospitals that performed MEG services 

in CY 2005 provide a better estimate of 

the hospital resources used in MEG 

procedures during the care of Medicare 

beneficiaries than our standard OPPS 

historical claims methodology. 

We agree with the APC Panel and are 

proposing to accept their 

recommendation to move the MEG CPT 

codes into clinical APCs for CY 2007. 

While the volumes for the MEG 

procedures are low, almost all 

procedures, including those with very 

low Medicare volume, are assigned to 

clinical APCs under the OPPS, with 

their payment rates based on the median 

costs of their assigned APCs. Therefore, 

we are proposing to assign CPT code 

95965 to new clinical APC 0038 

(Spontaneous MEG) with a proposed 

median cost of $3,166.30 and to assign 

both CPT codes 95966 and 95967 to 

APC 0209 (Level II MEG, Extended EEG 

Studies, and Sleep Studies) with a 

proposed median cost of $709.36. We 

believe that the assignment of CPT 

codes 95966 and 95967 to APC 0209 is 

appropriate because MEG studies are 

similar to EEGs and sleep studies in 

measuring activity of the brain over a 

significant time period, and our hospital 

claims data show that their hospital 

resources are also relatively comparable. 

MEG procedures and their CY 2007 

proposed APC assignments are 

displayed in Table 9. 


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TABLE 9.—PROPOSED CY 2007 APC ASSIGNMENT FOR MEG 

HCPCS 

Code Short descriptor CY 2006 SI CY 2006 APC 

CY 2006 

payment 

rate 

Proposed CY 

2007 SI 

Proposed 

CY 2007 

APC 

Proposed CY 

2007 APC median cost 

95965 ..... Meg, spontaneous ................................ S .................. 1523 $2,750.00 S .................. 0038 $3,166.30 

95966 ..... Meg, evoked, single ............................. S .................. 1514 1,250.00 S .................. 0209 709.36 

95967 ..... Meg, evoked, each additional .............. S .................. 1510 850.00 S .................. 0209 709.36 

As these procedures are performed on 

very few Medicare patients, we expect 

to continue to have small Medicare 

claims volumes for MEG services each 

year. However, we are confident that 

over time our claims data for these 

procedures will become more consistent 

and reflective of the full hospital 

resources used in MEG services, 

especially because only a small subset 

of hospitals provide MEG services. We 

have been told that hospitals performing 

MEG procedure recently have been 

paying increased attention to accurately 

reporting charges for all necessary 

hospital resources on their claims. We 

are optimistic that both increased public 

awareness of Medicare coding for these 

procedures and improved 

understanding of the standard OPPS 

methodology for establishing APC 

payment rates should result in 

improved claims data in the future that 

more accurately reflect the required 

hospital resources. 

e. Other Services in New Technology 

APCs 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Other New Technology 

Services’’ at the beginning of your 

comment.) 

Other than the PET, PET/CT, and SRS 

new technology services discussed 

above, there are 23 procedures currently 

assigned to New Technology APCs for 

which we believe we also have data 

adequate to support their assignment to 

clinical APCs. For CY 2007, we are 

proposing to reassign these procedures 

to clinically appropriate APCs, applying 

their CY 2005 claims data to develop 

their clinical APC median costs on 

which payments would be based. These 

procedures and their proposed APC 

assignments are displayed in Table10. 

TABLE 10.—PROPOSED APC REASSIGNMENT OF OTHER NEW TECHNOLOGY PROCEDURES TO CLINICAL APCS FOR CY 

2007 

HCPCS 

Code Short descriptor CY 2006 SI CY 2006 APC 

CY 2006 

payment 

rate 

Proposed CY 

2007 SI 

Proposed 

CY 2007 

APC 

Proposed CY 

2007 APC median cost 

0003T ..... Cervicography ...................................... S .................. 1492 $15.00 T .................. 0191 $9.22 

0101T ..... Extracorp shockwv tx,hi enrg ............... T .................. 1547 850.00 T .................. 0050 1,548.05 

0102T ..... Extracorp shockwv tx,anesth ............... T .................. 1547 850.00 T .................. 0050 1,548.05 

0133T ..... Esophageal implant injexn ................... T .................. 1556 1,750.00 T .................. 0422 1,704.85 

19296 ..... Place po breast cath for rad ................ S .................. 1524 3,250.00 T .................. 0030 2,533.62 

19297 ..... Place breast cath for rad ..................... S .................. 1523 2,750.00 T .................. 0029 1,822.38 

20982 ..... Ablate, bone tumor(s) perq .................. T .................. 1557 1,850.00 T .................. 0050 1,548.05 

28890 ..... High energy eswt, plantar f .................. T .................. 1547 850.00 T .................. 0050 1,548.05 

36566 ..... Insert tunneled cv cath ......................... T .................. 1564 4,750.00 T .................. 0623 1,703.97 

77421 ..... Stereoscopic x-ray guidance ................ S .................. 1502 75.00 S .................. 0257 88.39 

78804 ..... Tumor imaging, whole body ................. S .................. 1508 650.00 S .................. 0408 308.82 

79403 ..... Hematopoietic nuclear tx ..................... S .................. 1507 550.00 S .................. 0413 315.17 

90473 ..... Immune admin oral/nasal ..................... S .................. 1491 5.00 S .................. 0436 10.71 

90474 ..... Immune admin oral/nasal addl ............. S .................. 1491 5.00 S .................. 0436 10.71 

91035 ..... G-esoph reflx tst w/electrod ................. S .................. 1506 450.00 X .................. 0361 242.86 

C9716 .... Radiofrequency energy to anu ............. S .................. 1519 1,750.00 T .................. 0150 1,818.31 

G0248 .... Demonstrate use home inr mon .......... S .................. 1503 150.00 V .................. 0604 49.45 

G0249 .... Provide test material,equipm ............... S .................. 1503 150.00 V .................. 0604 49.45 

G0293 .... Non-cov surg proc,clin trial .................. S .................. 1505 350.00 X .................. 0340 38.52 

G0294 .... Non-cov proc, clinical trial .................... S .................. 1502 75.00 X .................. 0340 38.52 

G0375 .... Smoke/tobacco counseling 3–10 ......... S .................. 1491 5.00 X .................. 0031 10.60 

G0376 .... Smoke/tobacco counseling >10 ........... S .................. 1491 5.00 X .................. 0031 10.60 

G3001 .... Admin + supply, tositumomab .............. S .................. 1522 2,250.00 S .................. 0442 1,515.80 

D. Proposed APC-Specific Policies 

1. Skin Replacement Surgery and Skin 

Substitutes (APCs 0024, 0025, 0027) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Skin Replacement Surgery and 

Skin Substitutes’’ at the beginning of 

your comment.) 

For CY 2006, the American Medical 

Association (AMA) made 

comprehensive changes, including code 

additions, deletions, and revisions, 

accompanied by new and revised 

introductory language, parenthetical 

notes, subheadings and cross-references, 

to the Integumentary, Repair (Closure) 

subsection of surgery in the CPT book 

to facilitate more accurate reporting of 

skin grafts, skin replacements, skin 

substitutes, and local wound care. In 

particular, the section of the CPT book 

previously titled ‘‘Free Skin Grafts’’ and 

containing codes for skin replacement 

and skin substitute procedures was 

renamed, reorganized, and expanded. 

New and existing CPT codes related to 

skin replacement surgery and skin 

substitutes were organized into five 

subsections: Surgical Preparation, 

Autograft/Tissue Cultured Autograft, 

Acellular Dermal Replacement, 

Allograft/Tissue Cultured Allogeneic 

Skin Substitute, and Xenograft. 


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As part of the CY 2006 CPT code 

update in the newly named ‘‘Skin 

Replacement Surgery and Skin 

Substitutes’’ section, certain codes were 

deleted that previously described skin 

allograft and tissue cultured and 

acellular skin substitute procedures, 

including CPT 15342 (Application of 

bilaminate skin substitute/neodermis; 

25 sq cm); CPT 15343 (Application of 

bilaminate skin substitute/neodermis; 

each additional 25 sq cm); CPT 15350 

(Application of allograft, skin; 100 sq 

cm or less), and CPT 15351 (Application 

of allograft, skin; each additional 100 sq 

cm). Thirty-seven new CPT codes were 

created in the ‘‘Skin Replacement 

Surgery and Skin Substitutes’’ section, 

and these codes received interim final 

status indicators and APC assignments 

in the CY 2006 final rule with comment 

period and were subject to comment. 

At its March 2006 meeting, the APC 

Panel heard several presentations on 

some of the new CY 2006 CPT codes for 

skin replacement and skin substitute 

procedures, and CMS has received 

additional information from the public 

regarding a number of these services. In 

particular, 18 new CPT codes that were 

created to more specifically describe 

skin allograft, skin replacement, and 

skin substitute procedures were the 

subject of the APC Panel discussion and 

recommendations. These codes are as 

follows: 

• CPT 15170 (Acellular dermal 

replacement, trunk, arms, legs; first 100 

sq cm or less, or one percent of body 

area of infants and children) 

• CPT 15171 (Acellular dermal 

replacement, trunk, arms, legs; each 

additional 100 sq cm, or each additional 

one percent of body area of infants and 

children, or part thereof) 

• CPT 15175 (Acellular dermal 

replacement, face, scalp, eyelids, mouth, 

neck, ears, orbits, genitalia, hands, feet 

and/or multiple digits; first 100 sq cm 

or less, or one percent of body area of 

infants and children) 

• CPT 15176 (Acellular dermal 

replacement, face, scalp, eyelids, mouth, 

neck, ears, orbits, genitalia, hands, feet 

and/or multiple digits; each additional 

100 sq cm, or each additional one 

percent of body area of infants and 

children, or part thereof) 

• CPT 15300 (Allograft skin for 

temporary wound closure, trunk, arms, 

legs; first 100 sq cm or less, or one 

percent of body area of infants and 

children) 

• CPT 15301 (Allograft skin for 

temporary wound closure; trunk, arms, 

legs; each additional 100 sq cm, or each 

additional one percent of body area of 

infants and children, or part thereof) 

• CPT 15320 (Allograft skin for 

temporary wound closure, face, scalp, 

eyelids, mouth, neck, ears, orbits, 

genitalia, hands, feet and/or multiple 

digits; first 100 sq cm or less, or one 

percent of body area of infants and 

children) 

• CPT 15321 (Allograft skin for 

temporary wound closure, face, scalp, 

eyelids, mouth, neck, ears, orbits, 

genitalia, hands, feet and/or multiple 

digits; each additional 100 sq cm, or 

each additional one percent of body area 

of infants and children, or part thereof) 

• CPT 15340 (Tissue cultured 

allogeneic skin substitute; first 25 sq cm 

or less) 

• CPT 15341 (Tissue cultured 

allogeneic skin substitute; each 

additional 25 sq cm) 

• CPT 15360 (Tissue cultured 

allogeneic dermal substitute; trunk, 

arms, legs; first 100 sq cm or less, or one 

percent of body area of infants and 

children) 

• CPT 15361 (Tissue cultured 

allogeneic dermal substitute; trunk, 

arms, legs; each additional 100 sq cm, 

or each additional one percent of body 

area of infants and children, or part 

thereof) 

• CPT 15365 (Tissue cultured 

allogeneic dermal substitute, face, scalp, 

eyelids, mouth, neck, ears, orbits, 

genitalia, hands, feet and/or multiple 

digits; first 100 sq cm or less, or one 

percent of body area of infants and 

children) 

• CPT 15366 (Tissue cultured 

allogeneic dermal substitute, face, scalp, 

eyelids, mouth, neck, ears, orbits, 

genitalia, hands, feet and/or multiple 

digits; first 100 sq cm or less, or one 

percent of body area of infants and 

children) 

• CPT 15420 (Xenograft skin 

(dermal), for temporary wound closure, 

face, scalp, eyelids, mouth, neck, ears, 

orbits, genitalia, hands, feet and/or 

multiple digits; first 100 sq cm or less, 

or one percent of body area of infants 

and children) 

• CPT 15421 (Xenograft skin 

(dermal), for temporary wound closure, 

face, scalp, eyelids, mouth, neck, ears, 

orbits, genitalia, hands, feet and/or 

multiple digits; each additional 100 sq 

cm, or each additional one percent of 

body area of infants and children, or 

part thereof) 

• CPT 15430 (Acellular xenograft 

implant; first 100 sq cm or less, or one 

percent of body area of infants and 

children) 

• CPT 15431 (Acellular xenograft 

implant; each additional 100 sq cm, or 

each additional one percent of body area 

of infants and children, or part thereof). 

The CY 2006 interim final APC 

assignments of these codes, the 

recommendations made by the APC 

Panel at its March 2006 meeting, and 

our proposed placement of the codes for 

CY 2007 are listed in Table 11 below. 

Note that in general, biological skin 

substitutes and replacements used in 

procedures described by these CPT 

codes are proposed for separate 

payment under the OPPS for CY 2007, 

according to the methodology outlined 

in section V. of the preamble of this 

proposed rule. 

TABLE 11.—CY 2007 PROPOSED ASSIGNMENTS OF SKIN SUBSTITUTE AND SKIN REPLACEMENT PROCEDURES

CPT code Short descriptor 

CY 2006 assignment 

APC panel recommendation 

CY 2007 proposed assignment 

APC SI APC median APC SI APC median 

15170 ..... Cell graft trunk/arm/legs ......................................... 24 T $92.22 27 25 T $314.58 

15171 ..... Cell graft t/arm/leg add-on ..................................... 24 T 92.22 25 25 T 314.58 

15175 ..... Acellular graft, f/n/hf/g ............................................ 24 T 92.22 27 25 T 314.58 

15176 ..... Acell graft, f/n/hf/g/add-on ...................................... 24 T 92.22 25 25 T 314.58 

15300 ..... Apply skin allograft, t/arm/lg ................................... 27 T 1081.66 N/A 25 T 314.58 

15301 ..... Apply sknallograft t/a/l addl .................................... 25 T 315.37 N/A 25 T 314.58 

15320 ..... Apply skin allogrft f/n/hf/g ....................................... 25 T 315.37 27 25 T 314.58 

15321 ..... Apply sknallogrft f/n/hfg add .................................. 25 T 315.37 25 25 T 314.58 

15340 ..... Apply cult skin substitute ....................................... 24 T 92.22 27 25 T 314.58 

15341 ..... Apply cult skin sub add-on ..................................... 24 T 92.22 25 25 T 314.58 

15360 ..... Apply cult derm sub, t/a/l ....................................... 24 T 92.22 27 25 T 314.58 


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TABLE 11.—CY 2007 PROPOSED ASSIGNMENTS OF SKIN SUBSTITUTE AND SKIN REPLACEMENT PROCEDURES—

Continued 

CPT code Short descriptor 

CY 2006 assignment 

APC panel recommendation 

CY 2007 proposed assignment 

APC SI APC median APC SI APC median 

15361 ..... Aply cult derm sub t/a/l/ add-on ............................. 24 T 92.22 25 25 T 314.58 

15365 ..... Apply cult derm sub f/n/hf/g ................................... 24 T 92.22 27 25 T 314.58 

15366 ..... Apply cult derm f/hf/g add ...................................... 24 T 92.22 25 25 T 314.58 

15420 ..... Apply skin xgraft, f/n/hf/g ....................................... 25 T 315.37 27 25 T 314.58 

15421 ..... Apply skn xgraft, f/n/hf/g add ................................. 25 T 315.37 25 25 T 314.58 

15430 ..... Apply acellular xenograft ........................................ 25 T 315.37 27 25 T 314.58 

15431 ..... Apply acellular xgraft add ...................................... 25 T 315.37 25 25 T 314.58 

We reviewed the presentations to the 

APC Panel; the APC Panel’s 

recommendations; the CPT code 

descriptors, introductory explanations, 

cross-references, and parenthetical 

notes; the clinical characteristic of the 

procedures; and the code-specific 

median costs for all related CPT codes 

available from our CY 2005 claims data. 

While we agree with the APC Panel that 

the codes currently placed in APC 0024 

(Level I Skin Repair) should be assigned 

to an APC with a higher median cost for 

CY 2007, we disagree that these 

procedures should be placed in APC 

0027 (Level IV Skin Repair). APC Panel 

presenters reasoned that some of the 

codes (CPTs 15170, 15175, 15320, 

15340, 15360, 15365, 15420, and 15430) 

for the first increment of body surface 

area treated should be placed in APC 

0027 because they are similar to CPT 

code 15300 (Allograft skin for temporary 

wound closure, trunk, arms, legs; first 

100 sq cm or less, or one percent of 

body area of infants and children). Upon 

further review of the clinical and 

expected hospital resource 

characteristics of CPT code 15300, we 

believe that this procedure is not 

appropriately placed in APC 0027. 

Split-thickness and full thickness skin 

autograft procedures currently assigned 

to APC 0027 are likely to require greater 

hospital resources, including additional 

operating room time and special 

equipment, in comparison to 

application of a separately paid allograft 

skin product. Instead, for CY 2007 we 

are proposing to reassign CPT code 

15300 to APC 0025 (Level II Skin 

Repair), with an APC median cost of 

$314.58. We agree, in principle, that 

other CPT codes for the first increment 

of body surface area treated with a skin 

replacement or skin substitute are 

similar clinically and from a hospital 

resource perspective to CPT code 15300 

and are, therefore, proposing to assign 

these procedures to APC 0025 as well 

for CY 2007. 

Similarly, presenters reasoned that 

the related add-on codes (CPTs 15171, 

15176, 15321, 15342, 15361, 15366, 

15421, and 15431) for procedures to 

treat additional body surface areas are 

similar to CPT code 15301 (Allograft 

skin for temporary wound closure, 

trunk, arms, legs; each additional 100 sq 

cm, or each additional one percent of 

body area of infants and children, or 

part thereof) in terms of required 

hospital resources. CPT code 15301 is 

assigned to APC 0025 for CY 2006. We 

are proposing to maintain the 

assignment of CPT code 15301 to APC 

0025 for CY 2007 and to reassign the 

other add-on codes to this APC. Note 

that APC 0025 has a status indicator of 

‘‘T,’’ so that the add-on codes will 

experience the standard OPPS multiple 

surgical procedure reduction when 

properly billed with the first body 

surface area treatment codes that are 

assigned to the same clinical APC. We 

believe that this reduction in payment 

for the procedural resources associated 

with the add-on services is appropriate. 

2. Treatment of Fracture/Dislocation 

(APC 0046) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Treatment of Fracture/ 

Dislocation’’ at the beginning of your 

comment.) 

APC 0046 is a large clinical APC to 

which many procedures related to the 

percutaneous or open treatment of 

fractures and dislocations are assigned 

for CY 2006. Most of the approximately 

100 procedures in the APC are relatively 

low volume, with even fewer single bills 

available for ratesetting. The median 

costs of the significant procedures in 

this APC as configured for CY 2006 

range from a low of about $1,415 to a 

high of about $3,893. We received 

comments to the CY 2006 proposed rule 

(70 FR 42674) requesting that we 

distinguish procedures containing ‘‘with 

or without external fixation’’ in their 

descriptors to provide greater payments 

when external fixation is used to treat 

fractures. The commenters explained 

that when external fixation devices are 

used, the costs of the procedures 

increase, and, therefore, the current APC 

placement significantly underpays those 

procedures in those instances. In the CY 

2006 final rule with comment period (70 

FR 68607), we declined to reassign 

procedures that could include external 

fixation at that time but we 

acknowledged that we had treated APC 

0046 as an exception to the 2 times rule 

for several years. For CY 2006, we again 

treated APC 0046 as an exception to the 

2 times rule, but noted we would ask 

the APC Panel to consider whether this 

APC could be reconfigured to improve 

its clinical and resource homogeneity. 

At the March 2006 meeting of the 

APC Panel, we asked the Panel to 

consider a possible reconfiguration of 

APC 0046 based on partial year CY 2005 

claims data. The reconfiguration would 

create three new APCs and would 

divide the codes in APC 0046 among 

them. The APC Panel recommended 

that CMS continue to evaluate the 

refinement of APC 0046 (Open/ 

Percutaneous Treatment Fracture or 

Dislocation) into at least three APC 

levels, with consideration of a fourth 

level should data support this 

additional level. We are accepting the 

APC Panel’s recommendation and are 

proposing for CY 2007 to split APC 0046 

into three new APCs: APC 0062 (Level 

I Treatment Fracture/Dislocation); APC 

0063 (Level II Treatment Fracture/ 

Dislocation); and APC 0064 (Level III 

Treatment Fracture/Dislocation). To 

ensure clinical and resource 

homogeneity in the new APCs, their 

proposed configurations are based on 

the procedure code descriptors, clinical 

considerations specific to each 

procedure, and service-specific hospital 

resource utilization as shown in the 

claims data from CY 2005. Restructuring 

APC 0046 into these three new APCs 

eliminates 2 times rule violations in the 

Fracture/Dislocation series. 


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We are not currently proposing a 

fourth APC level in the Fracture/ 

Dislocation series because we do not 

believe our claims data are sufficiently 

robust and consistent from year to year 

to support differential payment for 

another service level. One code, CPT 

27615 (Radical resection of tumor (e.g., 

malignant neoplasm), soft tissue of leg 

or ankle area), is not clinically coherent 

with the other procedures in APC 0046, 

and we are proposing to reassign this 

procedure outside of the Fracture/ 

Dislocation series to APC 0050 (Level II 

Musculoskeletal Procedures Except 

Hand and Foot) for CY 2007. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

3. Electrophysiologic Recording/ 

Mapping (APC 0087) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Electrophysiologic Recording/ 

Mapping’’ at the beginning of your 

comment.) 

At its March 2006 meeting, the APC 

Panel heard testimony from a presenter 

who asked that the Panel recommend 

that CPT codes 93609 (intraventricular 

and/or intra-atrial mapping of 

tachycardia, add-on), 93613 

(intracardiac electrophysiologic 3-D 

mapping), and 93631 (intra-operative 

epicardial & endocardial pacing and 

mapping to localize zone of slow 

conduction for surgical correction) be 

removed from APC 0087. The presenter 

asked the APC Panel to recommend that 

these codes be placed in APC 0086 for 

improved clinical and resource 

alignment. The presenter indicated that 

the median costs for these CPT codes 

were more than two times the median 

cost of the least costly HCPCS code in 

APC 0087 and, therefore, constituted a 

2 times violation. The presenter also 

indicated that the median cost of APC 

0087 had declined in recent years, and 

argued that the payment rate for APC 

0087 was too low to adequately 

compensate providers for these services. 

The APC Panel did not recommend 

that CMS move these codes from APC 

0087 to APC 0086, but instead 

recommended that CMS maintain the 

three codes in APC 0087 for CY 2007. 

The APC Panel noted that, due to the 

low volume of these and other services 

assigned to APC 0087, under the CMS’

rules there was no 2 times violation in 

APC 0087. Moreover, the APC Panel 

found that the services under discussion 

were cardiac electrophysiologic 

mapping services, like other procedures 

also assigned to APC 0087, and were, 

therefore, clinically coherent with other 

services in APC 0087. The APC Panel 

did not believe that these three cardiac 

electrophysiologic mapping procedures 

were similar clinically or from a 

resource perspective to the intracardiac 

catheter ablation procedures residing in 

APC 0086. We agree with the APC 

Panel’s assessment and are accepting 

this APC Panel recommendation. 

Therefore, we are proposing that CPT 

codes 93609, 93613, and 93631 remain 

assigned to APC 0087 for CY 2007. 

4. Insertion of Mesh or Other Prosthesis 

(APC 0154) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Insertion of Mesh or Other 

Prosthesis’’ at the beginning of your 

comment.) 

During the March 2006 APC Panel 

meeting, a presenter requested that we 


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reassign CPT code 57267 (Insertion of 

mesh or other prosthesis for repair of 

pelvic floor defect, each site (anterior, 

posterior compartment), vaginal 

approach) to a more clinically and 

resource-appropriate APC than its CY 

2006 assignment to APC 0154 (Hernia/ 

Hydrocele Procedures). The presenter 

expressed concern that the procedure is 

currently assigned to an APC with a ‘‘T’’

status indicator and stated that payment 

would be more accurate if it were 

assigned to an APC that has an ‘‘S’’

status indicator. The mesh insertion 

procedure is a CPT add-on code and is, 

by definition, performed at the same 

time as certain other procedures and 

will, therefore, be discounted every time 

it is performed. The presenter objected 

to our assignment of CPT code 57267 to 

an APC that is subject to the multiple 

procedure discount because it is always 

a secondary procedure, and the 

discounted payment amount is not 

adequate to pay even for the cost of the 

implantable mesh. The presenter also 

believed that its assignment to an APC 

where hernia and hydrocele procedures 

were also assigned was clinically 

inappropriate. 

The APC Panel recommended that 

CMS reassign CPT code 57267 to a more 

clinically and resource-appropriate 

APC. 

In the CY 2005 claims data, the 

median cost for CPT code 57267 is 

$529.14, the lowest by far for 

procedures in APC 0154, which has an 

APC median cost of $1,821 for CY 2007. 

However, the median cost of CPT code 

57267 is based on only 6 single claims 

of the total 1,038 submitted for the 

service. Because the procedure always is 

performed in addition to other related 

procedures, we expect that claims for 

this service will be multiple claims. 

Therefore, we are not confident that the 

procedure’s median cost based upon the 

six single claims is accurate. 

Therefore, in order to obtain more 

information about the cost of the 

procedure, we performed additional 

analyses of CY 2005 claims data in an 

attempt to specifically explore the cost 

of the mesh implant packaged into the 

payment for CPT code 57267. We 

believe that a significant portion of the 

procedural cost should be related to the 

cost of the mesh, based on information 

presented at the March 2006 APC Panel 

meeting. We looked at all claims that 

included charges for the HCPCS code 

for implantable mesh (C1781) and either 

CPT code 57267 or 49568 (Implantation 

of mesh or other prosthesis for 

incisional or ventral hernia repair). We 

examined the bills for CPT code 49568 

in addition to those for CPT code 57267 

because it is a high volume procedure 

that also uses implantable mesh, and we 

expected that the extra volume would 

improve our chances of identifying 

meaningful charge data. 

We found 210 claims with charges 

reported for both CPT code 57267 and 

HCPCS code C1781 on the same day and 

6,345 claims with reported charges for 

both CPT code 49568 and HCPCS code 

C1781 on the same day. Costs developed 

from these two claims subsets included 

the cost of the implanted mesh device 

that was used in performing the 

procedure. Table 13 below displays the 

median costs from those claims. The 

costs shown in the column titled ‘‘Lineitem Median Cost’’ are those we 

obtained by looking at all CY 2005 

OPPS claims on which charges for both 

the procedure code (either CPT code 

57267 or 49568) and the code for the 

implantable mesh (HCPCS code C1781) 

were reported. The costs shown in the 

column titled ‘‘Single Claims Median 

Cost’’ are the median costs calculated 

using only single procedure claims for 

the specific procedure that also 

included the C-code for the mesh. 

Our additional data analysis supports 

the APC Panel presenter’s assertion that 

the cost of the mesh is greater than 50 

percent of the total cost of CPT code 

57267, but it also indicates that the 

mesh cost is far less than 50 percent of 

the payment amount for APC 0154. In 

CY 2006 the payment rate for APC 0154 

is $1,704.59, and the payment when the 

multiple procedure discount is taken is 

$852.30, which is much greater than 

both the line-item median cost of the 

mesh and the median single claims cost 

of CPT code 57267 (which explicitly 

includes the implantable mesh) 

reflected in our claims data. 

TABLE 13.—MEDIAN COSTS OF HCPCS CODE C1781 AND ASSOCIATED PROCEDURES

HCPCS code Short descriptor Line-item 

median cost 

Single claims 

median cost 

CY 2006 APC 

0154 payment 

amount 

(T status) 

57267 .............................................................. Insert mesh/pelvic flr add-on .......................... $423.28 $529.14 $1,704.59 

C1781 (billed with 57267) ............................... Mesh (implantable) ......................................... 383.35 N/A N/A 

49568 .............................................................. Hernia repair w/mesh ..................................... 363.41 1,323.29 1,704.59 

C1781 (billed with 49568) ............................... Mesh (implantable) ......................................... 242.20 N/A N/A 

We agree with the APC Panel that the 

procedure should be assigned to a more 

clinically appropriate APC, and 

therefore, we are proposing to accept its 

recommendation and reassign CPT code 

57267 to APC 0195 (Level IX Female 

Reproductive Procedures), with status 

indicator ‘‘T’’ for CY 2007. The 

proposed median cost of APC 0195 is 

$1,777 for CY 2007, very comparable to 

the CY 2006 median cost of APC 0154, 

where CPT code 57267 is currently 

assigned. The median cost for the 

procedure remains very low in 

comparison with other procedures 

assigned to APC 0195, so that payment 

for the service when the multiple 

procedure reduction is applied should 

be appropriate. While not affecting the 

procedure’s payment significantly, this 

reassignment improves the clinical 

homogeneity of APCs 0154 and 0195. 

5. Percutaneous Renal Cryoablation 

(APC 0163) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Percutaneous Renal 

Cryoablation’’ at the beginning of your 

comment.) 

During the March 2006 APC Panel 

meeting, a presenter requested that we 

reassign CPT code 0135T (Ablation 

renal tumor(s), unilateral, percutaneous, 

cryotherapy) to APC 0423 (Level II 

Percutaneous Abdominal and Biliary 

Procedures). The presenter provided 

information about the costs of 

performing these procedures and 

compared the resource requirements for 

the procedures to those for CPT code 

47382 (Ablation, one or more liver 

tumor(s), percutaneous, 

radiofrequency), which is currently 

assigned to APC 0423. The presenter 

proposed reassignment of CPT code 

0135T to APC 0423 because that is 

where CPT code 47382 is assigned, and 

stated that the costs of the two 

procedures are very similar. 


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The APC Panel recommended that we 

assign CPT code 0135T to APC 0423 for 

CY 2007. 

CPT code 0135T is new for CY 2006 

and therefore, we have no claims data 

on which to base our APC assignment 

decision. The procedure currently has 

an interim assignment to APC 0163 

(Level IV Cystourethroscopy and Other 

Genitourinary Procedures), with a CY 

2006 payment amount of $1,999.35. 

We are proposing to accept the APC 

Panel’s recommendation to reassign 

CPT code 0135T to APC 0423 for CY 

2007. We believe that assignment of 

CPT code 0135T to APC 0423 is 

clinically appropriate, and that the CY 

2007 median cost of APC 0423 of $2,410 

is reasonably close to our expectations 

regarding the resource requirements for 

the renal cryoablation procedure. 

6. Keratoprosthesis (APC 0244) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Keratophrosthesis’’ at the 

beginning of your comment.) 

CPT code 65770 is a surgical 

procedure for implantation of a 

keratoprosthesis, an artificial cornea. 

The keratoprosthesis device that is 

required for the implantation is 

described by HCPCS code C1818 

(Integrated keratoprosthesis), a device 

category that received transitional passthrough payment under the OPPS from 

July 2003 through December 2005. 

When the device came off pass-through 

status for CY 2006 and its costs were 

packaged into the implantation 

procedure, CPT code 65770 continued 

to be assigned to APC 0244 (Corneal 

Transplant), with a payment rate of 

about $2,275, despite an increase in the 

median cost of the implantation 

procedure of about $1,200 associated 

with the packaging of the device. There 

is no 2 times violation in APC 0244 for 

CY 2006. 

At the March 2006 meeting of the 

APC Panel, following a presentation 

regarding the procedure to implant a 

keratoprosthesis that described the 

clinical and hospital resource 

characteristics of CPT code 65770, the 

Panel recommended moving CPT code 

65770 to a more appropriate APC in 

order to make appropriate payment. We 

agree with the recommendation of the 

APC Panel. Claims data from CY 2005 

demonstrate that the median cost for 

implantation of a keratoprosthesis of 

$3,127.51 remains significantly higher 

than the median costs of other 

procedures assigned to APC 0244, 

although there is no 2 times violation. 

In addition, CPT code 65770 contributes 

less than 1 percent of the single claims 

in the APC available for ratesetting, and 

it is likely to continue to be an 

uncommon procedure among Medicare 

beneficiaries, resulting in its persistent 

small contribution to the median cost of 

APC 0244. Therefore, for CY 2007 we 

are proposing to create a new APC 0293 

(Level V Anterior Segment Eye 

Procedures) with a median cost of 

$3,127.51 and to move CPT code 65770 

into that APC in order to more 

appropriately pay for the procedure and 

the related device. 

7. Medication Therapy Management 

Services 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Medication Therapy 

Management Services’’ at the beginning 

of your comment.) 

Following a presentation at its March 

2006 meeting, the APC Panel made two 

recommendations regarding Category III 

CPT codes for pharmacist medication 

therapy management services that were 

new for CY 2006. These services include 

CPT codes 0115T (medication therapy 

management services provided by a 

pharmacist, individual, face-to-face with 

patient, initial 15 min., w/assessment 

and intervention if provided; initial 

encounter), 0116T (medication therapy 

management; subsequent encounter), 

and 0117T (medication therapy 

management; additional 15 min.). These 

codes were assigned status indicator 

‘‘B’’ in the CY 2006 OPPS final rule with 

comment period, indicating that they 

are not recognized by the OPPS when 

submitted on an outpatient hospital Part 

B bill type, with comment indicator 

‘‘NI’’ to identify them as subject to 

comment. The APC Panel recommended 

that we create a new APC, with a 

nominal payment, to which we would 

assign these codes; implement the 

assignment in July 2006, if possible, or 

otherwise in CY 2007; and provide 

guidance to hospitals on how and when 

these codes should be reported. We are 

not accepting the APC Panel’s 

recommendations. Rather, we are 

proposing to continue to assign status 

indicator ‘‘B’’ to CPT codes 0115T, 

0116T, and 0117T for CY 2007. 

According to the AMA, the purpose of 

Category III CPT codes is to facilitate 

data collection on and assessment of 

new services and procedures. 

Medication therapy management 

services are not new services in the 

OPPS, as they have been provided to 

patients by hospitals in the past as 

components of a wide variety of services 

provided by hospitals, including clinic 

and emergency room visits, procedures, 

and diagnostic tests. As such, we 

believe their associated hospital 

resource costs are already incorporated 

into the OPPS payments for these other 

services that are based on historical 

hospital claims data. The three Category 

III CPT codes specifically describe 

medication therapy management 

services provided by a pharmacist. We 

have no need to distinguish medication 

therapy management services provided 

by a pharmacist in a hospital from 

medication therapy management 

services provided by other hospital staff, 

as the OPPS only makes payments for 

services provided incident to 

physicians’ services. Hospitals 

providing medication therapy 

management services incident to 

physicians’ services may choose a 

variety of staffing configurations to 

provide those services, taking into 

account other relevant factors such as 

State and local laws and hospital 

policies. 

In general, we do not establish new 

clinical APCs for new codes and set 

payment rates for those APCs when we 

have no cost data for any services 

populating the APCs. New codes where 

we believe that there are no existing 

clinical APCs compatible with their 

expected clinical and hospital resource 

characteristics are often assigned to New 

Technology APCs until we have 

sufficient cost data to determine 

appropriate clinical APC assignments. 

However, these medication therapy 

management codes would not be 

eligible to map to New Technology 

APCs because they are not new services 

which are unrepresented in historical 

hospital claims data. As stated earlier, 

because we believe the costs of 

medication therapy management 

services are imbedded as a component 

within our claims data, we are confident 

that our claims data reflect the costs of 

pharmacist medication management 

services provided to hospital 

outpatients who are receiving hospital 

services. 

8. Complex Interstitial Radiation Source 

Application (APC 0651) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Complex Interstitial Radiation 

Source Application’’ at the beginning of 

your comment.) 

APC 0651 (Complex Interstitial 

Radiation Source Application), contains 

only one code, CPT code 77778 

(Complex interstitial application of 

brachytherapy sources). The coding, 

APC assignment, median cost, and 

resulting payment rate for CPT code 

77778 have not been stable since the 

inception of the OPPS, and that 

instability has been a source of concern 

to hospitals that furnish the service and 

to specialty societies. The vast majority 


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of claims for interstitial brachytherapy 

are for the treatment of patients with a 

diagnosis of prostate cancer. The 

historical coding, APC assignments, and 

payment rates for CPT code 77778 and 

the related service CPT code 55859 

(Transperitoneal placement of needles 

or catheters into the prostate for 

application of brachytherapy sources), 

are shown in Table 14. 

TABLE 14.—HISTORICAL PAYMENT RATES FOR COMPLEX INTERSTITIAL APPLICATION OF BRACHYTHERAPY SOURCES

OPPS CY Combination APC CPT code 

77778 

APC for 

77778 

CPT code 

55859 

APC for 

55859 Source 

2000 ................................................. N/A ............................... $198.31 APC 312 .. $848.04 APC 162 .. Pass-through. 

2001 ................................................. N/A ............................... 205.495 APC 312 .. 878.72 APC 162 .. Pass-through. 

2002 ................................................. N/A ............................... 6344.67 APC 312 .. 2068.23 APC 163 .. Pass-through with pro 

rata reduction. 

2003 (if prostate brachytherapy with 

iodine sources).

G0261, APC 648, 

$5154.34.

N/A N/A ........... N/A N/A ........... Packaged. 

2003 (if prostate brachytherapy with 

palladium sources).

G0256, APC 649, 

$5998.24.

N/A N/A ........... N/A N/A ........... Packaged. 

2003 (if not prostate brachytherapy, 

not including sources).

N/A ............................... 2853.58 APC 651 .. 1479.60 APC 163 .. Separate payment 

based on scaled median cost per source. 

2004 ................................................. N/A ............................... 558.24 APC 651 .. 1848.55 APC 163 .. Cost. 

2005 ................................................. N/A ............................... 1248.93 APC 651 .. 2055.63 APC 163 .. Cost. 

2006 ................................................. N/A ............................... 666.21 APC 651 .. 1993.35 APC 163 .. Cost. 

We have frequently been told by the 

public that the instability in our 

payment rates for APC 0651 creates 

difficulty in planning and budgeting for 

hospitals. Moreover, we have been told 

that in this case reliance on single 

procedure claims results in use of only 

incorrectly coded claims for prostate 

brachytherapy because, for application 

to the prostate, which is estimated to be 

85 percent of all occurrences of CPT 

code 77778, a correctly coded claim is 

a multiple procedure claim. 

Specifically, we are told that a correctly 

coded claim for prostate brachytherapy 

should include, for the same date of 

service, both CPT codes 55859 and 

77778, brachytherapy sources reported 

with C-codes, and typically separately 

coded imaging and radiation therapy 

planning services. We are further 

advised that in the cases of complex 

interstitial brachytherapy where sources 

are placed in sites other than the 

prostate, the charges for both placing the 

needles or catheters and for applying 

the sources may be reported by CPT 

code 77778 alone because there are no 

other specific CPT codes for placement 

of needles or catheters in those sites. In 

other cases, the placement of needles or 

catheters may be reported with not 

otherwise classified codes specific to 

the treated body area. 

At the March 2006 APC Panel 

meeting, presenters urged the Panel to 

recommend that CMS use only single 

procedure claims that contain charges 

for brachytherapy sources on the same 

claim with CPT code 77778 to set the 

median cost for APC 0651. Presenters 

also urged that CMS adopt a process for 

using multiple procedure claims to set 

the median for APC 0651 that would 

sum the costs on multiple procedure 

claims containing CPT codes 77778 and 

55859 (and no other separately payable 

services not on the bypass list) and, 

excluding the costs of sources, split the 

resulting aggregate median cost on the 

multiple procedure claim according to a 

preestablished attribution ratio between 

CPT codes 77778 and 55859. Presenters 

also urged that we provide hospital 

education on correct coding of 

brachytherapy services and devices of 

brachytherapy required to perform 

brachytherapy procedures. They 

indicated that any claim for a 

brachytherapy service that did not also 

report a brachytherapy source should be 

considered to be incorrectly coded and 

thus not reflective of the hospital 

resources required for the interstitial 

source application procedure. They 

believed that these claims should be 

excluded from use in establishing the 

median cost for APC 0651. They 

believed that hospitals which report the 

brachytherapy sources on their claims 

are more likely to report complete 

charges for the associated brachytherapy 

procedure than hospitals that do not 

report the separately payable 

brachytherapy sources. 

The APC Panel recommended that 

CMS reevaluate the proposed payment 

for brachytherapy services in APC 0651 

for CY 2007. The APC Panel also 

recommended that CMS formally work 

with the Coalition for the Advancement 

of Brachytherapy, American 

Brachytherapy Society, and the 

American Society for Therapeutic 

Radiology and Oncology to evaluate the 

methodology for setting brachytherapy 

service payment rates in APC 0651. 

In response to the APC Panel 

recommendations, we are explicitly 

analyzing the standard OPPS 

methodology that we used in 

determining our proposed payment rate 

for APC 0651 in this proposed rule in 

the context of alternative multiple bill 

methodologies. In addition, we note that 

we routinely accept requests from 

interested organizations to discuss their 

views about OPPS payment policy 

issues. 

The organizations that the APC Panel 

asked us to work with have frequently 

brought their concerns to our attention 

through the rulemaking process and 

otherwise. We will consider the input of 

any individual or organization to the 

extent allowed by Federal law including 

the Administrative Procedure Act (APA) 

and the Federal Advisory Committee 

Act (FACA). We establish the OPPS 

rates through regulations. We are 

required to consider the timely 

comments of interested organizations, 

establish the payment policies for the 

forthcoming year, and respond to the 

timely comments of all public 

commenters in the final rule in which 

we establish the payments for the 

forthcoming year. 

For this proposed rule, we developed 

a median cost for APC 0651 using single 

procedure claims using the general 

OPPS process, but we also looked at 

multiple procedure claims that contain 

the most common combinations of 

codes used with APC 0651. Our single 

procedure claims process results in 

using 1,123 claims to calculate a median 

cost of $1028.93 for APC 0651. We have 

added CPT code 76965, a CPT code for 

ultrasound guidance that commonly 

appears on claims for complex 


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interstitial brachytherapy, to the bypass 

list for CY 2007 after close clinical 

review because we believe that it would 

typically have little associated 

packaging. We believe that this change, 

along with maintenance of CPT code 

77290 for complex therapeutic radiology 

simulation-aided field setting on the 

bypass list, is responsible for the growth 

in single procedure claims from the 381 

single bills on which the APC 0651 

median cost was calculated for the CY 

2006 OPPS final rule with comment 

period. However, only 6 of these 1,123 

single and ‘‘pseudo’’ single claims also 

included brachytherapy sources used in 

complex interstitial brachytherapy 

source application, and the median cost 

for these 6 claims at $600.68 is 

significantly less than the median cost 

for all single claims. It is unclear why 

so many of these claims do not contain 

brachytherapy sources, which were 

separately paid at cost in CY 2005. 

Because we are proposing to pay 

separately for brachytherapy sources 

again for CY 2007, we see no reason to 

believe that these few claims for 

brachytherapy services that included 

sources, which also do not report CPT 

code 55859 for placement of needles or 

catheters into the prostate, are more 

correctly coded than those claims which 

do not separately report brachytherapy 

sources. We believe it is possible that 

hospitals billing CPT code 77778 and 

not the associated brachytherapy 

sources may have bundled their charges 

for the brachytherapy sources into their 

charge for CPT code 77778. 

We also identified multiple procedure 

claims that contained both CPT codes 

77778 and 55859 and also included any 

one or more of the following procedure 

codes, which have repeatedly appeared 

as common procedures that are reported 

on the same claim with CPT codes 

55859 and 77778: 76000, 76965, or 

77290. We then calculated median costs 

for interstitial prostate brachytherapy in 

two different ways: (1) Bypassing the 

line item charges for these three 

ancillary codes; and (2) packaging the 

costs of these three ancillary codes. We 

applied this methodology both (1) to all 

claims that met these criteria with and 

without sources and (2) to claims that 

met the criteria and also separately 

reported brachytherapy sources that 

would be expected to be reported with 

CPT code 77778. See Tables 15 and 16 

below for the results of this 

investigation. 

We found 10,571 multiple procedure 

claims with CPT codes 55859 and 77778 

reported on the claim, including those 

both with and without separately 

reported sources. We found that 7,181 of 

the 10,571 claims contained any 

combination of the 3 ancillary codes 

(76000, 76965, or 77290). Table 15 

shows the results of bypassing and 

packaging the line-item costs of the 3 

ancillary procedures. 

TABLE 15.—MULTIPLE PROCEDURE CLAIMS INCLUDING CPT CODES 55859 AND 77778 

Frequency Minimum 

cost 

Maximum 

cost Mean cost Median cost 

Ancillary Codes Packaged ....................................................................... * 7180 $828.46 $11,202.81 $3,326.50 $3,062.99 

Ancillary Codes Bypassed ....................................................................... 7181 811.95 11,203.81 3,300.16 3,030.01 

* 1 lost to trimming. 

We found 9,791 multiple procedure 

claims with CPT codes 55859 and 77778 

reported on the claim that also included 

brachytherapy sources that would be 

used with CPT code 77778. We found 

that 6,748 of the 9,791 claims contained 

any combination of the 3 ancillary 

codes. Table 16 shows the results of 

bypassing and packaging the line-item 

costs of the 3 ancillary procedures. 

TABLE 16.—MULTIPLE PROCEDURE CLAIMS INCLUDING CPT CODES 55859 AND 77778 AND ONE OR MORE

BRACHYTHERAPY SOURCES

Frequency Minimum 

cost 

Maximum 

cost Mean cost Median cost 

Ancillary Codes Packaged ....................................................................... 6748 $890.56 $10,224.17 $3,240.13 $3,026.62 

Ancillary Codes Bypassed ....................................................................... 6748 912.81 10,307.37 3,215.75 2,992.60 

The claims containing CPT codes 

55859 and 77778 and any combination 

of the three identified ancillary codes 

have mean and median costs that are 

very close to one another, regardless of 

whether the hospital billed separately 

for the brachytherapy sources on the 

claim with the procedure codes. 

Moreover, most of the multiple 

procedure claims we identified 

contained sources. This leads us to 

conclude that the presence of sources on 

the claim does not make a significant 

difference in the median cost of the 

combined service. 

Moreover, when we calculate the total 

median cost from single bills for the 

APCs for the two major procedures 

codes without regard to the separate 

payments that would be made for CPT 

codes 76000, 76965, and 77290, the sum 

of the CY 2007 proposed medians for 

APC 0651 and APC 0163 is $3,197.07, 

which is greater than the combination 

medians, even when the three ancillary 

services are packaged into the 

combination median. Under our 

proposed policies for CY 2007, hospitals 

would also be paid separately for 

brachytherapy sources, guidance 

services, and radiation therapy planning 

services that may be provided in 

support of services reported with CPT 

codes 55859 and 77778. 

Therefore, we believe that the 

summed median cost for APC 0651 and 

APC 0163 results in an appropriate level 

of full payment for the dominant type of 

service provided under APC 0651, 

interstitial prostate brachytherapy. We 

are proposing to use the median cost of 

$1,028.93, as derived from all single 

bills for APC 0651 according to our 

standard OPPS methodology, to 

establish the median for that APC. 

We recognize that prostate 

brachytherapy is not the sole use of CPT 

code 77778, although it is the 

predominant use. Costs attributable to 

the placement of needles and catheters 

and to the interstitial application of 

brachytherapy sources to sites other 

than the prostate may also be reported 

on claims whose data map to APC 0651. 


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This clinically driven variability in the 

claims data is difficult to assess without 

adding additional levels of complexity 

to the issue by considering diagnoses in 

establishing payments rates. However, 

recognizing that a PPS is a system based 

on averages and, to the extent that 

claims for all types of complex 

interstitial brachytherapy source 

application are included in the body of 

claims used to set the median cost for 

APC 0651, we believe that the payment 

for these services is appropriate. 

9. Single Allergy Tests (APC 0381) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Allergy Testing’’ at the 

beginning of your comment.) 

We are proposing to continue with 

our methodology of differentiating 

single allergy tests (‘‘per test’’) from 

multiple allergy tests (‘‘per visit’’) by 

assigning these services to two different 

APCs to provide accurate payments for 

these tests in CY 2007. Multiple allergy 

tests are assigned to APC 0370, with a 

median cost calculated based on the 

standard OPPS methodology. We 

provided billing guidance in CY 2006 in 

Transmittal 804 (issued on January 3, 

2006) specifically clarifying that 

hospitals should report charges for the 

CPT codes that describe single allergy 

tests to reflect charges ‘‘per test’’ rather 

than ‘‘per visit’’ and should bill the 

appropriate number of units of these 

CPT codes to describe all of the tests 

provided. However, our CY 2005 claims 

data available for the CY 2007 proposed 

rule do not yet reflect the improved and 

more consistent hospital billing 

practices of ‘‘per test’’ ‘‘for single allergy 

tests. Some claims for single allergy 

tests still appear to provide charges that 

represent a ‘‘per visit’’ charge, rather 

than a ‘‘per test’’ charge. Therefore, 

consistent with our payment policy for 

CY 2006, we are proposing to calculate 

a ‘‘per unit’’ median cost for APC 0381, 

based upon 349 claims containing 

multiple units or multiple occurrences 

of a single CPT code, where packaging 

on the claims is allocated equally to 

each unit of the CPT code. Using this 

methodology, we are proposing a 

median cost of $13.29 for APC 0381 for 

CY 2007. We are hopeful that the better 

and more accurate hospital reporting 

and charging practices for these single 

allergy test CPT codes beginning in CY 

2006 will allow us to calculate the 

median cost of APC 0381 using the 

standard OPPS process in future OPPS 

updates. 

10. Hyperbaric Oxygen Therapy (APC 

0659) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Hyperbaric Oxygen Therapy’’

at the beginning of your comment.) 

When hyperbaric oxygen therapy 

(HBOT) is prescribed for promoting the 

healing of chronic wounds, it typically 

is prescribed for 90 minutes and billed 

using multiple units of HBOT on a 

single line or multiple occurrences of 

HBOT on a claim. In addition to the 

therapeutic time spent at full hyperbaric 

oxygen pressure, treatment involves 

additional time for achieving full 

pressure (descent), providing air breaks 

to prevent neurological and other 

complications from occurring during the 

course of treatment, and returning the 

patient to atmospheric pressure (ascent). 

The OPPS recognizes HCPCS code 

C1300 (Hyperbaric oxygen under 

pressure, full body chamber, per 30 

minute interval) for HBOT provided in 

the hospital outpatient setting. 

In the CY 2005 final rule with 

comment period (69 FR 65758 through 

65759), we finalized a ‘‘per unit’’

median cost calculation for HBOT using 

only claims with multiple units or 

multiple occurrences of HCPCS code 

C1300 because delivery of a typical 

HBOT service requires more than 30 

minutes. We observed that claims with 

only a single occurrence of the code 

were anomalies, either because they 

reflected terminated sessions or because 

they were incorrectly coded with a 

single unit. In the same rule, we also 

established that HBOT would not 

generally be furnished with additional 

services that might be packaged under 

the standard OPPS APC median cost 

methodology. This enabled us to use 

claims with multiple units or multiple 

occurrences. Finally, we also used each 

hospital’s overall cost-to-charge ratio 

(CCR) to estimate costs for HCPCS code 

C1300 from billed charges rather than 

the CCR for the respiratory therapy cost 

center. Comments on the CY 2005 

proposed rule effectively demonstrated 

that hospitals report the costs and 

charges for HBOT in a wide variety of 

cost centers. We used this methodology 

to estimate payment for HBOT in CYs 

2005 and 2006. For CY 2007, we are 

proposing to continue using the same 

methodology to estimate a ‘‘per unit’’

median cost for HCPCS code C1300. 

Using 50,311 claims with multiple units 

or multiple occurrences, we estimate a 

median cost of $98.36. 

11. Myocardial Positron Emission 

Tomography (PET) Scans (APCs 0306, 

0307) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Myocardial PET Scans’’ at the 

beginning of your comment.) 

From August 2000 to December 31, 

2005, under the OPPS we assigned to 

one clinical APC all myocardial 

positron emission tomography (PET) 

scan procedures, which were reported 

with multiple G-codes through March 

31, 2005. Effective April 1, 2005, 

myocardial PET scans were reported 

with three CPT codes, specifically CPT 

codes 78459, 78491, and 78492, under 

the OPPS. Public comments to the CY 

2006 OPPS proposed rule suggested that 

the HCPCS codes describing multiple 

myocardial PET scans should be 

assigned to a separate APC from single 

study codes because their hospital 

resource costs are significantly higher 

than single scans. Review of the CY 

2004 claims data for myocardial PET 

scans revealed a median cost of $2,482 

for the 9 G-codes that describe multiple 

myocardial PET scans, based upon 978 

single claims of 2,001 total claims for 

multiple scan procedures. The CY 2004 

claims data showed a median cost of 

$800 for the 6 G-codes describing single 

PET studies, based on 391 single claims 

of 575 total claims. A review of CY 2003 

claims data showed a similar pattern of 

significantly higher hospital costs for 

multiple myocardial PET studies in 

comparison with single studies, 

although there were fewer claims for the 

procedures in CY 2003 in comparison 

with CY 2004. In response to the 

comments received and based on this 

claims information, myocardial PET 

services were assigned to two clinical 

APCs for the CY 2006 OPPS. HCPCS 

codes for single scans were assigned to 

APC 0306 with a payment rate of 

$800.55, and HCPCS codes for the 

multiple scan procedures were assigned 

to APC 0307 with a payment rate of 

$2,484.88. 

Analysis of the latest CY 2005 claims 

data for myocardial PET scans reveals 

that the APC median costs for the single 

and multiple myocardial PET codes are 

$836 and $680 respectively, based on 

296 single claims for single studies and 

1,150 single claims for multiple scan 

procedures. Despite more CY 2005 

single claims for multiple scan 

procedures, the median cost of these 

procedures declined significantly from 

CY 2004 to CY 2005, dropping below 

the median cost of single studies. As 

indicated earlier, there was a significant 

coding change for myocardial PET 

services in CY 2005, with the reporting 


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of a single CPT code for multiple studies 

(CPT code 78492) for most of CY 2005, 

in comparison with nine G-codes in CY 

2004. We examined the single bills for 

multiple scan procedures from CY 2004 

and noted 17 hospitals were 

represented, with the majority of those 

claims from a single hospital. In 

contrast, in the CY 2005 claims, 25 

hospitals were represented in the single 

bills for multiple scan procedures, and 

no single hospital contributed a majority 

of claims to the median cost calculation. 

We also examined differences in charges 

associated with G-codes versus the CPT 

code to determine if hospitals had 

adjusted the charge for the CPT code to 

reflect the termination of the multiple 

study G-codes. However, the individual 

charging practices of hospitals did not 

appear to vary with the use of a G-code 

versus the CPT code in either the CY 

2004 or the CY 2005 claims. Greater 

volume of claims and consistent 

charging for both the G-codes and CPT 

code by hospitals suggest that the 

median appropriately captures the 

greater variability in relative hospital 

costs for multiple myocardial PET 

studies in the CY 2005 claims data. 

Based on our claims data, the use of 

myocardial PET scan technology has 

become more widely prevalent in 

hospitals, and as a result, we now have 

more data to support our proposed 

payment rates. We believe that the 

median costs from our CY 2005 claims 

data for myocardial PET scan services, 

calculated based upon our standard 

OPPS methodology and based on almost 

1,500 single claims, for both the single 

and multiple scans, should be reflective 

of the hospital resources required to 

provide the services to Medicare 

beneficiaries in the outpatient hospital 

setting. Based on these data, the 

differential median costs of the single 

and multiple study procedures do not 

support the present two-level APC 

payment structure. Although we 

acknowledge that some people may 

believe that multiple scan procedures 

should require increased resources at 

some hospitals in comparison with 

single scans, particularly because of the 

longer scan times required for multiple 

studies, our data do not support a 

resource differential that would 

necessitate the placement of these single 

and multiple scan procedures into two 

separate APCs. As myocardial PET 

scans are being provided more 

frequently at a greater number of 

hospitals than in the past, it is possible 

that most hospitals performing multiple 

PET scans are particularly efficient in 

their delivery of higher volumes of these 

services and, therefore, incur hospital 

costs that are similar to those of single 

scans, which are provided less 

commonly. 

When all myocardial PET scan 

procedure codes are combined into a 

single clinical APC, as they were prior 

to CY 2006, the APC median cost for 

myocardial PET services is about $721, 

very similar to the $703 median cost of 

their single CY 2005 clinical APC. 

Therefore, for CY 2007, we are 

proposing to assign CPT codes 78459, 

78491, and 78492 to a single APC, 

specifically, APC 0307 titled Myocardial 

Positron Emission Tomography (PET) 

Imaging, with a proposed median cost of 

$721. We believe that the assignment of 

these three CPT codes to APC 0307 is 

appropriate as the CY 2005 claims data 

reveal that more hospitals are providing 

multiple myocardial PET scan services, 

most myocardial PET scans are multiple 

studies, and the hospital resource costs 

of single and multiple studies are 

similar. We believe that the proposed 

median cost appropriately reflects the 

hospital resources associated with 

providing myocardial PET scans to 

Medicare beneficiaries in cost-efficient 

settings. Further, we believe that the 

proposed rates are adequate to ensure 

appropriate access to these services for 

Medicare beneficiaries. We are seeking 

comments on our proposal to provide a 

single payment rate for all myocardial 

PET scans in CY 2007. The myocardial 

PET scan CPT codes and their CY 2007 

proposed APC assignments are 

displayed in Table 17. 

TABLE 17.—PROPOSED CY 2007 APC ASSIGNMENT FOR MYOCARDIAL PET 

HCPCS 

code Short descriptor CY 2006 SI CY 2006 APC 

CY 2006 

payment 

rate 

Proposed CY 

2007 SI 

Proposed 

CY 2007 

APC 

Proposed CY 

2007 APC 

median cost 

78459 ..... Heart muscle imaging (PET) ................ S .................. 0306 $800.55 S .................. 0307 $721.26 

78491 ..... Heart image (PET), single ................... S .................. 0306 800.55 S .................. 0307 721.26 

78492 ..... Heart image (PET), multiple ................ S .................. 0307 2,484.88 S .................. 0307 721.26 

12. Radiology Procedures (APCs 0333, 

0662, and Other Imaging APCs) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Radiology Procedures’’ at the 

beginning of your comment.) 

At its March 2006 meeting, the APC 

Panel made three recommendations 

regarding radiology services. These 

include the following: 

• Reaffirming the CY 2005 

recommendation that CMS postpone 

implementation of the multiple 

procedure reduction policy for imaging 

services as included in the CY 2006 

OPPS proposed rule for CY 2007, to 

allow CMS to gather more data on the 

efficiencies associated with multiple 

imaging procedures that may already be 

reflected in OPPS payment rates for 

imaging services. 

• Recommending that CMS review 

payment rates for computed tomography 

(CT) and computed tomographic 

angiography (CTA) procedures to ensure 

that their payment rates are 

comparatively consistent and that they 

accurately reflect resource use. 

• Recommending that CMS invite 

comments on ways that hospitals can 

uniformly and consistently report 

charges and costs related to radiology 

services. 

In the CY 2006 OPPS final rule with 

comment period (70 FR 68707), we 

indicated that based on the APC Panel’s 

recommendations and public comments 

received, we decided not to finalize our 

CY 2006 proposal to reduce OPPS 

payments for some second and 

subsequent diagnostic imaging 

procedures performed in the same 

session. Our analyses did not disprove 

the commenters’ contentions that there 

are efficiencies already reflected in their 

hospital costs, and, therefore, their CCRs 

and the median costs for the procedures. 

Over the past 7 months, we have 

conducted additional studies of our 

hospital claims data for single and 

multiple diagnostic imaging procedures, 

and our analyses to date support 

continued deferral for CY 2007 of 

implementation of a multiple imaging 

procedure payment reduction policy in 

the OPPS. Therefore, we are accepting 

the APC Panel’s recommendation to not 

adopt such a policy for CY 2007 

pending the results of further analyses. 

Depending upon the findings from such 

studies, in a future rulemaking we may 

propose revisions to the structure of our 


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rates to further refine these rates in the 

context of additional study findings. 

We also are accepting the APC Panel’s 

recommendation to review the CY 2007 

proposed payment rates for CT and CTA 

procedures to ensure that their rates are 

comparatively consistent and accurately 

reflective of hospitals’ resource costs. 

Presenters at the March 2006 APC Panel 

meeting indicated to the Panel that 

hospital resources for CTA procedures 

are similar to those for CT procedures 

that include scans without contrast 

followed by scans with contrast, but 

additional resources are required for the 

3-dimensional reconstruction that is 

part of the CTA procedures. As a result 

of this image postprocessing, CTA scans 

display the vasculature in a 3- 

dimensional format rather than in the 2- 

dimensional cross-sectional images of 

conventional CT scans. Based upon CY 

2005 claims data, the CY 2007 proposed 

median cost for APC 0333 for CT 

procedures that include scans without 

contrast material, followed by contrast 

scans to complete the studies is $309, 

and the CY 2007 proposed median cost 

for APC 0662 for CTA procedures is 

$304. As has been the case for the past 

several years, the median costs 

associated with these two APCs are 

virtually identical to one another and 

are also quite consistent with their 

historical costs from prior years of 

claims data. The CY 2007 proposed 

median costs for APCs 0333 and 0662 

are based on about 500,000 and 150,000 

single claims, respectively. The stability 

of these APC median costs, based on 

large numbers of single claims, is 

consistent with our belief that the 

median costs of these APCs accurately 

reflect hospitals’ resource use. From CY 

2004 to CY 2005 the number of CTA 

procedures performed in the outpatient 

department increased by 50 percent, 

whereas the number of CT procedures 

that included a scan without contrast 

followed by a scan with contrast to 

complete each full study increased by 

only about 1 percent. The large annual 

increases in the OPPS frequencies of 

CTA procedures through CY 2005 

provide no evidence that Medicare 

beneficiaries are experiencing difficulty 

accessing these services in the hospital 

outpatient setting. CTA procedures are 

being more commonly performed for 

various clinical indications, likely 

resulting in more consistent and 

efficient use of the associated image 

postprocessing technology. Accordingly, 

it is not surprising that the hospital 

costs of typical CTA procedures in 

contemporary medical practice are very 

similar to the hospital costs of the more 

involved and resource-intensive 

complex CT services that, like CTA 

procedures, include scans without 

contrast material, followed by scans 

with contrast. Thus, we believe that our 

CY 2007 proposed payment rates for CT 

and CTA procedures are generally 

consistent with one another and 

accurately reflective of hospitals’

resource costs. 

With respect to the APC Panel’s 

recommendation regarding the reporting 

of costs and charges for radiology 

services, CMS requires hospitals to 

report their costs and charges through 

the cost report with sufficient specificity 

to support CMS’ use of cost report data 

for monitoring and payment. Within 

generally accepted principles of cost 

accounting, we allow providers 

flexibility to accommodate the unique 

attributes of each institution’s 

accounting systems. For example, 

providers must match the generally 

intended meaning of the line-item cost 

centers, both standard and nonstandard, 

to the unique configuration of 

department and service categories used 

by each hospital’s accounting system. 

Also, while the cost report provides 

recommended bases of allocation for the 

general services cost centers, a provider 

is permitted, within specified 

guidelines, to use an alternative basis 

for a general service cost if it can justify 

to its fiscal intermediary that the 

alternative is more accurate than the 

recommended basis. This approach 

creates internal consistency between a 

hospital’s accounting system and the 

cost report, but cannot guarantee the 

precise comparability of costs and 

charges for individual cost centers 

across institutions. 

However, we believe that achieving 

greater uniformity by, for example, 

specifying the exact components of 

individual cost centers, would be very 

burdensome for hospitals and auditors. 

Hospitals would need to tailor their 

internal accounting systems to reflect a 

national definition of a cost center. It is 

not clear that the marginal improvement 

in precision created by such a 

requirement would justify the 

additional administrative burden. The 

current hospital practice of matching 

costs to the general intended meaning of 

a cost center ensures that most services 

in the cost center will be comparable 

across providers, even if the precise 

composition of a cost center among 

hospitals differs. Further, every hospital 

provides a different mix of services. 

Even if CMS specified the components 

of each cost center, costs and charges on 

the cost report would continue to reflect 

each individual hospital’s mix of 

services. At the same time, internal 

consistency is very important to the 

OPPS. Costs are estimated on claims by 

matching cost-to-charge ratios for a 

given hospital to their own claims data 

through a cost center-to-revenue code 

crosswalk. OPPS relative weights are 

based on the median cost for all services 

in an APC. The components resulting in 

CCRs for a given revenue code would 

have to be dramatically different for the 

providers contributing the majority of 

claims used to calculate an APC’s 

median cost in order to impact relative 

weights. 

We are accepting the APC Panel’s 

recommendation and specifically 

inviting comments on ways that 

hospitals can uniformly and 

consistently report charges and costs 

related to all cost centers, not just 

radiology, that also acknowledge the 

ubiquitous tradeoff between greater 

precision in developing CCRs and 

administrative burden associated with 

reduced flexibility in hospital 

accounting practices. 

IV. Proposed OPPS Payment Changes 

for Devices 

A. Proposed Treatment of DeviceDependent APCs 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Device-Dependent APCs’’ at 

the beginning of your comment.) 

1. Background 

Device-dependent APCs are 

populated by HCPCS codes that usually, 

but not always, require that a device be 

implanted or used to perform the 

procedure. For the CY 2002 OPPS, we 

used external data, in part, to establish 

the device-dependent APC medians 

used for weight setting. At that time, 

many devices were eligible for passthrough payment. For the CY 2002 

OPPS, we estimated that the total 

amount of pass-through payments 

would far exceed the limit imposed by 

statute. To reduce the amount of a pro 

rata adjustment to all pass-through 

items, we packaged 75 percent of the 

cost of the devices, using external data 

furnished by commenters on the August 

24, 2001 proposed rule and information 

furnished on applications for passthrough payment, into the median costs 

for the device-dependent APCs 

associated with these pass-through 

devices. The remaining 25 percent of 

the cost was considered to be passthrough payment. 

In the CY 2003 OPPS, we determined 

APC medians for device-dependent 

APCs using a three-pronged approach. 

First, we used only claims with device 

codes on the claim to set the medians 

for these APCs. Second, we used 


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external data, in part, to set the medians 

for selected device-dependent APCs by 

blending that external data with claims 

data to establish the APC medians. 

Finally, we also adjusted the median for 

any APC (whether device-dependent or 

not) that declined more than 15 percent. 

In addition, in the CY 2003 OPPS we 

deleted the device codes (‘‘C’’ codes) 

from the HCPCS file in the belief that 

hospitals would include the charges for 

the devices on their claims, 

notwithstanding the absence of specific 

codes for devices used. 

In the CY 2004 OPPS, we used only 

claims containing device codes to set 

the medians for device-dependent APCs 

and again used external data in a 50/50 

blend with claims data to adjust 

medians for a few device-dependent 

codes when it appeared that the 

adjustments were important to ensure 

access to care. However, hospital device 

code reporting was optional. 

In the CY 2005 OPPS, which was 

based on CY 2003 claims data, there 

were no device codes on the claims and, 

therefore, we could not use devicecoded claims in median calculations as 

a proxy for completeness of the coding 

and charges on the claims. For the CY 

2005 OPPS, we adjusted devicedependent APC medians for those 

device-dependent APCs for which the 

CY 2005 OPPS payment median was 

less than 95 percent of the CY 2004 

OPPS payment median. In these cases, 

the CY 2005 OPPS payment median was 

adjusted to 95 percent of the CY 2004 

OPPS payment median. We also 

reinstated the device codes and made 

the use of the device codes mandatory 

where an appropriate code exists to 

describe a device utilized in a 

procedure. We also implemented 

HCPCS code edits to facilitate complete 

reporting of the charges for the devices 

used in the procedures assigned to the 

device-dependent APCs. 

In the CY 2006 OPPS, which was 

based on CY 2004 claims data, we set 

the median costs for device-dependent 

APCs for CY 2006 at the highest of: (1) 

The median cost of all single bills; (2) 

the median cost calculated using only 

claims that contained pertinent device 

codes and for which the device cost is 

greater than $1; or (3) 90 percent of the 

payment median that was used to set 

the CY 2005 payment rates. We set 90 

percent of the CY 2005 payment median 

as a floor rather than 85 percent as 

proposed, in consideration of public 

comments that stated that a 15-percent 

reduction from the CY 2005 payment 

median was too large of a transitional 

step. We noted in our CY 2006 proposed 

rule that we viewed our proposed 85- 

percent payment adjustment as a 

transitional step from the adjusted 

medians of past years to the use of 

unadjusted medians based solely on 

hospital claims data with device codes 

in future years (70 FR 42714). We also 

incorporated, as part of our CY 2006 

methodology, the recommendation to 

base payment on medians that were 

calculated using only claims that passed 

the device edits. As stated in the CY 

2006 OPPS final rule with comment 

period (70 FR 68620), we believed that 

this policy provided a reasonable 

transition to full use of claims data in 

CY 2007, which would include device 

coding and device editing, while better 

moderating the amount of decline from 

the CY 2005 OPPS payment rates. 

2. Proposed CY 2007 Payment Policy 

For CY 2007, we are proposing to base 

the device-dependent APC medians on 

CY 2005 claims, the most current data 

available. As stated earlier, in CY 2005 

we reinstated the use of device codes 

and made the reporting of device codes 

mandatory where an appropriate code 

exists to describe a device utilized. In 

CY 2005, we also implemented HCPCS 

code edits to facilitate complete 

reporting of the charges for the devices 

used in the procedures assigned to the 

device-dependent APCs. We 

implemented the first set of device edits 

on April 1, 2005, for those APCs for 

which the CY 2005 payment rate was 

based on an adjusted median cost. We 

continued to take public comment on 

the remaining device edits after April 1, 

2005, and implemented device edits for 

the remaining device-dependent APCs 

on October 1, 2005. Subsequent to the 

implementation of the device edits, we 

received public comments that caused 

us to remove the requirement for edits 

for several APCs on the basis that the 

services in them do not always require 

the use of a device or there may be no 

suitable device codes available for 

reporting all devices that may be used 

to perform the procedures. 

For example, we removed the 

requirement for device codes for APC 

0080 (Diagnostic Cardiac 

Catheterization) based on the 

information provided by hospitals that 

the codes assigned to this APC do not 

always require a device for which there 

is an appropriate HCPCS code. 

Therefore, we no longer consider this 

APC to be device dependent and have 

removed it from the list of devicedependent APCs. In the case of some 

procedures assigned to other devicedependent APCs, where we determined 

that no device was required to provide 

a particular service or where there were 

no HCPCS codes that described all 

devices that could be used to furnish the 

service, we removed the requirement for 

a device code for the individual 

procedure code but retained the device 

requirement for other procedure codes 

assigned to that device-dependent APC. 

In its February 2005 meeting, the APC 

Panel recommended that we consider 

calculating the median costs for APCs 

0107 (Insertion of Cardioverter 

Defibrillator) and 0108 (Insertion/ 

Replacement/Repair of CardioverterDefibrillator Leads) by bypassing the 

line-item costs of CPT code 33241 

(Subcutaneous removal of single or dual 

chamber pacing cardioverterdefibrillator pulse generator) and 

packaging the line item-costs of CPT 

codes 93640 (Electrophysiological 

evaluation of single or dual chamber 

pacing cardioverter-defibrillator leads 

including defibrillation threshold 

evaluation (induction of arrhythmia, 

evaluation of sensing and pacing for 

arrhythmia termination) at time of 

initial implantation or replacement) and 

93641 (Electrophysiological evaluation 

of single or dual chamber pacing 

cardioverter-defibrillator leads 

including defibrillation threshold 

evaluation (induction of arrhythmia, 

evaluation of sensing and pacing for 

arrhythmia termination) at time of 

initial implantation or replacement; 

with testing of single or dual chamber 

pacing cardioverter-defibrillator) when 

these codes, separately or in 

combination, are reported on the same 

claim with HCPCS codes G0297 

(Insertion of single chamber pacing 

cardioverter defibrillator pulse 

generator), G0298 (Insertion of dual 

chamber pacing cardioverter 

defibrillator pulse generator), G0299 

(Insertion or repositioning of electrode 

lead for single chamber pacing 

cardioverter defibrillator and insertion 

of pulse generator) and G0300 (Insertion 

or repositioning of electrode lead(s) for 

dual chamber pacing cardioverter 

defibrillator and insertion of pulse 

generator), which are assigned to APCs 

0107 and 0108. The APC Panel 

recommended bypassing the line-item 

costs for CPT code 33241 because 

members believed that when a pacing 

cardioverter-defibrillator (ICD) pulse 

generator removal is performed in the 

same operative session as the insertion 

of a new pulse generator described by a 

procedure code assigned to APC 0107 or 

0108, the packaging on the claim is 

appropriately assigned to the procedure 

code in APC 0107 or 0108. Moreover, 

CPT codes 93640 and 93641 may only 

be correctly coded when the 

electrophysiologic evaluation of ICD 

leads is performed at the time of initial 

implantation or replacement of an ICD 


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pulse generator and/or leads, with or 

without testing of the pulse generator. 

Thus, the APC Panel expected that the 

costs of the evaluations of the ICD leads 

(CPT codes 93640 and 93641) could be 

appropriately packaged with the 

procedure codes that describe the 

insertion of ICD generators, which are 

assigned to APCs 0107 and 0108, or the 

insertion of ICD leads assigned to APCs 

0106 (Insertion/Replacement/Repair of 

Pacemaker and/or Electrodes), 0108, 

and 0418 (Insertion of Left Ventricular 

Pacing Elect). Because APCs 0107 and 

0108 have typically had very few single 

bills on which the medians have been 

based, and because the APC Panel 

indicated that it believed that we could 

use many more claims if we bypassed 

CPT code 33241 and packaged CPT 

codes 93640 and 93641, we calculated 

median costs for APCs 0107 and 0108 

using these rules. We excluded claims 

that did not meet the device edits, and 

we also excluded token claims. 

The effect of packaging CPT codes 

93640 and 93641 into claims that both 

pass the device edits and also contain 

no token charges for devices are shown 

in Table 19 below. This affected APCs 

0106, 0107, 0108, and 0418. Bypassing 

the line-item cost of CPT code 33241 

could not be done for all claims on 

which this CPT code was reported 

because there are clinical circumstances 

in which the ICD pulse generator is 

removed and no new device is 

implanted. Therefore, the APC 

assignment for CPT code 33241 and the 

payment for that code need to reflect the 

packaging associated with the procedure 

when it is performed alone. Because of 

this problem with assigning packaging 

in all the circumstances in which the 

procedure may be reported, we decided 

against proposing to bypass CPT code 

33241, either in general for all 

procedures or selectively, when it is 

reported with the procedures in APCs 

0107 and 0108. 

However, CPT codes 93640 and 93641 

are always performed during an 

operative procedure for ICD initial 

implantation or replacement or with 

implantation, revision or replacement of 

leads, and, therefore, it would be 

appropriate to package them into the 

surgical procedure with which they are 

performed. Moreover, as a result of the 

descriptors of the lead evaluation CPT 

codes, they should never be billed as 

single procedure claims and packaging 

them would also resolve the problem of 

setting their payment rates in part on 

the basis of claims that reflect erroneous 

coding. Packaging the costs of the 

intraoperative electrophysiologic testing 

of the ICD leads yields many more 

single bills on which to set median costs 

and also increases the median costs for 

APCs 0106, 0107, 0108, and 0418. 

Therefore, we are proposing to package 

CPT codes 93640 and 93641 for CY 

2007. 

We calculated the median cost for 

device-dependent APCs using two 

different sets of claims. We first 

calculated a median cost using all single 

procedure claims for the procedure 

codes in those APCs. We also calculated 

a second median cost using only claims 

that contain allowed device codes and 

also for which charges for all device 

codes were in excess of $1.00 (nontoken 

charge device claims). We excluded 

claims for which the charge for a device 

was less than $1.01, in part, to recognize 

hospital charging practices due to a 

recall of cardioverter defibrillator and 

pacemaker pulse generators in CY 2005 

for which the manufacturers provided 

replacement devices without cost to the 

beneficiary or hospital. We also found 

that there are other devices for which 

the charge was less than $1.01, and we 

removed those claims also. 

As expected, the median costs 

calculated using all single procedure 

bills, including both bills that lack 

appropriate device codes (where there 

are edits) and bills with token charges 

for devices, are, in many cases, less than 

the medians calculated using only 

claims that contain appropriate device 

codes and that have no token charges for 

devices. In some cases the medians are 

significantly different when claims 

either without device codes or which 

have only token device charges are 

removed. We believe that the claims 

that reflect the best estimated costs for 

these APCs, including the costs of the 

devices, are those claims that contain 

appropriate devices and which also 

have no token charges for devices. (See 

section IV.A.4. below for our discussion 

of payments when the hospital incurs 

no cost for the principal device required 

for the service.) 

When we compare the proposed 

median costs calculated using only CY 

2005 claims that contain correct device 

codes and which do not contain token 

charges for devices to the unadjusted 

median costs that were derived from CY 

2004 claims data, we find that the 

medians for only 2 APCs decline (6.3 

percent for APC 0061 (Laminectomy or 

Incision for Implantation of 

Neurostimulator Electrodes, Excluding 

Cranial Nerve) and 2.78 percent for APC 

0115 (Cannula/Access Device 

Procedures)). When we compared the 

proposed CY 2007 medians to the 

adjusted medians used to set the 

payment rates for CY 2006, only 6 APCs 

would decline more than 10 percent in 

median cost. This compares favorably to 

the data for the CY 2006 OPPS final rule 

with comment period in which 12 APCs 

declined more than 10 percent when the 

unadjusted median cost from the data 

for the CY 2006 OPPS final rule with 

comment period were compared to the 

adjusted median cost on which the CY 

2005 OPPS payments were based. Some 

APC cost variation from year to year, 

whether increasing or decreasing, is to 

be expected. 

Therefore, we are proposing to base 

the payment rates for CY 2007 for these 

device-dependent APCs on median 

costs calculated using claims with 

appropriate device codes and which 

have no token charges for devices 

reported on the claim. We do not 

believe that adjustment of these median 

costs is necessary to provide adequate 

payment for these services, and, 

therefore, we are not proposing to adjust 

the median costs for these APCs to 

moderate any decreases in medians 

from CY 2006 to CY 2007. We recognize 

that, notwithstanding the device edits, it 

may continue to be necessary for 

purposes of median cost calculations to 

remove claims that do not contain 

devices because it is likely that there 

would be incidental occurrences of 

interrupted procedures in which a 

device is not used and does not appear 

on the claim. (The interrupted 

procedure modifier nullifies the device 

edit.) Moreover, there are likely to 

continue to be incidental occurrences of 

token charges for devices as a result of 

devices that are replaced without cost 

by the manufacturer. However, each of 

these circumstances could cause the 

procedure code median cost to 

underrepresent the cost of the complete 

procedure, including the device cost, 

where the hospital purchases the 

device. 

Hence, we believe that use of claims 

that meet the device edits and which do 

not contain token charges for devices 

are the appropriate claims to use to set 

the median costs for the devicedependent APCs, ensuring that the costs 

of the principal devices are included in 

the APC medians. In addition, we 

believe that, with our proposed changes 

to the OPPS packaging status of two 

codes for electrophysiologic evaluation 

of ICD leads, no special payment 

policies are needed to establish payment 

rates that correctly reflect the relative 

costs of these procedures to other 

procedures paid under the OPPS. 

BILLING CODE 4120–01–P 


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Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49573 

BILLING CODE 4120–01–C 

TABLE 19.—EFFECT OF PACKAGING CPT CODES 93640 AND 93641 ON ALL SINGLE BILLS

APC SI APC group title Post cost total 

frequency 

Proposed CY 

2007 single bill 

frequency 

93640/93641 

not packaged 

Proposed CY 

2007 single bill 

median 93640/ 

93641 not 

packaged 

Proposed CY 

2007 single bill 

frequency 

93640/93641 

packaged 

Proposed CY 

2007 single bill 

median 93640/ 

93641 packaged 

0106 ........................ T Insertion/Replacement/ 

Repair of Pacemaker 

and/or Electrodes.

3819 457 $2,459.08 494 $2,549.70 

0107 ........................ T Insertion of CardioverterDefibrillator.16276 481 9,669.32 886 11,215.82 

0108 ........................ T Insertion/Replacement/ 

Repair of CardioverterDefibrillator Leads.

9075 929 18,030.96 2950 22,362.68 

0418 ........................ T Insertion of Left Ventricular Pacing Elect.4824 142 5,098.03 225 9,696.51 

3. Devices Billed in the Absence of an 

Appropriate Procedure Code 

In the course of examining claims 

data for creation of the payment rates for 

this proposed rule, we identified 

circumstances in which hospitals billed 

a device code but failed to also bill any 

procedure code with which the device 

could be used correctly. These errors in 

billing lead to the costs of the device 

being packaged with an incorrect 

procedure code and also cause the 

hospital to be paid incorrectly for the 

service furnished if the device was 

appropriately reported. We discussed 

the billing of devices with incorrect 

procedure codes with the APC Panel at 

its March 2006 meeting, and the APC 

Panel recommended that we explore the 

extent to which it would be appropriate 

to establish edits for HCPCS device 

codes to ensure that hospitals also bill 

procedures in which the devices would 

be used on the same claim. 

We examined our CY 2005 claims 

data and found that incorrect billing 

occurs more often with some devices 

than with others. We are taking this 

opportunity to inform the public that we 

expect to implement device to 

procedure code edits for the specified 

devices and their associated procedures, 

which we believe must be reported on 

a claim with the specified device for the 

claim to be correctly coded and the 

device costs properly attributed to 

procedures with which they are used. 

The devices for which we expect to 

implement edits are shown below in 

Table 20 and are posted on the CMS 

outpatient hospital Web site, along with 

our initial draft of all the procedures 

with which they could be appropriately 

used and thus reported. We believe the 

establishment of claims edits reflects 

merely operational and administrative 

practice. However, as the public may 

assist in establishing appropriate edits, 

we, therefore, are asking that comments 

regarding the specific associations of 

device codes and procedure codes be 

provided to the following e-mail 

address: OutpatientPPS@cms.hhs.gov. 

This is the same e-mail address to 

which comments on the existing 

procedure to device edits should be 

directed. 

Comments submitted on this issue to 

this mail box are not comments on this 

proposed rule and we will not respond 

to them in the CY 2007 OPPS final rule. 

TABLE 20.—DEVICES WHICH MUST BE

BILLED WITH ASSOCIATED PROCEDURE CODES

Device Description 

C1721 .................... AICD, dual chamber. 

C1722 .................... AICD, single chamber. 

C1767 .................... Generator, neuro nonrecharg. 

C1777 .................... Lead, AICD, endo single 

coil. 

C1778 .................... Lead, neurostimulator. 


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49574 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

TABLE 20.—DEVICES WHICH MUST BE

BILLED WITH ASSOCIATED PROCEDURE CODES—Continued 

Device Description 

C1779 .................... Lead, pmkr, 

transvenous VDD. 

C1785 .................... Pmkr, dual, rate-resp. 

C1786 .................... Pmkr, single, rate-resp. 

C1820 .................... Generator, neuro rechg 

bat sys. 

C1882 .................... AICD, other than sing/ 

dual. 

C1895 .................... Lead, AICD, endo dual 

coil. 

C1896 .................... Lead, AICD, non sing/ 

dual. 

C1897 .................... Lead, neurostim test kit. 

C1898 .................... Lead, pmkr, other than 

trans. 

C1899 .................... Lead, pmkr/AICD combination. 

C1900 .................... Lead, coronary venous. 

C2619 .................... Pmkr, dual, non rateresp. 

C2620 .................... Pmkr, single, non rateresp. 

C2621 .................... Pmkr, other than sing/ 

dual. 

4. Proposed Payment Policy When 

Devices are Replaced Without Cost or 

Where Credit for a Replaced Device Is 

Furnished to the Hospital 

As we discuss above in the context of 

the calculation of median costs for ICDs 

and pacemakers, in recent years there 

have been several field actions and 

recalls with regard to failure of these 

devices. In many of these cases, the 

manufacturers have offered replacement 

devices without cost to the hospital or 

credit for the device being replaced if 

the patient required a more expensive 

device. In some circumstances 

manufacturers have also offered, 

through a warranty package, to pay 

specified amounts for unreimbursed 

expenses to persons who had 

replacement devices implanted. In 

addition, we believe that incidental 

device failures that are covered by 

manufacturer warranties occur 

routinely. While we understand that 

some device malfunctions may be 

inevitable as medical technology grows 

increasingly sophisticated, we believe 

that early recognition of problems 

would reduce the number of people 

with the potential to be adversely 

affected by these device problems. The 

medical community needs heightened 

and early awareness of patterns of 

device failures, voluntary field actions, 

and recalls so that they can take 

appropriate action to care for our 

beneficiaries. Systematic efforts must be 

undertaken by all interested and 

involved parties, including 

manufacturers, insurers, and the 

medical community, to ensure that 

device problems are recognized and 

addressed as early as possible so that 

people’s health is protected and high 

quality medical care is provided. We are 

taking several steps to assist in the early 

recognition and analysis of patterns of 

device problems to minimize the 

potential for harmful device-related 

effects on the health of Medicare 

beneficiaries and the public in general. 

In recent years, CMS has recognized 

the importance of data collection as a 

condition of Medicare coverage for 

selected services. In 2005, CMS issued 

a National Coverage Determination 

(NCD) that expanded coverage of ICDs 

and required registry participation when 

the devices were implanted for certain 

clinical indications. The NCD included 

this requirement in order to ensure that 

the care received by Medicare 

beneficiaries was reasonable and 

necessary and, therefore, appropriately 

reimbursed. Presently, the American 

College of Cardiology—National 

Cardiovascular Data Registry (ACC—

NCDR) collects these data and maintains 

the registry. 

In addition to ensuring appropriate 

payment of claims, collection, and 

ongoing analysis of ICD implantation, 

data can speed public health action in 

the event of future device recalls. The 

systematic recording of device 

manufacturer and model number can 

enhance patient and provider 

notification. Analysis of registry data 

may uncover patterns in complication 

rates (for example, device malfunction, 

device-related infection, and early 

battery depletion) associated with 

particular devices that signify the need 

for a more specific investigation. 

Patterns found in registry data may 

identify problems earlier than the 

currently available mechanisms, which 

do not systematically collect such 

detailed information surrounding 

procedures. 

We encourage the medical community 

to work to develop additional registries 

for implantable devices, so that timely 

and comprehensive information is 

available regarding devices, recipients 

of those devices, and their health status 

and outcomes. While participation in an 

ICD registry is required as a condition 

of coverage for ICD implantation for 

certain clinical conditions, we believe 

that the potential benefits of registries 

extend well beyond their application in 

Medicare’s specific national coverage 

determinations. As medical technology 

continues to swiftly advance, data 

collection regarding the short and long 

term outcomes of new technologies, and 

especially concerning implanted 

devices that may remain in the bodies 

of patients for their lifetimes, will be 

essential to the timely recognition of 

specific problems and patterns of 

complications. This information will 

facilitate early interventions to mitigate 

harm and improve the quality and 

efficiency of health care services. 

Moreover, data from registries may 

help further the development of high 

quality, evidence-based clinical practice 

guidelines for the care of patients who 

may receive device-intensive 

procedures. In turn, widespread use of 

evidence-based guidelines may reduce 

variation in medical practice, leading to 

improved personal and public health. 

Registry information may also 

contribute to the development of more 

comprehensive and refined quality 

metrics that may be used to 

systematically assess and then improve 

the safety and quality of health care. 

Such improvements in the quality of 

care that result in better personal health 

will require the sustained commitment 

of industry, payers, health care 

providers, and others towards that goal, 

along with excellent and open 

communication and rapid system-wide 

responses in a comprehensive effort to 

protect and enhance the health of the 

public. We look forward to further 

discussions with the public about new 

strategies to recognize device problems 

early and how to definitively address 

them, in order to minimize both the 

harmful health effects and increased 

health care costs that may result. 

In addition, we believe that the 

routine identification of Medicare 

claims where hospitals identify and 

then appropriately report selected 

services performed under the OPPS 

when devices are replaced without cost 

to the hospital or with full credit to the 

hospital for the cost of the replaced 

device, should provide comprehensive 

information regarding the outpatient 

hospital experiences of Medicare 

beneficiaries with certain devices that 

are being replaced. Because Medicare 

beneficiaries are common recipients of 

implanted devices, this claims 

information may be particularly helpful 

in identifying patterns of device 

problems early in their natural history 

so that appropriate strategies to reduce 

future problems may be developed. 

In addition to our concern for the 

public health, we also have a fiduciary 

responsibility to the Medicare trust fund 

to ensure that Medicare pays only for 

covered services. Therefore, we are 

proposing, effective for services 

furnished on or after January 1, 2007, to 

reduce the APC payment and 

beneficiary copayment for selected 

APCs in cases in which an implanted 


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device is replaced without cost to the 

hospital or with full credit for the 

removed device. Specifically, we are 

proposing to revise the existing 

regulations by adding new § 419.45, 

Payment and copayment reduction for 

replaced devices. This regulation is 

intended to cover certain devices for 

which credit for the replaced device is 

given or which are replaced as a result 

of or pursuant to a warranty, field 

action, voluntary recall, involuntary 

recall, and certain devices which are 

provided free of charge. It would 

provide for a reduction in the APC 

payment rate when we determine that 

the device is replaced without cost to 

the provider or beneficiary or when the 

provider receives full credit for the cost 

of a replaced device. The amount of the 

reduction to the APC payment rate 

would be calculated in the same manner 

as the offset amount that would be 

applied if the implanted device assigned 

to the APC had pass-through status as 

defined under § 419.66. The 

beneficiary’s copayment amount would 

be calculated based on the reduced APC 

payment rate. 

We believe that this is appropriate 

because in these cases the full cost of 

the replaced device is not incurred and, 

therefore, we believe that an adjustment 

to the APC payment is necessary to 

remove the cost of the device. We 

believe that the averaging nature of the 

calculation of the amount of the 

adjustment causes it to be appropriately 

applied to cases of credit for the 

replaced device, regardless of whether 

there is a residual cost due to the 

implantation of a more expensive 

device. 

We also believe that the proposed 

adjustment is consistent with section 

1862(a)(2) of the Act, which excludes 

from Medicare coverage an item or 

service for which neither the beneficiary 

nor anyone on his or her behalf has an 

obligation to pay. Payment of the full 

APC payment rate in these cases in 

which the device was replaced under 

warranty or in which there was a full 

credit for the price of the recalled or 

failed device effectively results in 

Medicare payment for a noncovered 

item. Moreover, it results in creation of 

a beneficiary liability for the copayment 

associated with the device for which the 

beneficiary has no liability. Therefore, 

we are proposing to adjust the APC 

payment rate in these circumstances 

under the authority of section 

1833(t)(2)(E) of the Act, which permits 

us to make equitable adjustments to the 

OPPS payment rates. 

We recognize that in many cases, the 

packaged cost of the device is a 

relatively modest part of the APC 

payment for the procedure into which 

the device cost is packaged. In the case 

of devices of modest cost, we believe 

that the averaging nature of payments 

under the OPPS based on the 

conversion of charges to costs with 

CCRs would incorporate any significant 

savings from a warranty replacement, 

field action, or recall into the payment 

rate for the associated procedural APC 

and that no specific adjustment would 

be necessary or appropriate. However, 

in other cases, such as implantation of 

an ICD, the cost of the device is the 

majority of the cost of the APC and 

payment at the full payment rate for the 

procedural APC would pay the hospital 

much in excess of its incurred cost of 

the service. 

As we discuss above, we are 

proposing to set the APC payment rates 

for device-dependent APCs for the CY 

2007 OPPS using only claims that 

contain appropriate devices to ensure 

that we make appropriate full payment 

when the hospital initially incurs the 

full cost of the device. Beginning in CY 

2005, we required that device codes be 

billed for devices used and specifically 

required that hospitals bill certain 

device codes for some services. We are 

using the CY 2005 claims to set the 

payment rates for the CY 2007 OPPS. 

Currently, where the device is furnished 

without cost to the hospital, we have 

authorized hospitals to charge less than 

$1.01, although Medicare’s longstanding 

policy has been that, in these cases, 

providers may not charge for the device 

furnished to them without cost. (See the 

Medicare Internet Only Manual, 

Medicare Benefit Policy Manual, 

Publication 100–02 Chapter 16, section 

40.4.) 

We authorized this charge because the 

CMS device edits require that the 

hospital must report an appropriate 

device if they bill for certain codes that 

cannot be performed without a device or 

the claim will be returned. Moreover, 

the Fiscal Intermediary Standard 

System will not accept the claim unless 

there is a charge for each HCPCS code 

billed. In addition, we were seeking a 

means of identifying these recall cases 

in the data. Therefore, by authorizing 

hospitals to charge less than $1.01 for 

the device we enabled the claim to be 

paid and also provided a mechanism for 

identifying devices for which the 

hospital incurred no expense. 

Where we set the payment rates for 

these device-dependent APCs using 

only claims that contain the full costs of 

devices when they are purchased by 

hospitals and exclude claims for which 

there is no appropriate device code or 

a charge for the device of less than 

$1.01, the proposed APC payments into 

which the full costs of the devices have 

been packaged would result in excessive 

program payments and beneficiary 

copayments for the services being 

furnished if the devices were provided 

without cost to hospitals. To avoid 

excessive payments in these 

circumstances, as noted previously we 

are proposing to adjust the APC 

payment rates when implanted devices 

have been replaced without cost to the 

hospital or beneficiary or where full 

credit for such a device has been given 

because the replacement device is of 

greater cost than the originally 

implanted device. 

We are proposing that the adjustment 

would be limited to the APCs listed in 

Table 21, but only when the purpose of 

the procedure is to replace a device that 

is reported by a HCPCS code in Table 

22 which was furnished without cost or 

at full credit by the manufacturer. We 

are proposing that the following three 

criteria must each be met for an APC to 

be subject to the adjustment. We 

selected the APCs in Table 21 on the 

basis of these three criteria. 

The first criterion is that all 

procedures assigned to the selected 

APCs must require implantable devices 

that would be reported if device 

replacement procedures were 

performed. Therefore, the device being 

replaced must be necessary for the 

service to be furnished and without the 

devices, the services assigned to the 

APCs could not be performed. For 

services, and, therefore, their assigned 

APCs, where a device is not needed or 

where it may or may not be needed to 

perform a procedure, we do not believe 

that reducing the payment for the APCs 

would be appropriate because the 

charges for the devices are unlikely to 

be a significant factor in establishing the 

rates for the APCs. 

The second criterion is that the 

required devices must be surgically 

inserted or implanted devices that 

remain in the patient’s body after the 

conclusion of the procedures, at least 

temporarily. We believe this is 

necessary to establish that the 

replacement device is a direct 

replacement for the device being 

removed. In cases of failures of devices 

that are surgically inserted or implanted 

but do not remain in the patient’s body 

after the conclusion of procedures, we 

believe that it is highly likely that the 

replacement device is not specifically 

used to care for the patient on whom the 

original defective device was used and 

that, where a defective device of this 

type is used, there is no savings to the 

hospital. For example, if a vascular 

catheter fails during a procedure, we 

believe that the physician will probably 


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use another similar catheter to finish the 

procedure. In these cases the hospital 

would correctly charge for the catheter 

that was used, and there would be no 

savings to the hospital from that 

procedure. The hospital would likely 

charge for both the defective device and 

the device used to complete the 

procedure because both catheters were 

used to provide the full service. We 

believe that if a replacement catheter is 

furnished to the hospital under 

warranty from the manufacturer, it 

would be used at a much later date on 

a different patient, it would most likely 

be charged to that patient account, and 

it would be unlikely to be specifically 

identified as being furnished without 

cost to the hospital. In these cases, we 

expect that any cost savings from the 

replacement devices such as these (for 

example, catheters) that are furnished 

without cost would be incorporated into 

the median costs for the procedures in 

the normal course of the data process 

through application of the CCRs 

generated from the cost reports. 

The third criterion is that the offset 

percent for the APC (that is, the median 

cost of the APC without device costs 

divided by the median cost of the APC 

with devices) must be significant. For 

this purpose, we are defining a 

significant offset percent as exceeding 

40 percent. We believe that this percent 

is appropriate because our studies have 

shown that approximately 60 percent of 

the cost of OPPS services is wagerelated, and that approximately 40 

percent of the cost of OPPS services is 

not wage related. This is why we wage 

adjust 60 percent of the APC payment 

rates for all APCs, including APCs for 

which a greater percentage of the APC 

payment is for the cost of a device. 

We believe that once the device share 

of an APC exceeds the 40 percent we 

attribute to costs other than wage costs 

(for example, device costs, capital costs, 

plant costs, and supplies other than 

devices), the device cost is a significant 

part of the APC cost. Therefore, where 

the device costs in an APC exceed 40 

percent, which is the average of all 

types of nonwage-related costs across all 

APCs, we are proposing to define the 

device costs as ‘‘significant’’ for 

purposes of this proposed policy. 

We recognize that it may be 

appropriate to define ‘‘significant’’ for 

this purpose at a different percentage of 

the APC cost because there are costs 

other than device costs (for example, 

capital costs and other supply costs) in 

the 40 percent of service costs to which 

the wage adjustment does not apply. We 

would reassess for future years whether 

it is appropriate to define ‘‘significant’’

for this purpose at a level other than 40 

percent. 

For purposes of making the proposed 

adjustment, we would adapt the 

methodology that we have employed to 

establish an offset for the device costs 

incorporated into APCs in cases where 

a pass-through device is also being 

billed. We currently calculate the offset 

amount by first calculating a median 

including the device costs and then 

calculating a median excluding device 

costs using single bills that contain 

devices. We then divide the ‘‘without 

device’’ median by the ‘‘with device’’

median and subtract the percent from 

100 to acquire the percent of cost 

attributable to devices in the APC. We 

apply this percent to the payment rate 

of the APC to determine the offset 

amount. For example, this is the 

methodology we used to calculate the 

offset amount for APC 0222 when 

current pass-through device C1820 

(Generator, neuro rechg bat sys) is billed 

on the same claim. We believe that it is 

appropriate to apply this same 

methodology in circumstances when we 

need to remove the cost of the device 

from the APC payment, not because the 

device is being paid under pass-through 

but because the hospital is either not 

incurring the cost for the replaced 

device or has been given full credit for 

the replaced device. In both cases, the 

intent is to remove the cost of the device 

from the APC payment rate. 

Using this methodology, we 

calculated the proposed offset amounts 

in Table 21 by first calculating an APC 

median cost including device costs and 

then calculating a median cost 

excluding device costs, using only 

single bills that meet our device edits 

and do not have token charges for 

devices. We then divided the ‘‘without 

device’’ median cost by the ‘‘with 

device’’ median cost and subtracted the 

percent from 100 to acquire the percent 

of cost attributable to devices in the 

APC. We next applied this percent to 

the payment rate for the APC to 

determine the offset amount. 

The following is an example of the 

payment reduction in the case of 

replacement of an ICD under warranty. 

Where the cardioverter defibrillator 

pulse generator described by HCPCS 

code C1721 (AICD, dual chamber) is 

replaced under warranty during a 

procedure described by HCPCS code 

G0298 (Insertion of dual chamber 

pacing cardioverter defibrillator pulse 

generator), the hospital would report 

HCPCS code G0298 with a specified 

modifier and would also report HCPCS 

code C1721 with a token charge for the 

device. Assuming the hospital had a 

wage index of 1, the payment rate for 

APC 0107 after adjustment would be 

$1862.27. That is, the adjusted payment 

rate would equal the unadjusted 

payment rate for APC 0107 ($17,185.34) 

less the warranty reduction percentage 

in Table 21 of 89.13 percent 

($15,317.29). Because the adjustment 

amount is set for the APC, the same 

adjustment amount would be removed if 

devices reported under HCPCS code 

C1722 or C1882 were reported with 

HCPCS code G0297. This is identical to 

the amount of adjustment that would 

apply to the payment for a pass-through 

device if there were, hypothetically, a 

new ICD to which we had given passthrough status (no ICD currently has 

pass-through status). 

We are proposing to both adjust the 

APC payment to remove payment for 

the device furnished without cost to the 

hospital or beneficiary and also to 

decrease the beneficiary copayment in 

proportion to the reduced APC payment 

so that the beneficiary would, in many 

but not all cases, share in the cost 

savings attributable to the provision of 

the device without cost by the 

manufacturer. We are proposing that 

when a device is replaced without cost 

to the hospital under warranty or recall 

or a credit is provided for the cost of a 

failed or recalled device (unlike cases of 

offset for a pass-through device), the 

beneficiary’s copayment would be 

calculated based on the reduced APC 

payment rate, maintaining the same 

percentage copayment as applies to the 

unadjusted APC payment if the 

inpatient deductible is not exceeded. 

We believe that it is appropriate to 

reduce the beneficiary copayment in 

these cases because the device is being 

furnished or credited by the 

manufacturer without obligation on the 

part of the beneficiary. We note, 

however, that in the case of some high 

cost APCs, making the payment 

adjustment in a recall or warranty 

situation may not result in reduction of 

the copayment because the copayment, 

although based on the reduced payment 

rate, may continue to exceed the 

inpatient deductible and, therefore, 

would continue to be set at the inpatient 

deductible. 

In contrast, in the case of passthrough devices, the beneficiary is liable 

for the copayment on the full APC 

amount (which, in the case of high cost 

APCs, is limited to the Medicare 

inpatient deductible) but pays no 

copayment for the incremental cost of 

the pass-through device. This is 

appropriate in the case of payment for 

pass-through devices because the 

hospital incurs costs for both the service 

and the device, and Medicare pays for 

both the service through the full APC 


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payment and for the incremental cost of 

the pass-through device above the costs 

of associated devices already reflected 

in the APC payment at charges reduced 

to cost by a CCR. The pass-through 

payment amount is reduced only to 

prevent the program from making 

duplicate payment for a portion of the 

device, once as part of the APC payment 

and once through the pass-through 

payment. 

We are proposing to implement the 

adjustment through the use of an 

appropriate modifier specific to a device 

replacement without cost or crediting of 

the cost of a device by the manufacturer. 

Hospitals would be required to report 

the modifier appended to a specific 

procedure on claims for services when 

two conditions are met. The first 

condition is that the procedure is 

assigned to one of the APCs in Table 21. 

We have discussed above the criteria 

that we employed for selecting the APCs 

in Table 21. The second condition is 

that the device for which the 

manufacturer furnished a replacement 

device (or provided credit for the device 

being replaced) is one of the devices 

included in Table 22. We are restricting 

the devices to which the adjustment 

would apply to those included in Table 

22 in order to ensure that the 

adjustment is not triggered by the 

replacement of an inexpensive device 

whose cost does not constitute a 

significant proportion of the total 

payment rate for an APC. 

The presence of the modifier would 

trigger the adjustment in payment for 

the APCs in Table 21. While we 

recognize that this creates a reporting 

burden for hospitals, we believe the 

reporting requirement is unavoidable. 

Only hospitals can report whether the 

circumstances for reduced payment as 

described above are met and, therefore, 

we see no option other than to have 

hospitals report this information to us. 

We recognize that the current FB 

modifier (‘‘Item furnished without cost 

to provider, supplier or practitioner’’) 

may not be appropriate in cases in 

which the replacement device is a more 

expensive device than the device being 

removed and may need to be changed to 

expand its use for all potential APC 

payment adjustment scenarios. 

Our proposed policy would 

accomplish three important goals. First 

and foremost, it would advise us of the 

extent to which devices are being 

replaced due to device failures so that, 

if patterns are identified, we can explore 

them to see if there are systemic 

problems with certain devices. The 

reporting of a specific modifier with 

certain procedure codes would allow us 

to examine patterns of delivery of 

specific hospital services when 

implanted devices are replaced without 

cost or with full credit for the cost of a 

device by the manufacturer, in 

comparison with publicly available 

information about problematic devices. 

Analysis of outpatient hospital claims 

would serve as an additional source of 

information to the medical community 

about patterns of device failures, 

voluntary field actions, and recalls, 

contributing to improved awareness and 

understanding of problems. 

Secondly, it would ensure equitable 

adjustment to the payments for surgical 

procedures to replace problematic 

devices by providing payments to 

hospitals only for the nondevice related 

procedural costs when a device is 

replaced without cost to the hospital for 

the device or with full credit for the 

removed device. Thirdly, it would also 

identify those claims that contain 

reduced device charges due to the full 

credit provided by the manufacturer for 

a replaced device so that in the future 

we can assess the impact of these claims 

on median costs for the services into 

which the device costs are packaged. 

This proposed policy would be 

effective for services furnished on or 

after January 1, 2007. We believe that 

this proposed policy is necessary to 

enable us to secure claims data that may 

be used to identify trends in device 

problems that lead to device 

replacements. It is also necessary to 

fulfill our fiduciary responsibility to the 

Medicare program by not providing 

payments for items that are excluded 

from coverage under Medicare law 

because neither the beneficiary nor any 

party on his or her behalf has an 

obligation to pay. 

TABLE 21.—PROPOSED ADJUSTMENT TO APCS IN CASES OF REPLACEMENT OF OR FULL CREDIT FOR FAILED OR

RECALLED DEVICE

APC SI APC group title 

CY 2007 

proposed 

offset 

percent 

0039 ....... S Level I Implantation of Neurostimulator ................................................................................................................ 78.51% 

0040 ....... S Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve ......................................... 54.66% 

0061 ....... S Laminectomy or Incision for Implantation of Neurostimulator Electrodes, Excludin ............................................ 60.59% 

0089 ....... T Insertion/Replacement of Permanent Pacemaker and Electrodes ...................................................................... 77.14% 

0090 ....... T Insertion/Replacement of Pacemaker Pulse Generator ....................................................................................... 74.56% 

0106 ....... T Insertion/Replacement/Repair of Pacemaker and/or Electrodes ......................................................................... 41.04% 

0107 ....... T Insertion of Cardioverter-Defibrillator .................................................................................................................... 89.13% 

0108 ....... T Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads ....................................................................... 89.15% 

0222 ....... T Implantation of Neurological Device ..................................................................................................................... 78.10% 

0225 ....... S Implantation of Neurostimulator Electrodes, Cranial Nerve ................................................................................. 80.62% 

0226 ....... T Implantation of Drug Infusion Reservoir ............................................................................................................... 62.21% 

0227 ....... T Implantation of Drug Infusion Device ................................................................................................................... 81.50% 

0229 ....... T Transcatherter Placement of Intravascular Shunts .............................................................................................. 42.32% 

0259 ....... T Level VI ENT Procedures ..................................................................................................................................... 84.03% 

0315 ....... T Level II Implantation of Neurostimulator ............................................................................................................... 83.52% 

0385 ....... S Level I Prosthetic Urological Procedures ............................................................................................................. 46.88% 

0386 ....... S Level II Prosthetic Urological Procedures ............................................................................................................ 61.32% 

0418 ....... T Insertion of Left Ventricular Pacing Elect ............................................................................................................. 86.11% 

0654 ....... T Insertion/Replacement of a permanent dual chamber pacemaker ...................................................................... 76.73% 

0655 ....... T Insertion/Replacement/Conversion of a permanent dual chamber pacemaker ................................................... 76.89% 

0680 ....... S Insertion of Patient Activated Event Recorders ................................................................................................... 77.03% 

0681 ....... T Knee Arthroplasty ................................................................................................................................................. 73.26% 


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TABLE 22.—DEVICES FOR WHICH THE

PROPOSED MODIFIER MUST BE REPORTED WITH THE PROCEDURE

CODE WHEN FURNISHED WITHOUT

COST OR AT FULL CREDIT FOR A

REPLACED DEVICE

Device Description 

C1721 .... AICD, dual chamber. 

C1722 .... AICD, single chamber. 

C1764 .... Event recorder, cardiac. 

C1767 .... Generator, neurostim, imp. 

C1771 .... Rep dev, urinary, w/sling. 

C1772 .... Infusion pump, programmable. 

C1776 .... Joint device (implantable). 

C1777 .... Lead, AICD, endo single coil. 

C1778 .... Lead, neurostimulator. 

C1779 .... Lead, pmkr, transvenous VDD. 

C1785 .... Pmkr, dual, rate-resp. 

C1786 .... Pmkr, single, rate-resp. 

C1813 .... Prosthesis, penile, inflatab. 

C1815 .... Pros, urinary sph, imp. 

C1820 .... Generator, neuro rechg bat sys. 

C1882 .... AICD, other than sing/dual. 

C1891 .... Infusion pump, non-prog, perm. 

C1895 .... Lead, AICD, endo dual coil. 

C1896 .... Lead, AICD, non sing/dual. 

C1897 .... Lead, neurostim, test kit. 

C1898 .... Lead, pmkr, other than trans. 

C1899 .... Lead, pmkr/AICD combination. 

C1900 .... Lead coronary venous. 

C2619 .... Pmkr, dual, non rate-resp. 

C2620 .... Pmkr, single, non rate-resp. 

C2621 .... Pmkr, other than sing/dual. 

C2622 .... Prosthesis, penile, non-inf. 

C2626 .... Infusion pump, non-prog, temp. 

C2631 .... Rep dev, urinary, w/o sling. 

L8614 ..... Cochlear device/system. 

B. Proposed Pass-Through Payments for 

Devices 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Pass-Through Devices’’ at the 

beginning of your comment.) 

1. Expiration of Transitional PassThrough Payments for Certain Devices 

a. Background 

Section 1833(t)(6)(B)(iii) of the Act 

requires that, under the OPPS, a 

category of devices be eligible for 

transitional pass-through payments for 

at least 2, but not more than 3, years. 

This period begins with the first date on 

which a transitional pass-through 

payment is made for any medical device 

that is described by the category. The 

device category codes became effective 

April 1, 2001, under the provisions of 

the BIPA. Prior to pass-through device 

categories, Medicare payments for passthrough devices under the OPPS were 

made on a brand-specific basis. All of 

the initial 97 category codes that were 

established as of April 1, 2001, have 

expired; 95 categories expired after CY 

2002, and 2 categories expired after CY 

2003. In addition, nine new categories 

have expired since their creation. We 

currently have no category codes for 

pass-through devices that will expire 

January 1, 2007. We created one new 

category effective January 1, 2006, for 

C1820 (Generator, neurostimulator 

(implantable), with rechargeable battery 

and charging system), which we are 

proposing to continue to pay under the 

pass-through provision in CY 2007 

under the OPPS. This category was 

created after we published 

modifications to our criteria in the CY 

2006 OPPS final rule with comment 

period on November 10, 2005 (70 FR 

68628 through 68631) allowing CMS to 

refine previous pass-through category 

descriptions that would have prevented 

us from making pass-through payments 

for a new technology that otherwise met 

our criteria. These modifications 

amended the original criteria and 

process for creating additional device 

categories for pass-through payment that 

we published on November 2, 2001 (66 

FR 55850 through 55857). Under our 

established policy, we base the 

expiration dates for the category codes 

on the date on which a category was 

first eligible for pass-through payment. 

In the November 1, 2002 OPPS final 

rule, we established a policy for 

payment of devices included in passthrough categories that are due to expire 

(67 FR 66763). For CY 2003 through CY 

2006, we packaged the costs of the 

devices no longer eligible for passthrough payments into the costs of the 

procedures with which the devices were 

billed in the claims data used to set the 

payment rates for those years. 

Brachytherapy sources, which are now 

separately paid in accordance with 

section 1833(t)(2)(H) of the Act, are an 

exception to this established policy 

(with the exception of brachytherapy 

sources for prostate brachytherapy, 

which were packaged in the CY 2003 

OPPS only). 

b. Proposed Policy for CY 2007 

As we stated earlier, currently we 

have one effective device category for 

pass-through payment, C1820, which 

we created for pass-through payment 

effective January 1, 2006. We are 

proposing to continue to make payment 

under the pass-through provisions for 

category C1820 for CY 2007. We are 

proposing that this category would 

expire from pass-through payment after 

December 31, 2007. This would provide 

the category transitional pass-through 

payment status for a 2-year period, in 

accordance with the statutory 

requirement that no category be paid as 

a pass-through device for less than 2 

years, nor more than 3 years. 

2. Provisions for Reducing Transitional 

Pass-Through Payments To Offset Costs 

Packaged Into APC Groups 

a. Background 

In the November 30, 2001 OPPS final 

rule, we explained the methodology we 

used to estimate the portion of each 

APC payment rate that could reasonably 

be attributed to the cost of the 

associated devices that are eligible for 

pass-through payments (66 FR 59904). 

Beginning with the implementation of 

the CY 2002 OPPS quarterly update 

(April 1, 2002), we deducted from the 

pass-through payments for the 

identified devices an amount that 

reflected the portion of the APC 

payment amount that we determined 

was associated with the cost of the 

device, as required by section 

1833(t)(6)(D)(ii) of the Act. In the 

November 1, 2002 interim final rule 

with comment period, we published the 

applicable offset amounts for CY 2003 

(67 FR 66801). 

For the CY 2002 and CY 2003 OPPS 

updates, to estimate the portion of each 

APC payment rate that could reasonably 

be attributed to the cost of an associated 

device eligible for pass-through 

payment, we used claims data from the 

period used for recalibration of the APC 

rates. That is, for CY 2002 OPPS 

updating, we used CY 2000 claims data, 

and for CY 2003 OPPS updating, we 

used CY 2001 claims data. For CY 2002, 

we used median cost claims data based 

on specific revenue centers used for 

device-related costs because C-code cost 

data were not available until CY 2003. 

For CY 2003, we calculated a median 

cost for every APC without packaging 

the costs of associated C-codes for 

device categories that were billed with 

the APC. We then calculated a median 

cost for every APC with the costs of the 

associated device category C-codes that 

were billed with the APC packaged into 

the median. Comparing the median APC 

cost without device packaging to the 

median APC cost, including device 

packaging, enabled us to determine the 

percentage of the median APC cost that 

is attributable to the associated passthrough devices. By applying those 

percentages to the APC payment rates, 

we determined the applicable amount to 

be deducted from the pass-through 

payment, the ’’offset’’ amount. We 

created an offset list comprised of any 

APC for which the device cost was at 

least 1 percent of the APC’s cost. 

The offset list that we published for 

CY 2002 through CY 2004 was a list of 

offset amounts associated with those 

APCs with identified offset amounts 

developed using the methodology 

described above. As a rule, we do not 


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know in advance which procedures 

residing in certain APCs may be billed 

with new device categories. Therefore, 

an offset amount is applied only when 

a new device category is billed with a 

HCPCS procedure code that is assigned 

to an APC appearing on the offset list. 

For CY 2004, we modified our policy 

for applying offsets to device passthrough payments. Specifically, we 

indicated that we would apply an offset 

to a new device category only when we 

could determine that an APC contains 

costs associated with the device. We 

continued our existing methodology for 

determining the offset amount, 

described earlier. We were able to use 

this methodology to establish the device 

offset amounts for CY 2004 because 

providers reported device codes (Ccodes) on the CY 2002 claims used for 

the CY 2004 OPPS update. For the CY 

2005 update to the OPPS, our data 

consisted of CY 2003 claims that did not 

contain device codes and, therefore, for 

CY 2005, we utilized the device 

percentages as developed for CY 2004. 

In the CY 2004 OPPS update, we 

reviewed the device categories eligible 

for continuing pass-through payment in 

CY 2004 to determine whether the costs 

associated with the device categories are 

packaged into the existing APCs. Based 

on our review of the data for the device 

categories existing in CY 2004, we 

determined that there were no close or 

identifiable costs associated with the 

devices relating to the respective APCs 

that are normally billed with them. 

Therefore, for those device categories, 

we set the offset amount to $0 for CY 

2004. We continued this policy of 

setting the offset amount to $0 for the 

device categories that continued to 

receive pass-through payment in CY 

2005. 

For the CY 2006 OPPS update, CY 

2004 hospital claims were available for 

analysis. Hospitals billed device Ccodes in CY 2004 on a voluntary basis. 

We reviewed our CY 2004 data and 

found that the numbers of claims for 

services in many of the APCs for which 

we calculated device percentages using 

CY 2004 data were quite small. We also 

found that many of these APCs already 

had relatively few single claims 

available for median calculations 

compared with the total bill frequencies 

because of our inability to use many 

multiple bills in establishing median 

costs for all APCs. In addition, we found 

that our claims demonstrated that 

relatively few hospitals specifically 

coded for devices utilized in CY 2004. 

Thus, we were not confident that CY 

2004 claims reporting C-codes 

represented the typical costs of all 

hospitals providing the services. 

Therefore, we did not use CY 2004 

claims with device coding to calculate 

CY 2006 device offset amounts. In 

addition, we did not use the CY 2005 

methodology, for which we utilized the 

device percentages as developed for CY 

2004. Two years had passed since we 

developed the device offsets for CY 

2004, and the device offsets originally 

calculated from CY 2002 hospitals’

claims data may either have 

overestimated or underestimated the 

contributions of device costs to total 

procedural costs in the outpatient 

hospital environment of CY 2004. In 

addition, a number of the APCs on the 

CY 2004 and CY 2005 device offset 

percentage lists were either no longer in 

existence or were so significantly 

reconfigured that the past device offsets 

likely did not apply. 

For CY 2006, we reviewed the single 

new device category established thus 

far, C1820, to determine whether device 

costs associated with the new category 

are packaged into the existing APC 

structure. Under our established policy, 

if we determine that the device costs 

associated with the new category are 

closely identifiable to device costs 

packaged into existing APCs, we set the 

offset amount for the new category to an 

amount greater than $0. Our review of 

the service indicated that the median 

costs for the applicable APC 0222 

(Implantation of Neurological Device) 

contained costs for neurostimulators 

similar to the costs of the new device 

category C1820. Therefore, we 

determined that a device offset would 

be appropriate. We announced an offset 

amount for that category in Program 

Transmittal No. 804, dated January 3, 

2006. 

For CY 2006, we are using available 

partial year CY 2005 hospital claims 

data to calculate device percentages and 

potential offsets for CY 2006 

applications for new device categories. 

Effective January 1, 2005, we require 

hospitals to report device C-codes and 

their costs when hospitals bill for 

services that utilize devices described 

by the existing C-codes. In addition, 

during CY 2005, we implemented 

device edits for many services that 

require devices and for which 

appropriate device C-codes exist. 

Therefore, we expected that the number 

of claims that include device codes and 

their respective costs to be much more 

robust and representative for CY 2005 

than for CY 2004. We believe that use 

of the most current claims data to 

establish offset amounts when they are 

needed to ensure appropriate payment 

is consistent with our stated policy; 

therefore, we are proposing to continue 

to do so for the CY 2007 OPPS. 

Specifically, if we create a new device 

category for payment in CY 2007, to 

calculate potential offsets we are 

proposing to examine the most current 

available claims data, including device 

costs, to determine whether device costs 

associated with the new category are 

already packaged into the existing APC 

structure, as indicated earlier. If we 

conclude that some related device costs 

are packaged into existing APCs, we are 

proposing to use the methodology 

described earlier and first used for the 

CY 2003 OPPS to determine an 

appropriate device offset percentage for 

those APCs with which the new 

category would be reported. 

We did not publish a list of APCs 

with device percentages as a transitional 

policy for CY 2006 because of the 

previously discussed limitations of the 

CY 2004 OPPS data with respect to 

device costs associated with procedures. 

We stated in the CY 2006 final rule with 

comment period (70 FR 68628) that we 

expected to reexamine our previous 

methodology for calculating the device 

percentages and offset amounts for the 

CY 2007 OPPS update, which would be 

based on CY 2005 hospital claims data 

where device C-code reporting is 

required. 

b. Proposed Policy for CY 2007 

For CY 2007, we are proposing to 

continue to review each new device 

category on a case-by-case basis as we 

have done in CY 2004, CY 2005, and CY 

2006, to determine whether device costs 

associated with the new category are 

packaged into the existing APC 

structure. If we determine that, for any 

new device category, no device costs 

associated with the new category are 

packaged into existing APCs, we are 

proposing to continue our current 

policy of setting the offset amount for 

the new category to $0 for CY 2007. 

There is currently one new device 

category that would continue for passthrough payment in CY 2007. This 

category, described by HCPCS code 

C1820, currently has an offset amount of 

$8,647.81, which is applied to APC 

0222. We are proposing to update this 

offset for CY 2007 based on the full year 

of claims data for CY 2005, the claims 

data year for our CY 2007 rate update. 

We are proposing an offset amount for 

C1820 of 78.1 percent of the proposed 

CY 2007 payment rate for APC 0222 

based on the CY 2005 data used to 

calculate the proposed payment amount 

in this proposed rule. (See Addendum 

A of this proposed rule for a listing of 

the proposed CY 2007 APC payment 

rates.) 

We are proposing to continue our 

existing policy to establish new 


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categories in any quarter when we 

determine that the criteria for granting 

pass-through status for a device category 

are met. If we create a new device 

category and determine that our data 

contain a sufficient number of claims 

with identifiable costs associated with 

the new category of devices in any APC, 

we are proposing to adjust the APC 

payment if the offset amount is greater 

than $0. If we determine that a device 

offset greater than $0 is appropriate for 

any new category that we create, we are 

proposing to announce the offset 

amount in the program transmittal that 

announces the new category. 

In summary, for CY 2007, we are 

proposing to use CY 2005 hospital 

claims data to calculate device 

percentages and potential offsets for CY 

2007 applications for new device 

categories. We are proposing to publish, 

through program transmittals, any new 

or updated offsets that we calculate for 

CY 2007, corresponding to newly 

created categories or existing categories, 

respectively. 

V. Proposed OPPS Payment Changes for 

Drugs, Biologicals, and 

Radiopharmaceuticals 

A. Proposed Transitional Pass-Through 

Payment for Additional Costs of Drugs 

and Biologicals 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Pass-Through Drugs’’ at the 

beginning of your comment.) 

1. Background 

Section 1833(t)(6) of the Act provides 

for temporary additional payments or 

‘‘transitional pass-through payments’’

for certain drugs and biological agents. 

As originally enacted by the Medicare, 

Medicaid, and SCHIP Balanced Budget 

Refinement Act (BBRA) of 1999 (Pub. L. 

106–113), this provision requires the 

Secretary to make additional payments 

to hospitals for current orphan drugs, as 

designated under section 526 of the 

Federal Food, Drug, and Cosmetic Act 

(Pub. L. 107–186); current drugs and 

biological agents and brachytherapy 

sources used for the treatment of cancer; 

and current radiopharmaceutical drugs 

and biological products. For those drugs 

and biological agents referred to as 

‘‘current,’’ the transitional pass-through 

payment began on the first date the 

hospital OPPS was implemented (before 

enactment of the Medicare, Medicaid, 

and SCHIP Benefits Improvement and 

Protection Act BIPA of 2000 (Pub. L. 

106–554), on December 21, 2000). 

Transitional pass-through payments 

are also required for certain ‘‘new’’

drugs and biological agents that were 

not being paid for as a hospital 

outpatient department service as of 

December 31, 1996, and whose cost is 

‘‘not insignificant’’ in relation to the 

OPPS payments for the procedures or 

services associated with the new drug or 

biological. Under the statute, 

transitional pass-through payments can 

be made for at least 2 years but not more 

than 3 years. In Addenda A and B of 

this proposed rule, proposed CY 2007 

pass-through drugs and biological 

agents are identified by status indicator 

‘‘G.’’

The process to apply for transitional 

pass-through payment for eligible drugs 

and biological agents can be found on 

our CMS Web site: http:// 

www.cms.hhs.gov. If we revise the 

application instructions in any way, we 

will post the revisions on our Web site 

and submit the changes to the Office of 

Management and Budget (OMB) for 

approval, as required under the 

Paperwork Reduction Act (PRA). 

Notification of new drugs and 

biologicals application processes is 

generally posted on the OPPS Web site 

at: http://www.cms.hhs.gov/providers/ 

hopps. 

2. Expiration in CY 2006 of PassThrough Status for Drugs and 

Biologicals 

Section 1833(t)(6)(C)(i) of the Act 

specifies that the duration of 

transitional pass-through payments for 

drugs and biologicals must be no less 

than 2 years and no longer than 3 years. 

The 12 drugs and biologicals listed in 

Table 23, whose pass-through status 

will expire on December 31, 2006, meet 

that criterion. For all drugs and 

biologicals with pass-through status 

expiring on December 31, 2006, that are 

currently assigned temporary C-codes, if 

there is a permanent HCPCS code 

available for CY 2007 that describes the 

product, then we are proposing to delete 

the C-code and use the permanent 

HCPCS code for purposes of OPPS 

billing and payment for the product in 

CY 2007. Based on our review of the 

existing permanent HCPCS codes 

available at the time of this proposed 

rule, we have determined that HCPCS 

code J7344 (Nonmetabolic active tissue) 

appropriately describes the product 

reported under HCPCS code C9221 in 

the CY 2006 OPPS; therefore, we 

propose to delete C9221 and pay for this 

product using J7344 in CY 2007. The 

coding changes for the other products 

will depend on what the final HCPCS 

codes are for CY 2007, which will be 

included in the CY 2007 OPPS final 

rule. We specifically request comments 

on this proposed policy for CY 2007. 

TABLE 23.—PROPOSED LIST OF

DRUGS AND BIOLOGICALS FOR

WHICH PASS-THROUGH STATUS EXPIRES DECEMBER 31, 2006 

HCPCS APC Short descriptor 

C9220 .. 9220 .... Sodium hyaluronate. 

C9221 .. 9221 .... Graftjacket Reg Matrix. 

C9222 .. 9222 .... Graftjacket Sft Tis. 

J0128 .. 9216 .... Abarelix injection. 

J0878 .. 9124 .... Daptomycin injection. 

J2357 .. 9300 .... Omalizumab injection. 

J2783 .. 0738 .... Rasburicase. 

J2794 .. 9125 .... Risperidone, long acting. 

J7518 .. 9219 .... Mycophenolic acid. 

J9035 .. 9214 .... Bevacizumab injection. 

J9055 .. 9215 .... Cetuximab injection. 

J9305 .. 9213 .... Pemetrexed injection. 

3. Drugs and Biologicals With Proposed 

Pass-Through Status in CY 2007 

We are proposing to continue passthrough status in CY 2007 for nine drugs 

and biologicals. These items, which are 

listed in Table 24 below, were given 

pass-through status as of April 1, 2006. 

The APCs and HCPCS codes for drugs 

and biologicals that we are proposing to 

continue with pass-through status in CY 

2007 are assigned status indicator ‘‘G’’

in Addenda A and B of this proposed 

rule. 

Section 1833(t)(6)(D)(i) of the Act sets 

the payment rate for pass-through 

eligible drugs (assuming that no pro rata 

reduction in pass-through payment is 

necessary) as the amount determined 

under section 1842(o) of the Act. We 

note that this section of the Act also 

states that if a drug or biological is 

covered under a competitive acquisition 

contract under section 1847B of the Act, 

the payment rate is equal to the average 

price for the drug or biological for all 

competitive acquisition areas and the 

year established as calculated and 

adjusted by the Secretary. 

Section 1847A of the Act, as added by 

section 303(c) of Pub. L. 108–173, 

establishes the use of the average sales 

price (ASP) methodology as the basis for 

payment of drugs and biologicals 

described in section 1842(o)(1)(C) of the 

Act and furnished on or after January 1, 

2005. This payment methodology is set 

forth in § 419.64 of the regulations. 

Section 1847B of the Act, as added by 

section 303(d) of Pub. L. 108–173, 

establishes the payment methodology 

for drugs and biologicals under the 

competitive acquisition program. The 

competitive acquisition program was 

implemented as of July 1, 2006. The list 

of drugs and biologicals covered under 

this program can be found on http:// 

www.cms.hhs.gov/ 

CompetitiveAcquisforBios, along with 


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their payment rates and information on 

the program’s methodology. 

Section 1833(t)(6)(D)(i) of the Act sets 

the payment rate for pass-through 

eligible drugs as the amount determined 

under section 1842(o) of the Act, or if 

a drug or biological is covered under a 

competitive acquisition contract under 

section 1847B of the Act, the payment 

rate is equal to the average price for the 

drug or biological for all competitive 

acquisition areas and the year 

established as calculated and adjusted 

by the Secretary. For CY 2007, under the 

OPPS we are proposing payment for 

drugs and biologicals with pass-through 

status that will also be covered under 

the competitive acquisition program to 

be based on the competitive acquisition 

program methodology. Similar to the 

payment policy established for passthrough drugs and biologicals in CY 

2006, we are proposing to pay under the 

OPPS for all other drugs and biologicals 

with pass-through status in CY 2007 

consistent with the provisions of section 

1842(o) of the Act, as amended by 

section 621 of Pub. L. 108–173, at a rate 

that is equivalent to the payment these 

drugs and biologicals would receive in 

the physician office setting. 

Table 24 lists the drugs and 

biologicals for which we are proposing 

that pass-through status continue in CY 

2007. Of these nine drugs and 

biologicals, only HCPCS codes J2503 

(Pegaptanib sodium injection) and J9264 

(Paclitaxel injection) are covered under 

the competitive acquisition program at 

the time of the development of this 

proposed rule. Therefore, in CY 2007, 

we are proposing to set payment for 

HCPCS codes J2503 and J9264 at the 

amounts determined under the 

competitive acquisition program, which 

will be a rate slightly different than the 

rate determined under the ASP 

methodology. Payment for all other 

drugs and biologicals would be 

equivalent to the payment these drugs 

and biologicals would receive in the 

physician office setting in CY 2007, 

where payment will be determined by 

the methodology described in § 419.904 

and generally be equal to ASP+6 

percent. In accordance with the ASP 

methodology, in the absence of ASP 

data, we are continuing the policy we 

implemented during CYs 2005 and 2006 

of using the wholesale acquisition cost 

(WAC) for the product to establish the 

initial payment rate. We note, however, 

that if the WAC is also unavailable, then 

we would make payment at 95 percent 

of the product’s most recent AWP. We 

adopted this interim payment 

methodology in order to be consistent 

with how we pay for new drugs, 

biologicals, and radiopharmaceuticals 

without HCPCS codes, as discussed in 

the CY 2006 OPPS final rule with 

comment period (70 FR 68669). We 

further note that with respect to items 

for which we currently do not have ASP 

data, once their ASP data become 

available in later quarter submissions, 

their payment rates under OPPS will be 

adjusted so that the rates are based on 

the ASP methodology and set to ASP+6 

percent. 

Currently, there are no 

radiopharmaceuticals that would have 

pass-through status in CY 2007. In the 

event that a new radiopharmaceutical 

agent receives pass-through status in CY 

2007, we propose to base its payment on 

the WAC for the product as ASP data for 

radiopharmaceuticals are not available. 

We note, however, that if the WAC is 

also unavailable, then we would 

calculate payment for the 

radiopharmaceutical at 95 percent of its 

most recent AWP. We are proposing to 

adopt this interim payment 

methodology in order to be consistent 

with how we pay for new drugs, 

biologicals, and radiopharmaceuticals 

without HCPCS codes, as discussed in 

the CY 2006 OPPS final rule with 

comment period (70 FR 68669). 

Section 1833(t)(6)(D)(i) of the Act also 

sets the amount of additional payment 

for pass-through eligible drugs and 

biologicals (the pass-through payment 

amount). The pass-through payment 

amount is the difference between the 

amount authorized under section 

1842(o) of the Act (or under section 

1847B of the Act, if the drug or 

biological is covered under a 

competitive acquisition contract), and 

the portion of the otherwise applicable 

fee schedule amount (that is, the APC 

payment rate) that the Secretary 

determines is associated with the drug 

or biological. 

We discuss in section V.B.3.b. of the 

preamble that we are proposing to make 

separate payment in CY 2007 for new 

drugs and biologicals with a HCPCS 

code, consistent with the provisions of 

section 1842(o) of the Act at a rate that 

is equivalent to the payment they would 

receive in a physician office setting (or 

under section 1847B of the Act, if the 

drug or biological is covered under a 

competitive acquisition contract), 

whether or not we have received a passthrough application for the item. 

Accordingly, in CY 2007 the passthrough payment amount would equal 

zero for those new drugs and biologicals 

that we determine have pass-through 

status. That is, when we subtract the 

amount to be paid for pass-through 

drugs and biologicals under section 

1842(o) of the Act (or section 1847B of 

the Act, if the drug or biological is 

covered under a competitive acquisition 

contract), from the portion of the 

otherwise applicable fee schedule 

amount or the APC payment rate 

associated with the drug or biological 

that would be the amount paid for drugs 

and biologicals under section 1842(o) of 

the Act (or section 1847B of the Act, if 

the drug or biological is covered under 

a competitive acquisition contract), the 

resulting difference is equal to zero. 

We are proposing to use payment 

rates based on the ASP data from the 

fourth quarter of CY 2005 for budget 

neutrality estimates, impact analyses, 

and to complete Addenda A and B of 

this proposed rule because these are the 

most recent data available to us at this 

time. These payment rates are also the 

basis for drug payments in the physician 

office setting effective April 1, 2006. To 

be consistent with the ASP-based 

payments that would be made when 

these drugs and biologicals are 

furnished in physician offices, we are 

proposing to make any appropriate 

adjustments to the amounts shown in 

Addenda A and B of this proposed rule 

when we publish our CY 2007 OPPS 

final rule and also on a quarterly basis 

on our Web site during CY 2007 if later 

quarter ASP submissions (or more 

recent WACs or AWPs) indicate that 

adjustments to the payment rates for 

these pass-through drugs and biologicals 

are necessary. The payment rate for a 

radiopharmaceutical with pass-through 

status would also be adjusted 

accordingly. We also are proposing to 

make appropriate adjustments to the 

payment rates for these drugs and 

biologicals in the event that they 

become covered under the competitive 

acquisition program in the future. For 

drugs and biologicals that are currently 

covered under the competitive 

acquisition program, we are proposing 

to use the payment rates calculated 

under this program that are in effect as 

of July 1, 2006. We are proposing to 

update these payment rates if the rates 

change in the future. 

Table 24 lists the drugs and 

biologicals for which we are proposing 

that pass-through status continue in CY 

2007. We assigned pass-through status 

to these drugs and biologicals as of 

April 1, 2006. We also have included in 

Addenda A and B of this proposed rule, 

the proposed CY 2007 APC payment 

rates for all pass-through drugs and 

biologicals, based on ASP data from the 

fourth quarter of CY 2005 (or if 

applicable, payment rates calculated 

under the competitive acquisition 

program) as described above. 


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TABLE 24.—PROPOSED LIST OF

DRUGS AND BIOLOGICALS WITH

PASS-THROUGH STATUS IN CY 2007 

HCPCS APC Short descriptor 

C9225 .. 9225 .... Fluocinolone acetonide. 

C9227 .. 9227 .... Injection, micafungin sodium. 

C9228 .. 9228 .... Injection, tigecycline. 

J2278 .. 1694 .... Ziconotide injection. 

J2503 .. 1697 .... Pegaptanib sodium injection. 

J8501 .. 0868 .... Oral aprepitant. 

J9027 .. 1710 .... Clofarabine injection. 

J9264 .. 1712 .... Paclitaxel injection. 

Q4079 9126 .... Natalizumab injection. 

B. Proposed Payment for Drugs, 

Biologicals, and Radiopharmaceuticals 

Without Pass-Through Status 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Nonpass-Through 

Drugs, Biologicals, and 

Radiopharmaceuticals’’ at the beginning 

of your comment.) 

1. Background 

Under the CY 2006 OPPS, we 

currently pay for drugs, biologicals, and 

radiopharmaceuticals that do not have 

pass-through status in one of two ways: 

packaged payment within the payment 

for the associated service or separate 

payment (individual APCs). We 

explained in the April 7, 2000 OPPS 

final rule with comment period (65 FR 

18450) that we generally package the 

cost of drugs and radiopharmaceuticals 

into the APC payment rate for the 

procedure or treatment with which the 

products are usually furnished. 

Hospitals do not receive separate 

payment from Medicare for packaged 

items and supplies, and hospitals may 

not bill beneficiaries separately for any 

packaged items and supplies whose 

costs are recognized and paid within the 

national OPPS payment rate for the 

associated procedure or service. 

(Program Memorandum Transmittal A–

01–133, issued on November 20, 2001, 

explains in greater detail the rules 

regarding separate payment for 

packaged services.) 

Packaging costs into a single aggregate 

payment for a service, procedure, or 

episode of care is a fundamental 

principle that distinguishes a 

prospective payment system from a fee 

schedule. In general, packaging the costs 

of items and services into the payment 

for the primary procedure or service 

with which they are associated 

encourages hospital efficiencies and 

also enables hospitals to manage their 

resources with maximum flexibility. 

Notwithstanding our commitment to 

package as many costs as possible, we 

are aware that packaging payments for 

certain drugs, biologicals, and 

radiopharmaceuticals, especially those 

that are particularly expensive or rarely 

used, might result in insufficient 

payments to hospitals, which could 

adversely affect beneficiary access to 

medically necessary services. 

Section 1833(t)(16)(B) of the Act, as 

added by section 621(a)(2) of Pub. L. 

108–173, requires that the threshold for 

establishing separate APCs for drugs 

and biologicals be set at $50 per 

administration for CYs 2005 and 2006. 

However, this requirement for 

establishing the packaging threshold 

will expire at the end of CY 2006. For 

CY 2006, we finalized our policy to 

continue paying separately for drugs, 

biologicals, and radiopharmaceuticals 

whose per day cost exceeds $50 and 

packaging the costs of drugs, biologicals, 

and radiopharmaceuticals whose per 

day cost is less than $50 into the 

procedures with which they are billed. 

For CY 2006, we also continued an 

exception policy to our packaging rule 

for one particular class of drugs, the oral 

and injectable 5HT3 forms of antiemetic treatments (70 FR 68635 through 

68638). 

2. Proposed Criteria for Packaging 

Payment for Drugs, Biologicals, and 

Radiopharmaceuticals 

During the March 2006 meeting of the 

APC Panel, the Panel recommended that 

CMS maintain the $50 packaging 

threshold or if the threshold is 

reevaluated, that CMS provide the Panel 

with data that indicate the costs of 

packaged drugs that are incorporated 

into drug administration payment rates. 

As indicated above, in accordance 

with section 1833(t)(16)(B) of the Act, 

the threshold for establishing separate 

APCs for drugs and biologicals was set 

to $50 per administration during CYs 

2005 and 2006. Because this packaging 

threshold will expire at the end of CY 

2006, we evaluated four options for 

packaging levels so that we could 

determine what the appropriate 

packaging threshold proposal for drugs, 

biologicals, and radiopharmaceuticals 

would be for the CY 2007 OPPS update. 

One of the packaging options we 

considered for the CY 2007 OPPS 

update was to pay separately for all 

drugs, biologicals, and 

radiopharmaceuticals with a HCPCS 

code. This would be a straightforward 

policy that would speed the creation of 

procedural APC medians. However, this 

policy would be inconsistent with OPPS 

packaging principles, reduce hospitals’

incentives for economy and efficiency, 

and increase hospitals’ administrative 

burden related to separate billing for 

more drugs, biologicals, and 

radiopharmaceuticals. 

The second option we considered for 

CY 2007 was to increase the packaging 

threshold to a level much higher than 

the current $50 threshold. This option 

would result in the packaging of more 

drugs, biologicals, and 

radiopharmaceuticals and would be 

more consistent with OPPS packaging 

principles. This option would also 

provide greater administrative 

simplicity for hospitals. However, 

implementation of this option might 

result, in some cases, in the drug 

administration payments being less than 

the cost of the packaged drugs. 

Relatively expensive drugs, biologicals, 

and radiopharmaceuticals could also be 

packaged under this option. 

The third packaging threshold option 

we evaluated was to maintain the 

packaging threshold at $50. We believe 

that this is a reasonable policy option 

that would provide stability to the 

payment system, as the packaging 

threshold has been set at $50 since CY 

2004. This policy option would also be 

consistent with the APC Panel 

recommendation to maintain the 

packaging threshold at $50 in CY 2007; 

however, this policy would not take into 

account price inflation in determining 

the drug packaging threshold since the 

$50 threshold was initially established. 

Consequently, the fourth option we 

considered and are proposing for CY 

2007 and subsequent years is to update 

the packaging threshold for inflation 

using an inflation adjustment factor 

based on the Producer Price Index (PPI) 

for prescription preparations. In order to 

update the packaging threshold for CY 

2007 under this proposal, we used the 

four quarter moving average PPI levels 

for prescription preparations to trend 

the $50 threshold forward from the third 

quarter of CY 2005 (when the Pub. L. 

108–173-mandated threshold became 

effective) to the third quarter of CY 

2007. We are proposing that for each 

year beginning with CY 2007, we would 

adjust the packaging threshold by the 

PPI for prescription drugs, and the 

adjusted dollar amount would be 

rounded to the nearest $5 increment in 

order to determine the new threshold. 

The adjusted amount for CY 2007 was 

calculated to be $55.99, which we are 

rounding to $55. Therefore, for CY 2007, 

we are proposing to pay separately for 

drugs, biologicals, and 

radiopharmaceuticals whose per day 

cost exceeds $55 and packaging the 

costs of drugs, biologicals, and 

radiopharmaceuticals whose per day 

cost is less than or equal to $55 into the 

procedures with which they are billed. 


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This proposed policy is consistent 

with the principle employed in many 

health care payment policy areas (and 

many other areas of government policy) 

of acknowledging the real costs by using 

an inflation adjustment instead of static 

dollar values. We believe that our 

proposed policy is consistent with the 

APC Panel’s recommendation because 

we would be maintaining the $50 

threshold in terms of its real value 

during the calendar year in which it 

would be in effect. Also, in the absence 

of a mechanism to update the threshold, 

we believe that current relatively 

inexpensive drugs would begin to 

receive separate payment over time. The 

PPI for prescription preparations reflects 

price changes at the wholesale or 

manufacturer stage. Because OPPS 

payment rates for drugs and biologicals 

are generally based on average sales 

price (ASP) data that are reported by 

their manufacturers, we believe that the 

PPI for prescription preparations would 

be an appropriate price index to use to 

update the packaging threshold for CY 

2007 and beyond. 

For CY 2007, we are also proposing to 

continue our policy of exempting the 

oral and injectable 5HT3 anti-emetic 

products from our packaging rule (Table 

25), thereby making separate payment 

for all of the 5HT3 anti-emetic products. 

As stated in the CY 2005 OPPS final 

rule with comment period (69 FR 65779 

through 65780), chemotherapy is very 

difficult for many patients to tolerate, as 

the side effects are often debilitating. In 

order for Medicare beneficiaries to 

achieve the maximum therapeutic 

benefit from chemotherapy and other 

therapies with side effects of nausea and 

vomiting, anti-emetic use is often an 

integral part of the treatment regimen. 

We believe that we should continue to 

ensure that Medicare payment rules do 

not impede a beneficiary’s access to the 

particular anti-emetic that is most 

effective for him or her as determined 

by the beneficiary and his or her 

physician. We solicit comments on 

these packaging proposals. 

TABLE 25.—PROPOSED ANTI-EMETICS

TO EXEMPT FROM PROPOSED $55 

PACKAGING REQUIREMENT

HCPCS 

code Short description 

J1260 ..... Dolasetron mesylate. 

J1626 ..... Granisetron HCl injection. 

J2405 ..... Ondansetron HCl injection. 

J2469 ..... Palonosetron HCl. 

Q0166 .... Granisetron HCl 1 mg oral. 

Q0179 .... Ondansetron HCl 8 mg oral. 

Q0180 .... Dolasetron mesylate oral. 

To determine their CY 2007 proposed 

packaging status, we calculated the per 

day cost of all drugs, biologicals, and 

radiopharmaceuticals that had a HCPCS 

code in CY 2005 and were paid (via 

packaged or separate payment) under 

the OPPS using claims data from 

January 1, 2005, to December 31, 2005. 

In CY 2005, multisource drugs and 

radiopharmaceuticals had two HCPCS 

codes that distinguished the innovator 

multisource (brand) drug or 

radiopharmaceutical from the 

noninnovator multisource (generic) drug 

or radiopharmaceutical. We aggregated 

claims for both the brand and generic 

HCPCS codes in our packaging analysis 

of these multisource products. In order 

to calculate the per day cost for drugs, 

biologicals, and radiopharmaceuticals to 

determine their packaging status in CY 

2007, we are proposing to use the 

methodology that was described in 

detail in the CY 2006 OPPS proposed 

rule (70 FR 42723 through 42724) and 

finalized in the CY 2006 OPPS final rule 

with comment period (70 FR 68636 

through 68638). However, in our 

calculation of per day costs for this 

proposed rule for the CY 2007 OPPS 

update, we used the payment rate for 

each drug and biological at its ASP+5 

percent which was based on 

manufacturer-submitted ASP data from 

the fourth quarter of CY 2005. The ASP 

data from this period were also the basis 

for determining payments for drugs and 

biologicals in the physician office 

setting, effective April 1, 2006. The 

rationale for using ASP+5 percent as the 

payment for drugs and biologicals is 

described in section V.B.3.a.2. of this 

preamble. For items that did not have an 

ASP-based payment rate, we used their 

mean unit cost derived from the CY 

2005 hospital claims data to determine 

their per day cost. We packaged the 

items with per day cost less than or 

equal to $55 and made items with per 

day cost greater than $55 separately 

payable. We are requesting comments 

on the methodology we are proposing to 

use to determine the per day cost of 

drugs, biologicals, and 

radiopharmaceuticals under the CY 

2007 OPPS update. 

Our policy during previous cycles of 

the OPPS has been to use updated data 

for the final rules. For the CY 2007 

OPPS final rule, we are proposing to use 

the ASP data from the first quarter of CY 

2006, which would be the basis for 

calculating payment rates for drugs and 

biologicals in the physician office 

setting using the ASP methodology 

effective July 1, 2006, along with 

updated hospital claims data from CY 

2005 to determine the final per day 

costs of drugs, biologicals, and 

radiopharmaceuticals and their 

packaging status in CY 2007. 

Subsequently, payment rates for CY 

2007 separately payable drugs and 

biologicals will be updated to reflect 

applicable ASP-based rates effective in 

the physician office setting for services 

effective January 1, 2007. 

Because, for the CY 2007 OPPS final 

rule, we are proposing to use ASP data 

from the first quarter of CY 2006, which 

would be the basis for calculating 

payment rates for drugs and biologicals 

in the physician office setting using the 

ASP methodology, effective July 1, 

2006, along with updated hospital 

claims data from CY 2005 to determine 

the final per day costs of drugs, 

biologicals, and radiopharmaceuticals, 

the packaging status of these items using 

the updated data may be different from 

their packaging status determined based 

on the data we are using for this 

proposed rule. Under such 

circumstances, we are proposing to 

apply the following policies to these 

drugs, biologicals, and 

radiopharmaceuticals whose 

relationship to the $55 threshold 

changes based on the final updated data: 

• Drugs, biologicals, and 

radiopharmaceuticals that were paid 

separately in CY 2006 (which are 

proposed for separate payment in CY 

2007), and then have per day costs less 

than $55 based on the updated ASPs 

and hospital claims data that would be 

used for the CY 2007 final rule with 

comment period, would continue to 

receive separate payment in CY 2007. 

• Drugs, biologicals, and 

radiopharmaceuticals that were 

packaged in CY 2006, (which are 

proposed for separate payment in CY 

2007), and then have per day costs less 

than $55 based on the updated ASPs 

and hospital claims data that would be 

used for the CY 2007 final rule with 

comment period, would remain 

packaged in CY 2007. 

• Drugs, biologicals, and 

radiopharmaceuticals for which we 

propose packaged payment in CY 2007 

but then have per day costs greater than 

$55 based on the updated ASPs and 

hospital claims data that would be used 

for the CY 2007 final rule with comment 

period, would receive separate payment 

in CY 2007. 

We are requesting specific comments 

on these proposed policies for CY 2007. 


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3. Proposed Payment for Drugs, 

Biologicals, and Radiopharmaceuticals 

Without Pass-Through Status That Are 

Not Packaged 

a. Proposed Payment for Specified 

Covered Outpatient Drugs 

(1) Background 

Section 1833(t)(14) of the Act, as 

added by section 621(a)(1) of Public 

Law 108–173, requires special 

classification of certain separately paid 

radiopharmaceuticals, drugs, and 

biologicals and mandates specific 

payments for these items. Under section 

1833(t)(14)(B)(i) of the Act, a ‘‘specified 

covered outpatient drug’’ is a covered 

outpatient drug, as defined in section 

1927(k)(2) of the Act, for which a 

separate APC exists and that either is a 

radiopharmaceutical agent or is a drug 

or biological for which payment was 

made on a pass-through basis on or 

before December 31, 2002. 

Under section 1833(t)(14)(B)(ii) of the 

Act, certain drugs and biologicals are 

designated as exceptions and are not 

included in the definition of ‘‘specified 

covered outpatient drugs.’’ These 

exceptions are—

• A drug or biological for which 

payment is first made on or after 

January 1, 2003, under the transitional 

pass-through payment provision in 

section 1833(t)(6) of the Act. 

• A drug or biological for which a 

temporary HCPCS code has not been 

assigned. 

• During CYs 2004 and 2005, an 

orphan drug (as designated by the 

Secretary). 

Section 1833(t)(14)(A)(iii) of the Act, 

as added by section 621(a)(1) of Pub. L. 

108 173, requires that payment for 

specified covered outpatient drugs in 

CY 2006 and subsequent years be equal 

to the average acquisition cost for the 

drug for that year as determined by the 

Secretary subject to any adjustment for 

overhead costs and taking into account 

the hospital acquisition cost survey data 

collected by the Government 

Accountability Office (GAO) in CYs 

2004 and 2005. If hospital acquisition 

cost data are not available, the law 

requires that payment be equal to 

payment rates established under the 

methodology described in section 

1842(o), section 1847A, or section 

1847B of the Act as calculated and 

adjusted by the Secretary as necessary. 

For CY 2006, we adopted a policy of 

paying for the acquisition and overhead 

costs of separately paid drugs and 

biologicals at a combined rate of ASP+6 

percent. To calculate the ASP+6 percent 

payment rate, we evaluated the three 

data sources that were available to us for 

setting the CY 2006 payment rates for 

drugs and biologicals. As described in 

the CY 2006 OPPS final rule with 

comment period (70 FR 68639 through 

68644), these data sources were the 

GAO reported average purchase prices 

for 55 specified covered outpatient drug 

categories for the period July 1, 2003 to 

June 30, 2004 collected via a survey of 

1,400 acute care Medicare-certified 

hospitals; ASP data; and mean costs 

derived from CY 2004 hospital claims 

data used in developing the CY 2006 

final rule with comment period. For the 

CY 2006 final rule with comment 

period, we used ASP data from the 

second quarter of CY 2005, which were 

used to set payment rates for drugs and 

biologicals in the physician office 

setting effective October 1, 2005. We 

also used updated claims data, 

reflecting all of the hospital claims data 

from CY 2004 and updated CCRs. 

In our data analysis for the CY 2006 

OPPS final rule with comment period, 

we compared the payment rates for 

drugs and biologicals using data from all 

three sources described above. We 

estimated aggregate expenditures for all 

drugs and biologicals (excluding 

radiopharmaceuticals) that would be 

separately payable in CY 2006 and for 

the 55 drugs and biologicals reported by 

the GAO using mean costs from the 

claims data, the GAO mean purchase 

prices, and the ASP-based payment 

amounts (ASP+6 percent in most cases), 

and then calculated the equivalent 

average ASP-based payment rate under 

each of the three payment 

methodologies. The results based on 

updated ASP and claims data were 

published in Table 24 of the CY 2006 

OPPS final rule with comment period. 

For a full discussion of our reasons for 

using these data, refer to section V.B.3.a. 

of the CY 2006 OPPS final rule with 

comment period (70 FR 68639 through 

68644). 

As noted in the CY 2006 OPPS final 

rule with comment period, findings 

from a MedPAC survey of hospital 

charging practices indicated that 

hospitals set charges for drugs, 

biologicals, and radiopharmaceuticals 

high enough to reflect their pharmacy 

handling costs as well as their 

acquisition costs. Therefore, we believe 

the MedPAC survey indicated that 

payment for drugs and biologicals and 

pharmacy overhead at a combined 

ASP+6 percent rate would serve as the 

best proxy for the combined acquisition 

and overhead costs of each of these 

products. 

(2) Proposed Payment Policy for CY 

2007 

The provision in section 

1833(t)(14)(A)(iii) of the Act, as 

described above, continues to be 

applicable to determining payments for 

specified covered outpatient drugs for 

CY 2007. Similar to CY 2006, this 

provision requires that in CY 2007 

payment for specified covered 

outpatient drugs be equal to the average 

acquisition cost for the drug for that 

year as determined by the Secretary 

subject to any adjustment for overhead 

costs and taking into account the 

hospital acquisition cost survey data 

collected by the Government 

Accountability Office (GAO) in CYs 

2004 and 2005. If hospital acquisition 

cost data are not available, the law 

requires that payment be equal to 

payment rates established under the 

methodology described in section 

1842(o), section 1847A, or section 

1847B of the Act as calculated and 

adjusted by the Secretary as necessary. 

Additionally, section 1833(t)(14)(E)(ii) 

authorizes the Secretary to adjust APC 

weights for specified covered outpatient 

drugs to take into account the MedPAC 

report relating to overhead and related 

expenses, such as pharmacy services 

and handling costs. 

For the CY 2007 proposed rule, we 

evaluated two data sources that we have 

available to us for setting the CY 2007 

payment rates for drugs and biologicals. 

The first source of drug pricing 

information that we have is the ASP 

data from the fourth quarter of CY 2005, 

which were used to set payment rates 

for drugs and biologicals in the 

physician office setting effective April 1, 

2006. We have ASP-based prices for 

approximately 500 drugs and biologicals 

(including contrast agents) payable 

under the OPPS; however, we currently 

do not have any ASP data on 

radiopharmaceuticals. Payments for 

most of the drugs and biologicals paid 

in the physician office setting are based 

on ASP+6 percent, and payments for 

items with no reported ASP are based 

on wholesale acquisition cost (WAC). 

The second source of cost data that 

we have for drugs, biologicals, and 

radiopharmaceuticals are the mean and 

median costs derived from the CY 2005 

hospital claims data. As section 

1833(t)(14)(A)(iii) of the Act clearly 

specifies that payment for specified 

covered outpatient drugs in CY 2007 be 

equal to the ‘‘average’’ acquisition cost 

for the drug, we limited our analysis to 

the mean costs of drugs determined 

using the hospital claims data, instead 

of using median costs. 


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In our data analysis, we compared the 

payment rates for drugs and biologicals 

using data from both sources described 

above. We estimated aggregate 

expenditures for all drugs and 

biologicals (excluding 

radiopharmaceuticals) that would be 

separately payable in CY 2007 using 

mean costs from the hospital claims 

data and the ASP-based payment 

amounts (ASP+6 percent in most cases), 

and calculated the equivalent average 

ASP-based payment rate under both 

payment methodologies. 

The results of our data analysis 

indicate that using mean unit cost to set 

the payment rates for the drugs and 

biologicals that would be separately 

payable in CY 2007 would be equivalent 

to basing their payment rates, on 

average, at ASP+5 percent. As noted in 

the CY 2006 proposed and final rules, 

findings from a MedPAC survey of 

hospital charging practices indicated 

that hospitals set charges for drugs, 

biologicals, and radiopharmaceuticals 

high enough to reflect their pharmacy 

handling costs as well as their 

acquisition costs. Therefore, the mean 

costs calculated using charges from 

hospital claims data converted to costs 

are representative of hospital 

acquisition costs for these products, as 

well as their related pharmacy overhead 

costs. Our calculations indicate that 

using mean unit costs to set the 

payment rates for all separately payable 

drugs and biologicals would be 

equivalent to basing their payment rates 

on the ASP+5 percent, on average. 

Because pharmacy overhead costs are 

already built into the charges for drugs, 

biologicals, and radiopharmaceuticals, 

our current data therefore indicate that 

payment for drugs and biologicals and 

pharmacy overhead at a combined 

ASP+5 percent rate would serve as the 

best proxy for the combined acquisition 

and overhead costs of each of these 

products. Therefore, for CY 2007, we are 

proposing a policy of paying for the 

acquisition and overhead costs of 

separately paid drugs and biologicals at 

a combined rate of ASP+5 percent. 

In its final report on the hospital 

acquisition cost survey of specified 

covered outpatient drugs titled 

‘‘Medicare Hospital Pharmaceuticals: 

Survey Shows Price Variation and 

Highlights Data Collection Lessons and 

Outpatient Rate-setting Challenges for 

CMS’’, the GAO recommended that 

Secretary validate, on an occasional 

basis, manufacturers’ reported drug 

ASPs as a measure of hospitals’

acquisition costs using a survey of 

hospitals or other method that CMS 

determines to be similarly accurate and 

efficient. As we indicated in our written 

comments to the GAO on its draft 

report, we will continue to consider the 

best approach for setting payment rates 

for drugs and biologicals in light of this 

recommendation. We also indicated that 

we will continue to analyze the 

adequacy of ASP-based pricing in light 

of our hospital claims data, which for 

this CY 2007 OPPS proposed rule 

indicates that ASP+5 percent would be 

the best available proxy for hospitals’

average acquisition and handling costs 

of drugs and biologicals in CY 2007. 

We note that ASP data are unavailable 

for some drugs and biologicals. For 

these few drugs and biologicals, we are 

proposing to use the mean costs from 

the CY 2005 hospital claims data to 

determine their packaging status for 

ratesetting. Until we receive ASP data 

for these items, payment will be based 

on their mean cost calculated from CY 

2005 hospital claims data. The payment 

rates for separately payable drugs and 

biologicals shown in Addenda A and B 

to this proposed rule represent 

payments for their acquisition and 

overhead costs. 

Our proposal uses payment rates 

based on ASP data from the fourth 

quarter of 2005 because these are the 

most recent numbers available to us at 

this time. To be consistent with the ASP 

data that would be used to determine 

payments for these drugs and 

biologicals when furnished in physician 

offices, we propose to make any 

appropriate adjustments to the amounts 

shown in Addenda A and B to this 

proposed rule for those items on a 

quarterly basis as more recent ASP data 

become available and post the payment 

rate changes on our Web site during 

each quarter of CY 2007. We note that 

we would determine the packaging 

status of each drug or biological only 

once during the year during the update 

process; however, for the separately 

payable drugs and biologicals, we 

would update their ASP-based payment 

rates on a quarterly basis. 

During the March 2006 meeting of the 

APC Panel, the Panel recommended that 

CMS examine pharmacy overhead costs 

issues and work with appropriate 

associations to study how to measure 

pharmacy overhead costs. The Panel 

also recommended that CMS solicit 

feedback on how pharmacy overhead 

costs should be reimbursed in the 

future. 

In response to the APC Panel 

recommendations, we will continue to 

work on issues related to pharmacy 

overhead costs and request comments 

on other proposals that we can consider 

when establishing a future pharmacy 

overhead cost methodology. In addition, 

we note that we routinely accept 

requests from interested organizations to 

discuss their views about OPPS 

payment policy issues. We will consider 

the input of any individual or 

organization to the extent allowed by 

Federal law, including the 

Administrative Procedure Act (APA) 

and the Federal Advisory Committee 

Act (FACA). We establish the OPPS 

rates through regulations. We are 

required to consider the timely 

comments of interested organizations, 

establish the payment policies for the 

forthcoming year, and respond to the 

timely comments of all public 

commenters in the final rule in which 

we establish the payments for the 

forthcoming year. 

We are specifically requesting public 

comments on our proposal to pay for 

acquisition and overhead costs of drugs 

and biologicals under the OPPS at 

ASP+5 percent and the adequacy of the 

payment rates to account for actual 

acquisition and overhead costs incurred 

by hospitals for these items. 

In its October 31, 2005 letter of 

comment on proposed 2006 SCOD rates 

titled ‘‘Comments on Proposed 2006 

SCOD Rates,’’ the GAO recommended 

that to better approximate hospitals’

acquisition costs of SCODs the Secretary 

reconsider the level of proposed 

payment rates for drug SCODs, in 

relation to survey data on average 

purchase price, the role of rebates in 

determining acquisition costs, and the 

desirability of setting payment rates for 

SCODs at average acquisition costs. In 

the CY 2006 OPPS proposed rule (70 FR 

42726), we noted that the comparison 

between the GAO purchase price data 

and the ASP data indicated that the 

GAO data on average were equivalent to 

ASP+3 percent. However, we also 

indicated that using mean unit cost from 

the CY 2004 hospital claims data to set 

the payment rates for the drugs and 

biologicals that would be separately 

payable in CY 2006 would be equivalent 

to basing their payment rates, on 

average, at ASP+8 percent. Therefore, 

we had proposed to establish payment 

for drugs and biologicals and their 

overhead costs at a combined rate of 

ASP+8 percent, where ASP+6 percent 

represented the acquisition cost of these 

items and 2 percent of ASP was for their 

overhead costs. For the CY 2006 OPPS 

final rule with comment period, where 

more recent ASP data, updated CCRs, 

and updated CY 2004 hospital claims 

data were available, we found that the 

comparison between the GAO purchase 

price data and the ASP data indicated 

that the GAO data on average were 

equivalent to ASP+4 percent, and using 

mean unit cost from hospital claims to 

set the payment rates for the drugs and 


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biologicals that would be separately 

payable in CY 2006 would be equivalent 

to basing their payment rates, on 

average, at ASP+6 percent. Because 

pharmacy overhead costs are already 

built into the charges for drugs, 

biologicals, and radiopharmaceuticals, 

we noted in the CY 2006 OPPS final 

rule with comment period that our 

claims data indicated that payment for 

drugs and biologicals and their 

pharmacy overhead at a combined 

ASP+6 percent rate served as the best 

proxy for the combined acquisition and 

overhead costs of each of these 

products. For the CY 2007 proposed 

rule, as indicated earlier in the 

preamble, we compared the CY 2005 

hospital claims data with more recent 

ASP data and determined that using 

mean unit cost to set payment rates for 

separately payable drugs and biologicals 

in CY 2007 would be equivalent to 

basing their payment rates, on average, 

at ASP+5 percent. This is the policy we 

are proposing for CY 2007, and we 

believe that this payment level would 

serve as the best proxy for the combined 

acquisition and overhead costs of 

separately payable drugs and biologicals 

in CY 2007. 

In the CY 2006 OPPS final rule with 

comment period (70 FR 68661), we 

indicated that we will be paying for 

blood clotting factors at ASP+6 percent 

during CY 2006 under the OPPS and 

providing payment for the furnishing 

fee that is also a part of the payment for 

blood clotting factors furnished in 

physician offices under Medicare Part B. 

This furnishing fee will be updated each 

calendar year based on the consumer 

price index, and we will update the 

amount appropriately each year under 

the OPPS based upon the final amount 

noted in the Medicare Physician Fee 

Schedule final rule. In CY 2006, the 

furnishing fee is $0.146 per unit. For the 

CY 2007 OPPS, we are proposing to 

make payment for blood clotting factors 

at ASP+5 percent along with continuing 

payment for the furnishing fee using the 

updated amount for CY 2007. The 

proposed CY 2007 regulations 

establishing the ASP methodology and 

the furnishing fee for blood clotting 

factors under Medicare Part B can be 

found in the CY 2007 Medicare 

Physician Fee Schedule proposed rule. 

The updated furnishing fee amount for 

CY 2007 under the OPPS will be 

announced in the CY 2007 OPPS final 

rule. 

(3) CY 2007 Proposed Payment Policy 

for Radiopharmaceuticals 

Section 303(h) of Pub. L. 108–173 

exempted radiopharmaceuticals from 

ASP pricing in the physician office 

setting where the fewer numbers 

(relative to the hospital outpatient 

setting) of radiopharmaceuticals are 

priced locally by Medicare contractors. 

Consequently, we do not have ASP data 

for radiopharmaceuticals. However, the 

law also requires us to make payments 

for specified covered outpatient drugs, 

including radiopharmaceuticals, equal 

to the average acquisition cost for the 

drug as determined by the Secretary and 

subject to any adjustment for overhead 

costs. We expect hospitals’ different 

purchasing and preparation and 

handling practices for 

radiopharmaceuticals to be reflected in 

their charges. Therefore, for CY 2006, 

we calculated per day costs of 

radiopharmaceuticals using mean unit 

costs from the CY 2004 hospital claims 

data to determine the items’ packaging 

status similar to the drugs and 

biologicals with no ASP data. For CY 

2006, we implemented a 1-year 

temporary policy to pay for separately 

payable radiopharmaceuticals based on 

the hospital’s charge for each 

radiopharmaceutical adjusted to cost. 

We clearly stated in our CY 2006 OPPS 

final rule with comment period that we 

did not intend to maintain the CY 2006 

methodology permanently (70 FR 

68656) and that we would actively seek 

other methodologies for setting 

payments for radiopharmaceuticals in 

CY 2007. 

During the March 2006 meeting of the 

APC Panel, the Panel recommended that 

CMS work with stakeholders to 

continue to develop a methodology to 

pay for radiopharmaceuticals. We note 

that we routinely accept requests from 

interested organizations to discuss their 

views about OPPS payment policy 

issues. We will consider the input of 

any individual or organization to the 

extent allowed by Federal law, 

including the Administrative Procedure 

Act (APA) and the Federal Advisory 

Committee Act (FACA). We establish 

OPPS rates through regulations. We are 

required to consider the timely 

comments of interested organizations, 

establish the payment policies for the 

forthcoming year, and respond to the 

timely comments of all public 

commenters in the final rule in which 

we establish the payments for the 

forthcoming year. We have considered 

comments and information from 

interested organizations in developing 

these policy options for CY 2007. 

Over this past year, despite reviews of 

the literature and numerous discussions 

with interested individuals and 

organizations from the 

radiopharmaceutical industry, we have 

received no specific suggestions from 

hospitals or industry regarding 

alternative prospective payment 

methodologies for radiopharmaceuticals 

that could be used in place of our CY 

2006 cost-based payment methodology. 

However, in its final report on the 

hospital acquisition cost survey of 

specified covered outpatient drugs, 

titled ‘‘ Medicare Hospital 

Pharmaceuticals: Survey Shows Price 

Variations and Highlights Data 

Collection Lesson and Outpatient Ratesetting Challenges for CMS,’’ the GAO 

acknowledged that the distinctive 

nature of radiopharmaceuticals as 

compared with other drugs poses 

special challenges for collecting and 

interpreting hospital cost data. They 

discussed the challenges of balancing 

accuracy and efficiency in obtaining 

price data on radiopharmaceutical 

specified covered outpatient drugs. 

They concluded that the best option 

available to CMS, in terms of accuracy 

and efficiency, is for the Secretary to 

collect and use ready-to-use unit-dose 

prices paid by hospitals when available 

as the data source for setting and 

updating Medicare payment rates for 

radiopharmaceutical specified covered 

outpatient drugs. As we indicated in our 

written comments to the GAO on its 

draft report, we remain uncertain about 

whether a survey to collect unit-dose 

acquisition costs would be conducted as 

a survey of hospitals or manufacturers. 

We are also concerned about the level 

of expense and administrative burden 

that would be placed on the party 

reporting such information, based on 

the GAO’s experience in surveying 

hospitals regarding radiopharmaceutical 

acquisition costs. The survey approach 

could lead to a very inefficient 

methodology for establishing payment 

rates. We also note that in conducting a 

survey to obtain ready-to-use unit-dose 

prices for radiopharmaceuticals, we 

would be able to collect this information 

for only a small number of 

radiopharmaceuticals that are 

purchased in unit-dose forms by 

hospitals; however, we believe that it is 

important to apply a consistent payment 

methodology to determine payments for 

all separately payable 

radiopharmaceuticals. Even though we 

are not proposing to adopt the GAO’s 

recommendation for CY 2007, we will 

continue to explore this 

recommendation for future updates of 

the OPPS. 

In developing the payment policy 

proposal for separately payable 

radiopharmaceuticals for the CY 2007 

proposed rule, we considered several 

additional policy options. The first 

option we considered proposing was to 

package additional 


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radiopharmaceuticals, either through 

packaging payments for all 

radiopharmaceuticals with payments for 

the services with which they are billed 

or increasing the packaging threshold 

for radiopharmaceuticals from a cost of 

$55 per day to a higher amount. In 

contrast to other separately payable 

drugs where the administration of many 

drugs is reported with only a few drug 

administration HCPCS codes, only a 

small number of specific 

radiopharmaceuticals may be 

appropriately provided in the 

performance of each particular nuclear 

medicine procedure. Because the 

provision of nuclear medicine 

procedures always requires one or more 

radiopharmaceuticals, packaging more 

radiopharmaceuticals effectively results 

in some increases in the costs of the 

associated nuclear medicine procedures 

to reflect the greater packaging of the 

radiopharmaceuticals. The specific 

increased procedural costs observed are 

dependent upon the volumes and costs 

of various radiopharmaceuticals used in 

the procedures and thus reflect an 

average cost across clinical scenarios 

where providers may choose among 

several radiopharmaceuticals for the 

procedures. A policy to package 

additional radiopharmaceuticals would 

be very consistent with OPPS packaging 

principles and payment policies which 

generally provide appropriate payment 

for the average service and would 

provide greater administrative 

simplicity for hospitals. Because we 

believe that radiopharmaceutical 

handling costs are included in hospitals 

charges for the radiopharmaceuticals 

themselves, payments for the nuclear 

medicine procedures would include 

payments for the handling costs of the 

radiopharmaceuticals used under this 

option. 

In examining our claims data for CY 

2005, we noted that significant numbers 

of claims for nuclear medicine 

procedures included no HCPCS codes 

for radiopharmaceuticals. While it is 

possible that hospitals used packaged 

radiopharmaceuticals in some studies 

and therefore chose not to report them 

separately, it is also possible that some 

hospitals may have included charges for 

the required radiopharmaceuticals in 

their charges for the nuclear medicine 

procedures themselves. Packaging 

additional radiopharmaceuticals would 

be consistent with the charging 

practices of some hospitals that already 

may not be separately reporting 

radiopharmaceuticals, even when those 

radiopharmaceuticals would receive 

separate payment under the OPPS. Were 

we to package additional 

radiopharmaceuticals under the OPPS, 

consistent with our packaging policies 

for implantable devices, we might need 

to establish edits to ensure that 

radiopharmaceutical charges were 

always included on claims for nuclear 

medicine procedures, as has been 

suggested to us by interested 

organizations. 

However, under a policy of increased 

packaging of radiopharmaceuticals, 

payments for certain nuclear medicine 

procedures could potentially be less 

than the costs of some of the packaged 

radiopharmaceuticals and relatively 

expensive and high volume 

radiopharmaceuticals could become 

packaged. In addition, our payment 

policy could discourage selection of the 

most clinically appropriate 

radiopharmaceutical for a particular 

nuclear medicine procedure, especially 

if that radiopharmaceutical were 

expensive and not commonly used so 

that its costs were not fully reflected in 

the payment for the nuclear medicine 

procedure. In addition, the statutory 

definition of a ‘‘specified covered 

outpatient drug’’ for OPPS purposes that 

includes radiopharmaceutical agents 

appears more consistent with the 

treatment of radiopharmaceuticals like 

other drugs under the OPPS, at least 

when this is feasible. We solicit public 

comment on the merits of establishing a 

higher packaging threshold for 

radiopharmaceuticals, given their 

unique characteristics. 

The second option that we considered 

proposing was to continue the 

temporary CY 2006 methodology of 

paying for separately payable 

radiopharmaceuticals at charges 

reduced to cost, where payment would 

be determined using each hospital’s 

overall CCR, and establishing our 

radiopharmaceutical packaging 

threshold at $55, as we are proposing for 

other drugs under the CY 2007 OPPS. 

This policy would provide stability to 

the payment methodology for 

radiopharmaceuticals from CY 2006 to 

CY 2007. As we indicated for CY 2007, 

this payment methodology provides an 

acceptable proxy for the average 

acquisition of the radiopharmaceutical 

along with its handling cost. 

However, as also indicated 

previously, we stated in the CY 2006 

OPPS final rule with comment period 

that this payment policy was intended 

to be only a temporary policy, and that 

we would consider alternative 

methodologies to base 

radiopharmaceutical payments on for 

the CY 2007 OPPS update. We generally 

do not make payments under the OPPS 

for items and services at cost, 

particularly if we do not expect the 

costs of services to vary substantially 

and unpredictably over time and if we 

have hospital claims data available. 

Paying for radiopharmaceuticals at cost 

provides hospitals with no incentive to 

supply radiopharmaceuticals in the 

most efficient manner. In its comments 

on the CY 2006 OPPS proposed rule, the 

GAO expressed concern that this 

methodology would be likely to result 

in payments that exceed hospitals’

acquisition costs for certain 

radiopharmaceuticals. Estimates of our 

CY 2006 payments for 

radiopharmaceuticals reveal variation 

from the 25th to 75th payment 

percentile of 2 to 9 fold, depending on 

the specific radiopharmaceutical. We do 

not believe that the radiopharmaceutical 

acquisition and handling costs for 

different hospitals to provide most 

radiopharmaceuticals should vary that 

greatly. In addition, using hospitals’

overall CCRs to determine payments 

likely results in an overstatement of 

radiopharmaceutical costs, which are 

likely reported in several cost centers 

such as diagnostic radiology that have 

lower CCRs than hospitals’ overall 

CCRs. 

The third option that we considered 

and are proposing for CY 2007 is to 

establish prospective payment rates for 

separately payable 

radiopharmaceuticals using mean costs 

derived from the CY 2005 claims data, 

where the costs are determined using 

our standard methodology of applying 

hospital-specific departmental CCRs to 

radiopharmaceutical charges, defaulting 

to hospital-specific overall CCRs only if 

appropriate departmental CCRs are 

unavailable. This proposal establishes 

our packaging threshold for 

radiopharmaceuticals at $55, as for 

other drugs under the CY 2007 OPPS. 

We believe this option provides us with 

the most consistent, accurate, and 

efficient methodology for prospectively 

establishing payment rates for 

separately payable 

radiopharmaceuticals. This is our 

preferred payment proposal for 

radiopharmaceuticals because this 

methodology is consistent with how 

payment rates for other services are 

determined under the OPPS and 

provides for prospective payments that 

serve as appropriate proxies for the 

average acquisition costs of the 

radiopharmaceuticals along with their 

handling costs. The MedPAC has 

indicated that hospitals currently 

include the charge for 

radiopharmaceutical handling in their 

charge for the radiopharmaceutical. In 

addition, this approach provides an 

average payment to hospitals, consistent 


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with the statutory requirement that we 

pay the average acquisition cost, in 

comparison with our CY 2006 costbased policy which paid each hospital 

differently for each claim based on the 

claim’s charges and the hospital’s 

overall CCR. 

We believe that this methodology 

would likely pay more accurately for 

radiopharmaceuticals, and provide 

incentives for their efficient acquisition 

and preparation. Also, as discussed 

earlier, MedPAC indicated that 

hospitals include charges for handling 

costs in their charge for 

radiopharmaceuticals; therefore, mean 

costs based on our claims data would 

represent both the acquisition and 

overhead costs of the separately payable 

radiopharmaceuticals. We believe that 

this payment policy could also be an 

appropriate long-term 

radiopharmaceutical payment policy 

that would allow us to consistently 

establish prospective OPPS payment 

rates for the acquisition and overhead 

costs of separately payable 

radiopharmaceuticals. Because we will 

be paying separately for 

radiopharmaceuticals with mean costs 

per day greater than $55, without 

additional radiopharmaceutical 

packaging for CY 2007, we see no reason 

to establish edits for the presence of 

radiopharmaceutical codes on claims for 

nuclear medicine procedures as, in 

many cases, payments for the 

procedures do not include payments for 

the radiopharmaceuticals used. 

Under each of the payment options 

for radiopharmaceuticals, we 

considered that beginning with CY 2007 

and going forward we would update the 

packaging threshold for inflation using 

an inflation adjustment factor based on 

the Producer Price Index (PPI) for 

prescription preparations. As discussed 

elsewhere in the preamble, the adjusted 

amount for CY 2007 was determined to 

be $55. 

In its October 31, 2005 letter of 

comment on proposed 2006 SCOD rates 

titled ‘‘Comments on Proposed 2006 

SCOD Rates’’, the GAO recommended 

that to better approximate hospitals’

acquisition costs of SCODs that the 

Secretary reconsider the decision to 

base payment rates for 

radiopharmaceutical SCODs exclusively 

on estimated costs in light of the 

availability of data on actual prices paid 

for key radiopharmaceuticals. As we did 

not have ASPs for radiopharmaceuticals 

that best represent market prices, in the 

CY 2006 OPPS final rule with comment 

period, we finalized a temporary 1-year 

policy for CY 2006 to pay for 

radiopharmaceuticals that were 

separately payable in CY 2006 based on 

the hospital’s charge for each 

radiopharmaceutical agent adjusted to 

cost. We noted that MedPAC has 

indicated that hospitals currently 

include the charge for pharmacy 

overhead costs in their charge for the 

radiopharmaceutical. Therefore, we 

believed that paying for these items on 

the basis of charges converted to cost 

would be the best available proxy for 

the average acquisition cost of the 

radiopharmaceutical along with its 

handling cost in CY 2006. We did not 

use the GAO hospital purchase prices as 

the basis for setting payments because 

when we examined differences between 

the CY 2005 payment rates for these 

nine radiopharmaceuticals and their 

GAO mean purchase prices, we found 

that the GAO purchase prices were 

substantially lower for several of these 

agents. We indicated that our intent was 

to maintain consistency, whenever 

possible, between the payment rates for 

these agents from CY 2005 to CY 2006. 

For CY 2007, however, we considered 

several payment options for 

radiopharmaceuticals that we discussed 

above and are proposing to establish 

prospective payment rates for separately 

payable radiopharmaceuticals using 

mean costs derived from the CY 2005 

claims data. 

We note that the National HCPCS 

Panel changed the codes and the 

descriptors of many of the 

radiopharmaceutical products effective 

January 1, 2006, in some cases moving 

from prior code descriptors based upon 

units of radioactivity to new descriptors 

based on study doses. The hospital 

claims data we used for our analysis are 

based on radiopharmaceutical HCPCS 

codes that were in effect during CY 

2005. Because there were significant 

changes in HCPCS code descriptors for 

several radiopharmaceuticals from CY 

2005 to CY 2006, implementation of the 

proposed payment methodology for 

radiopharmaceuticals requires us to 

crosswalk the cost data for these 

radiopharmaceuticals that are in terms 

of the CY 2005 codes to the updated CY 

2006 codes that we expect to be in effect 

during CY 2007. The mean cost data per 

unit of many CY 2005 codes can be 

directly crosswalked to the new CY 

2006 codes because the products and 

units included in the code descriptors 

are essentially the same. However, there 

are several CY 2005 codes with 

descriptors specifying units of 

radioactivity that were changed to per 

study dose units in CY 2006. For these 

radiopharmaceuticals, we are proposing 

to calculate their per day costs based on 

the CY 2005 codes and use those per 

day costs as proxies for the per study 

dose costs of the CY 2006 codes. We 

believe that patients would generally 

receive one study dose of these 

radiopharmaceuticals each day, and our 

CY 2005 claims data show that they 

were most commonly billed with 

specific nuclear medicine procedures 

that normally include a single 

radiopharmaceutical dose on a given 

day. Therefore, the per day costs of 

these radiopharmaceuticals calculated 

based on claims reporting the CY 2005 

codes should be an appropriate basis for 

determining the payment rates for the 

CY 2006 HCPCS codes. 

Out of the 39 radiopharmaceutical 

HCPCS codes that we are proposing to 

pay separately for in CY 2007, we are 

able to directly crosswalk the CY 2005 

cost data to 31 of these codes. The 

descriptors for the remaining eight 

codes changed from per unit of 

radioactivity in CY 2005 to new 

descriptors based on per study doses in 

CY 2006. Therefore, we are proposing to 

use the per day costs based on the CY 

2005 claims data as proxies for the per 

study dose costs for this subset of 

radiopharmaceutical HCPCS codes to be 

reported in CY 2007. 

There are three cases where two CY 

2005 HCPCS codes were mapped to one 

new CY 2006 code that will be reported 

in CY 2007. These three CY 2006 

HCPCS codes are A9550, A9553, and 

A9559. Because of the complicated 

nature of crosswalking the cost data for 

two predecessor HCPCS codes with 

different units in their descriptors to 

each of these new HCPCS codes, we are 

proposing to crosswalk the cost data 

only from the predecessor HCPCS codes 

with the most claims volume in CY 

2005 to each of these three HCPCS 

codes to be reported for CY 2007. 

Table 26 below lists all of the CY 2007 

separately payable 

radiopharmaceuticals and the 

predecessor HCPCS codes whose claims 

data were used to set the CY 2007 

proposed payment rates and notes the 

crosswalk methodology used for the 

proposed rates. 

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BILLING CODE 4120–01–C 

We specifically request public 

comment on the radiopharmaceutical 

payment methodology that we are 

proposing for the CY 2007 OPPS update. 

We also seek public comment on the 

possibility of developing an alternative 

packaging threshold for 

radiopharmaceuticals to provide greater 

administrative simplicity for hospitals. 

Additionally, we request public 

comment on the crosswalk that we are 

proposing to use to determine the CY 

2007 payment rates for separately 

payable radiopharmaceuticals. 

While payments for drugs, biologicals 

and radiopharmaceuticals are taken into 

account when calculating budget 

neutrality, we note that we are 

proposing to make payments for drugs, 

biologicals, and radiopharmaceuticals 

without scaling these payment amounts. 


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Section 1833(t)(14)(A)(iii)(I) requires 

that, beginning in CY 2006, we pay for 

a separately payable drug on the basis 

of ‘‘the average acquisition cost of the 

drug.’’ As we stated in the CY 2006 

OPPS final rule with comment period 

(70 FR 42728), we believe that the best 

interpretation of the specific 

requirement that we pay for such drugs 

on the basis of average acquisition cost, 

is that these payments themselves 

should not be adjusted as part of 

meeting the statutory budget neutrality 

requirement. If we were to apply a 

budget neutrality scalar to these 

payments, we would no longer be 

paying the average acquisition cost, but 

rather an adjusted average acquisition 

cost, for separately payable drugs, 

biologicals, and radiopharmaceuticals. 

We believe that these amounts, without 

a budget neutrality scalar applied, are 

the best proxies we have for the 

aggregate average acquisition and 

pharmacy overhead and handling costs 

of drugs, biologicals, and 

radiopharmaceuticals. 

b. Proposed CY 2007 Payment for 

Nonpass-Through Drugs, Biologicals, 

and Radiopharmaceuticals With HCPCS 

Codes, But Without OPPS Hospital 

Claims Data 

Pub. L. 108–173 does not address the 

OPPS payment in CY 2005 and after for 

new drugs, biologicals, and 

radiopharmaceuticals that have assigned 

HCPCS codes, but that do not have a 

reference AWP or approval for payment 

as pass-through drugs or biologicals. 

Because there is no statutory provision 

that dictated payment for such drugs 

and biologicals in CY 2005, and because 

we had no hospital claims data to use 

in establishing a payment rate for them, 

we investigated several payment options 

for CY 2005 and discussed them in 

detail in the CY 2005 OPPS final rule 

with comment period (69 FR 65797 

through 65799). 

For CYs 2005 and 2006, we finalized 

the policy to pay separately for new 

drugs, biologicals, and 

radiopharmaceuticals with HCPCS 

codes, but which did not have passthrough status at a rate that was 

equivalent to the payment they received 

in the physician office setting, which 

was established in accordance with the 

ASP methodology. For CY 2007, we are 

proposing to continue payment for these 

new drugs and biologicals with HCPCS 

codes as of January 1, 2007, but which 

do not have pass-through status, at a 

rate that is equivalent to the payment 

they would receive in the physician 

office setting, which would be 

established in accordance with the ASP 

methodology described in the CY 2006 

Medicare Physician Fee Schedule final 

rule, where payment would generally be 

equal to ASP+6 percent. In accordance 

with the ASP methodology, in the 

absence of ASP data, we are continuing 

the policy we implemented during CYs 

2005 and 2006 of using the wholesale 

acquisition cost (WAC) for the product 

to establish the initial payment rate. We 

note, however, that if the WAC is also 

unavailable, we would make payment at 

95 percent of the product’s most recent 

AWP. We are proposing to adopt this 

interim payment methodology in order 

to be consistent with how we pay for 

new drugs, biologicals, and 

radiopharmaceuticals without HCPCS 

codes, as discussed in the CY 2006 

OPPS final rule with comment period 

(70 FR 68669). We further note that with 

respect to items for which we do not 

have ASP data, once their ASP data 

become available in later quarter 

submissions, their payment rates under 

OPPS will be adjusted so that the rates 

are based on the ASP methodology and 

set to ASP+6 percent. In the event that 

the drug or biological is covered under 

the competitive acquisition program, 

then we propose to pay for it at the 

payment rate calculated under this 

program consistent with the provisions 

in section 1847B of the Act. We propose 

to base payment for new 

radiopharmaceuticals with HCPCS 

codes as of January 1, 2007, but which 

do not have pass-through status, on the 

WACs for these products as ASP data 

for radiopharmaceuticals are not 

available. In addition, we note that if the 

WACs are also unavailable, then we 

would make payment for the 

radiopharmaceuticals at 95 percent of 

their most recent AWPs. We are 

proposing to adopt this interim payment 

methodology in order to be consistent 

with how we pay for new drugs, 

biologicals, and radiopharmaceuticals 

without HCPCS codes, as discussed in 

the CY 2006 OPPS final rule with 

comment period (70 FR 68669). To be 

consistent with the ASP-based 

payments that would be made when the 

new drugs and biologicals are furnished 

in physician offices, we are proposing to 

make any appropriate adjustments to 

their payment amounts in the CY 2007 

OPPS final rule and also on a quarterly 

basis on our Web site during CY 2007 

if later quarter ASP submissions (or 

more recent WACs or AWPs) indicate 

that adjustments to the payment rates 

for these drugs and biologicals are 

necessary. The payment rates for new 

radiopharmaceuticals would also be 

adjusted accordingly. We are also 

proposing to make appropriate 

adjustments to the payment rates for 

new drugs and biologicals in the event 

that they become covered under the 

competitive acquisition program in the 

future. 

As discussed in the CY 2005 OPPS 

final rule with comment period (69 FR 

65797), and the CY 2006 OPPS final rule 

with comment period (70 FR 68666), 

new drugs, biologicals, and 

radiopharmaceuticals may be expensive, 

and we are concerned that packaging 

these new items might jeopardize 

beneficiary access to them. In addition, 

we do not want to delay separate 

payment for these items solely because 

a pass-through application was not 

submitted. The payment methodologies 

described above are the same as the 

methodologies that would be used to 

calculate the OPPS payment amount 

that pass-through drugs, biologicals, and 

radiopharmaceuticals would be paid in 

CY 2007. We refer readers to section 

V.A. of this preamble for a discussion of 

payment policies of pass-through drugs, 

biologicals, and radiopharmaceuticals 

under OPPS. Consequently, we are 

proposing to continue to treat new 

drugs, biologicals, and 

radiopharmaceuticals with newly 

established HCPCS codes the same, 

irrespective of whether pass-through 

status has been determined. We also are 

proposing to assign status indicator ‘‘K’’

to HCPCS codes for new drugs, 

biologicals, and radiopharmaceuticals 

for which we have not received a passthrough application. We specifically 

request comments on our proposed 

payment policies for new drugs, 

biologicals, and radiopharmaceuticals 

with HCPCS codes but which do not 

have pass-through status as of January 1, 

2007. The new CY 2007 HCPCS codes 

for drugs, biologicals, and 

radiopharmaceuticals are not available 

at the time of the development of this 

proposed rule; however, they will be 

included in the CY 2007 OPPS final 

rule. 

There are several drugs, biologicals, 

and radiopharmaceuticals that were 

payable during CY 2005 or where 

HCPCS codes for products were created 

effective January 1, 2006, for which we 

do not have any CY 2005 hospital 

claims data. In order to determine the 

packaging status of these items for CY 

2007, we calculated an estimate of the 

per day cost of each of these items by 

multiplying the payment rate for each 

product based on ASP+5 percent similar 

to other separately payable nonpassthrough drugs and biologicals under the 

OPPS and, as determined using the ASP 

methodology as described in section 

V.B.3.a.2. of this preamble, by an 

estimated average number of units of 

each product that would typically be 


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furnished to a patient during one 

administration in the hospital 

outpatient setting. We are proposing to 

package items for which we estimate the 

per administration cost to be less than 

$55, which is the packaging threshold 

that we are proposing for drugs, 

biologicals, and radiopharmaceuticals in 

CY 2007, and pay separately for items 

with an estimated per administration 

cost greater than $55. We are proposing 

that the CY 2007 payment for separately 

payable items would be based on rates 

determined using the ASP methodology 

established in the physician office 

setting and set to ASP+5 percent, 

similar to other separately payable 

nonpass-through drugs and biologicals 

under the OPPS. In accordance with the 

ASP methodology used in the physician 

office setting, in the absence of ASP 

data, we would use the WAC for the 

product to establish the initial payment 

rate. We note, however, that if the WAC 

is also unavailable, then we would make 

payment at 95 percent of the most 

recent AWP available. We note that for 

radiopharmaceutical agents that do not 

have any CY 2005 hospital claims data, 

we propose to determine their 

packaging status and, if the items are 

separately payable, then establish their 

payment rates using the WACs for the 

products because ASP data are not 

available for any radiopharmaceuticals. 

We also note that if the WACs are 

unavailable, then we would use 

payment at 95 percent of the most 

recent AWPs to determine their 

packaging status and payment rates. In 

order to determine the packaging status 

and payment rates for these drugs, 

biologicals, and radiopharmaceuticals in 

this proposed rule, we used ASP data 

from the fourth quarter of 2005 or the 

most recent WAC or AWP data available 

at this time, as appropriate. 

Table 27 below lists all of the items 

without available CY 2005 claims data 

to which these policies would apply in 

CY 2007. There are three HCPCS codes 

for which we were not able to determine 

payment rates based on the ASP 

methodology. The HCPCS codes are 

90393 (Vaccina ig, im), 90693 (Typhoid 

vaccine, akd, sc), and A9567 

(Technitium TC-99m aerosol). Because 

we are unable to estimate the per 

administration cost of these items, we 

are proposing to package them in CY 

2007. We are seeking comments on our 

proposed policies for determining the 

per administration cost of the drugs, 

biologicals, and radiopharmaceuticals 

that are payable under the OPPS, but do 

not have any CY 2005 claims data. 

TABLE 27.—DRUGS, BIOLOGICALS, AND RADIOPHARMACEUTICALS WITHOUT CY 2005 CLAIMS DATA

HCPCS 

code Description ASP-based payment rate 

Estimated average 

number of 

units per 

administration 

CY 2007 

proposed 

SI 

90714 ..... Td vaccine no prsrv >/= 7 im ............................................................................. $18.09 1 N 

90727 ..... Plague vaccine, im ............................................................................................. 150.00 1 K 

A9535 .... Injection, methylene blue .................................................................................... 2.87 10 N

J0132 ..... Acetylcysteine injection ....................................................................................... 1.86 210 K 

J0200 ..... Alatrofloxacin mesylate ....................................................................................... 16.03 2.5 N 

J0278 ..... Amikacin sulfate injection ................................................................................... 1.33 5 .25 N 

J0288 ..... Ampho b cholesteryl sulfate ............................................................................... 12.00 35 K 

J0350 ..... Injection anistreplase 30 u .................................................................................. 2,265.46 1 K 

J0395 ..... Arbutamine HCl injection .................................................................................... 160.00 1 K 

J1452 ..... Intraocular Fomivirsen na ................................................................................... 210.00 1 K 

J2425 ..... Palifermin injection .............................................................................................. 11.37 84 K 

J2805 ..... Sincalide injection ............................................................................................... 44.14 1 N 

J2850 ..... Inj secretin synthetic human ............................................................................... 20.31 14 K

J3355 ..... Urofollitropin, 75 iu .............................................................................................. 48.84 2 K 

J3471 ..... Ovine, up to 999 USP units ................................................................................ 0.11 150 N 

J3472 ..... Ovine, 1000 USP units ....................................................................................... 133.77 1 K 

J7341 ..... Non-human, metabolic tissue ............................................................................. 1.64 50 K 

J8540 ..... Oral dexamethasone .......................................................................................... 0.07 80 N

J9225 ..... Histrelin implant .................................................................................................. 2,019.82 1 K 

Q9958 .... HOCM ≤ 149 mg/ml iodine, 1ml ......................................................................... 0.06 100 N 

Q9959 .... HOCM 150–199mg/ml iodine,1ml ...................................................................... 0.08 100 N 

Q9960 .... HOCM 200–249mg/ml iodine,1ml ...................................................................... 0.09 100 N 

Q9961 .... HOCM 250–299mg/ml iodine,1ml ...................................................................... 0.17 100 N 

Q9962 .... HOCM 300–349mg/ml iodine,1ml ...................................................................... 0.14 100 N 

Q9963 .... HOCM 350–399mg/ml iodine,1ml ...................................................................... 0.39 100 N 

Q9964 .... HOCM ≥ 400mg/ml iodine, 1ml .......................................................................... 0.19 100 N 

VI. Proposed Estimate of OPPS 

Transitional Pass-Through Spending in 

CY 2007 for Drugs, Biologicals, 

Radiopharmaceuticals, and Devices 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Estimated Transitional 

Pass-Through Spending’’ at the 

beginning of your comment.) 

A. Total Allowed Pass-Through 

Spending 

Section 1833(t)(6)(E) of the Act limits 

the total projected amount of 

transitional pass-through payments for 

drugs, biologicals, 

radiopharmaceuticals, and categories of 

devices for a given year to an 

‘‘applicable percentage’’ of projected 

total Medicare and beneficiary 

payments under the hospital OPPS. For 

a year before CY 2004, the applicable 

percentage was 2.5 percent; for CY 2004 

and subsequent years, we specify the 

applicable percentage up to 2.0 percent. 

If we estimate before the beginning of 

the calendar year that the total amount 

of pass-through payments in that year 

would exceed the applicable percentage, 

section 1833(t)(6)(E)(iii) of the Act 

requires a uniform reduction in the 

amount of each of the transitional passthrough payments made in that year to 

ensure that the limit is not exceeded. 

We make an estimate of pass-through 

spending to determine not only whether 


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payments exceed the applicable 

percentage, but also to determine the 

appropriate reduction to the conversion 

factor for the projected level of passthrough spending in the following year. 

For devices, making an estimate of 

pass-through spending in CY 2007 

entails estimating spending for two 

groups of items. The first group consists 

of those items for which we have claims 

data for procedures that we believe used 

devices that were eligible for passthrough status in CY 2005 and CY 2006 

and that would continue to be eligible 

for pass-through payment in CY 2007. 

The second group consists of those 

items for which we have no direct 

claims data, that is, items that became, 

or would become, eligible in CY 2006 

and would retain pass-through status in 

CY 2007, as well as items that would be 

newly eligible for pass-through payment 

beginning in CY 2007. 

B. Proposed Estimate of Pass-Through 

Spending for CY 2007 

We are proposing to set the applicable 

percentage cap at 2.0 percent of the total 

OPPS projected payments for CY 2007. 

As we discuss in section IV.B. of this 

preamble, there is one device category 

receiving pass-through payment in CY 

2006 that will continue for payment 

during CY 2007. Therefore, we estimate 

pass-through spending attributable to 

the first group of items described above 

to be $36.8 million. 

To estimate CY 2007 pass-through 

spending for device categories in the 

second group, that is, items for which 

we have no direct claims data, we used 

the following approach: For additional 

device categories that are approved for 

pass-through status after July 1, 2006, 

but before January 1, 2007, we are 

proposing to use price information from 

manufacturers and volume estimates 

based on claims for procedures that 

would most likely use the devices in 

question because we do not have any 

CY 2005 claims data upon which to base 

a spending estimate. We are proposing 

to project these data forward to CY 2007 

using inflation and utilization factors 

based on total growth in OPPS services 

as projected by CMS’ Office of the 

Actuary (OACT) to estimate CY 2007 

pass-through spending for this group of 

device categories. We may use an 

alternate growth factor for any specific 

new device category based on our 

claims data or the device’s clinical 

characteristics, or both. For device 

categories that become eligible for passthrough status in CY 2007, we are 

proposing to use the same methodology. 

We anticipate that any new categories 

for January 1, 2007, would be 

announced after the publication of this 

proposed rule, but before publication of 

the final rule with comment period. 

Therefore, the estimate of pass-through 

spending in the CY 2007 OPPS final 

rule with comment period would 

incorporate any pass-through spending 

for device categories made effective 

January 1, 2007, and during subsequent 

quarters of CY 2007. 

With respect to CY 2007 pass-through 

spending for drugs and biologicals, as 

we explain in section V.A.3. of this 

proposed rule, the pass-through 

payment amount for new drugs and 

biologicals that we determine have passthrough status will equal zero. 

Therefore, our estimate of pass-through 

spending for drugs and biologicals with 

pass-through status in CY 2007 equals 

zero. 

In the CY 2005 OPPS final rule with 

comment period (69 FR 65810), we 

indicated that we are accepting passthrough applications for new 

radiopharmaceuticals that are assigned a 

HCPCS code on or after January 1, 2005. 

(Prior to this date, radiopharmaceuticals 

were not included in the category of 

drugs paid under the OPPS, and 

therefore, were not eligible for passthrough status.) We have no new 

radiopharmaceuticals that were added 

for pass-through payment in CY 2005 or 

to this point in CY 2006, and we 

currently have no information 

identifying new radiopharmaceuticals to 

which a HCPCS code might be assigned 

on or after January 1, 2007, for which 

pass-through payment status would be 

sought. We also have no data regarding 

payment for new radiopharmaceuticals 

with pass-through status under the 

methodology that we specified in the 

CY 2005 OPPS final rule with comment 

period. However, we do not believe that 

pass-through spending for new 

radiopharmaceuticals in CY 2007 will 

be significant enough to materially 

affect our estimate of total pass-through 

spending in CY 2007. Therefore, we are 

not including radiopharmaceuticals in 

our estimate of pass-through spending 

for CY 2007. We discuss the 

methodology for determining the 

proposed CY 2007 payment amount for 

radiopharmaceuticals with pass-through 

status in section V.B.3.b. of this 

preamble. 

In accordance with the methodology 

described above, we estimate that total 

pass-through spending for both device 

categories that are continuing into CY 

2007 and that first become eligible for 

pass-through status during CY 2007 

would equal approximately $43.2 

million, which represents 0.13 percent 

of total OPPS projected payments for CY 

2007. This figure includes estimates for 

the current device category continuing 

into CY 2007, which equals $36.8 

million, in addition to projections for 

categories that may become eligible after 

publication of this proposed rule but 

before the end of CY 2006, and for 

projections for new categories that may 

become eligible during CY 2007. 

TABLE 28.—ESTIMATES FOR CY 2007 TRANSITIONAL PASS-THROUGH SPENDING FOR CURRENT PASS-THROUGH

CATEGORIES CONTINUING INTO CY 2007 

HCPCS APC Existing pass-through device category 

CY 2007 

estimated 

utilization 

CY 2007 

estimated 

pass-through 

payments 

C1820 .... 1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system 4,568 $36,766,720 

Because we estimate pass-through 

spending in CY 2007 will not amount to 

2.0 percent of total projected OPPS CY 

2007 spending, we are proposing to 

return 1.87 percent of the pass-through 

pool to adjust the conversion factor, as 

we discuss in section II.C. of this 

preamble. 

VII. Proposed Brachytherapy Source 

Payment Changes 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Brachytherapy’’ at the 

beginning of your comment.) 

A. Background 

Section 1833(t)(2)(H) of the Act, as 

added by section 621(b)(2)(C) of Pub. L. 

108–173, mandated the creation of 

separate groups of covered OPD services 

that classify brachytherapy devices 

separately from other services or groups 

of services. The additional groups must 


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reflect the number, isotope, and 

radioactive intensity of the devices of 

brachytherapy furnished, including 

separate groups for Palladium-103 and 

Iodine-125 devices. In accordance with 

this provision, since CY 2004 we have 

established four new brachytherapy 

source codes and descriptors. 

Section 1833(t)(16)(C) of the Act, as 

added by section 621(b)(1) of Pub. L. 

108–173, established payment for 

devices of brachytherapy consisting of a 

seed or seeds (or radioactive source) 

based on a hospital’s charges for the 

service, adjusted to cost. The period of 

payment under this provision is for 

brachytherapy sources furnished from 

January 1, 2004, through December 31, 

2006. Under section 1833(t)(16)(C) of 

the Act, charges for the brachytherapy 

devices may not be used in determining 

any outlier payments under the OPPS 

for that period of payment. Consistent 

with our practice under the OPPS to 

exclude items paid at cost from budget 

neutrality consideration, these items 

have been excluded from budget 

neutrality for that time period as well. 

In the OPPS interim final rule with 

comment period published on January 

6, 2004 (69 FR 827), we implemented 

sections 621(b)(1) and (b)(2)(C) of Pub. 

L. 108–173. In that rule, we stated that 

we would pay for the brachytherapy 

sources listed in Table 4 of the interim 

final rule with comment period (69 FR 

828) on a cost basis, as required by the 

statute. Since January 1, 2004, we have 

used status indicator ‘‘H’’ to denote 

nonpass-through brachytherapy sources 

paid on a cost basis, a policy that we 

finalized in the CY 2005 final rule with 

comment period (69 FR 65838). 

Furthermore, we adopted a standard 

policy for brachytherapy code 

descriptors, beginning January 1, 2005. 

We included ‘‘per source’’ in the HCPCS 

code descriptors for all those 

brachytherapy source descriptors for 

which units of payment were not 

already delineated. 

Section 621(b)(3) of Pub. L. 108–173 

requires the Government Accountability 

Office (GAO) to conduct a study to 

determine appropriate payment 

amounts for devices of brachytherapy, 

and to submit a report on its study to 

the Congress and the Secretary, 

including recommendations. The GAO’s 

final report, published at the end of July 

2006, was not available in time to 

review and discuss in this proposed 

rule. We plan to discuss the report’s 

findings and recommendations in the 

CY 2007 OPPS final rule with comment 

period. 

B. Proposed Payments for 

Brachytherapy Sources in CY 2007 

As indicated above, the provision to 

pay for brachytherapy sources at charges 

reduced to cost expires after December 

31, 2006, in accordance with section 

1833(t)(16)(C) of the Act. However, 

under section 1833(t)(2)(H) of the Act, 

we are still required to create APC 

groupings that classify devices of 

brachytherapy separately from other 

services or groups of services in a 

manner reflecting the number, isotope, 

and radioactive intensity of the devices 

of brachytherapy furnished. 

We are proposing to pay separately for 

each of the sources listed in Table 29 

below on a prospective basis for CY 

2007, with payment rates to be 

determined using the CY 2005 claimsbased median cost per source for each 

brachytherapy device. Consistent with 

our policy regarding APC payments 

made on a prospective basis, we are 

proposing that the cost of brachytherapy 

sources be subject to the outlier 

provisions of section 1833(t)(5) of the 

Act. As indicated in section II.A.2. of 

the preamble to this proposed rule, for 

CY 2007, we are proposing a specific 

payment rate for brachytherapy sources, 

which will be subject to scaling for 

budget neutrality. 

Table 29 includes a complete listing 

of the HCPCS codes, long descriptors, 

APC assignments, APC titles, and status 

indicators that we currently use for 

brachytherapy sources paid under the 

OPPS in CY 2006 and that we are 

proposing to use for CY 2007. The 

brachytherapy sources and related 

information in Table 29 are the same 

sources and information as those listed 

in Table 28 of the OPPS CY 2006 final 

rule with comment period (70 FR 

68676). No additional brachytherapy 

sources have been added since the CY 

2006 final rule with comment period. 

TABLE 29.—PROPOSED SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2007 

HCPCS 

code Long descriptor APC APC title New status indicator 

C1716 ..... Brachytherapy source, Gold 198, per source ............................ 1716 Brachytx source, Gold 198 ....................... K 

C1717 ..... Brachytherapy source, High Dose Rate Iridium 192, per 

source.

1717 Brachytx source, HDR Ir-192 ................... K 

C1718 ..... Brachytherapy source, Iodine 125, per source .......................... 1718 Brachytx source, Iodine 125 ..................... K 

C1719 ..... Brachytherapy source, Non-High Dose Rate Iridium 192, per 

source.

1719 Brachytx source, Non-HDR Ir-192 ............ K 

C1720 ..... Brachytherapy source, Palladium 103, per source .................... 1720 Brachytx source, Palladium 103 ............... K 

C2616 ..... Brachytherapy source, Yttrium-90, per source .......................... 2616 Brachytx source, Yttrium-90 ..................... K 

C2632 ..... Brachytherapy solution, Iodine125, per mCi .............................. 2632 Brachytx sol, I-125, per mCi ..................... K 

C2633 ..... Brachytherapy source, Cesium-131, per source ........................ 2633 Brachytx source, Cesium-131 .................. K 

C2634 ..... Brachytherapy source, High Activity, Iodine-125, greater than 

1.01 mCi (NIST), per source.

2634 Brachytx source, HA, I-125 ...................... K 

C2635 ..... Brachytherapy source, High Activity, Palladium-103, greater 

than 2.2 mCi (NIST), per source.

2635 Brachytx source, HA, P-103 ..................... K 

C2636 ..... Brachytherapy linear source, Palladium-103, per 1MM ............. 2636 Brachytx linear source, P-103 .................. K

C2637 ..... Brachytherapy source, Ytterbium-169, per source .................... 2637 Brachytx, Ytterbium-169 ........................... K 

There are a number of advantages to 

this proposed payment method. The 

OPPS is a prospective payment system 

under which payment rates are 

generally established based on median 

costs from historical hospital claims. 

Therefore, under this payment method, 

brachytherapy sources would be paid 

using the same basic median cost 

methodology as the overall OPPS. The 

payment of sources would thus be an 

integral part of the OPPS, rather than a 

separate cost-based payment 

methodology within the OPPS. In 

addition, consistent and predictable 

prospectively established payment rates 

under the OPPS for brachytherapy 

sources are appropriate because we do 

not believe that the hospital resource 

costs associated with specific 

brachytherapy sources should vary 


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greatly across hospitals or across 

clinical conditions under treatment, 

other than through differences in the 

numbers of sources utilized, which are 

already accounted for in our per source 

payment methodology. This prospective 

payment methodology would promote 

efficiency in the provision of sources, 

while continuing to provide payments 

that reflect the wide clinical variation in 

the use of brachytherapy sources related 

to many factors, including tumor type 

and stage, patient anatomy, and planned 

brachytherapy dose. In addition, under 

this method, we would continue to pay 

for brachytherapy sources separately 

using the same C-codes and descriptors 

that hospitals have reported for the last 

several years. 

We note that High Dose Rate (HDR) 

Iridium-192 (C1717) is a reusable 

source, across treatment sessions and 

across patients. It is unclear whether 

hospitals are reporting the number of 

units provided accurately. Thus, while 

we are currently proposing that HDR 

Iridium be paid separately on the basis 

of the median cost per source as we are 

proposing to pay for the other 

brachytherapy sources, we invite 

comments on alternatives to using this 

methodology for this source, such as on 

the basis of median costs per treatment 

day on hospital claims. 

During the March 1–2, 2006 APC 

Panel meeting, we discussed median 

cost data for brachytherapy sources 

developed from the partial CY 2005 

hospitals claims data available for 

analysis at the time of the meeting. 

While the APC Panel made no specific 

recommendations about a specific OPPS 

CY 2007 payment methodology for 

brachytherapy sources, the Panel 

reviewed the median costs for the 

sources of brachytherapy and generally 

commented that the median costs 

appeared reasonable for the commonly 

furnished brachytherapy sources. 

Because brachytherapy sources would 

no longer be paid on the basis of their 

charges reduced to costs, we are 

proposing to discontinue our use of 

payment status indicator ‘‘H’’ for APCs 

assigned to brachytherapy sources. We 

are proposing to use status indicator 

‘‘K’’ for all brachytherapy source APCs 

for CY 2007. We are also proposing for 

CY 2007 to change the definition of 

status indicator ‘‘K’’ to ensure that ‘‘K’’

appropriately describes brachytherapy 

source APCs. Payment status indicators 

are discussed in section XV.A. of this 

preamble. 

There is one source for which we 

have no claims data or payment 

information. We added Ytterbium-169 

(HCPCS code C2637) for payment 

effective October 1, 2005, because it met 

the requirements of section 1833(t)(2)(H) 

of the Act as a separate brachytherapy 

source. It is our understanding that this 

source, which is for use in high dose 

rate (HDR) brachytherapy, is not yet 

marketed by the manufacturer, although 

it has been approved by the Food and 

Drug Administration (FDA). Therefore, 

we have no claims data for this 

brachytherapy source in order to 

develop a prospective payment rate, as 

we do for the other brachytherapy 

sources for CY 2007. In addition, it is 

our understanding that no price for the 

product exists, as it has not yet been 

marketed. Thus, we also have no 

external information regarding the cost 

of this source to hospitals. We are 

weighing our payment options for CY 

2007 for brachytherapy sources for 

which we have no payment or claims 

information, such as the present case 

with Ytterbium-169. This includes 

considering our CY 2007 payment 

options for other new brachytherapy 

sources that come to our attention, 

which historically have been newly 

recognized under the OPPS on a 

quarterly basis. 

One option for CY 2007 would be to 

pay for the currently existing HCPCS 

code C2637 at charges converted to 

costs. However, this would be 

inconsistent with our proposed policy 

with regard to payment for 

brachytherapy sources under 

prospectively established payment rates. 

We paid for all brachytherapy sources 

based upon charges converted to costs 

for CYs 2004 through 2006 because the 

law required us to do so. However, that 

provision will expire for the CY 2007 

OPPS. In addition, this methodology 

would be inconsistent with the 

prospective payment methodologies we 

use to provide payments for other new 

items and services under the OPPS for 

which we do not yet have claims data. 

A second option would be to assign 

the code to its own APC or to a New 

Technology APC with a payment rate 

set at or near the lowest proposed 

payment rate for any source of 

brachytherapy paid on a per source 

basis (as opposed, for example, per 

mCi), for CY 2007. However, we have no 

claims data or other information 

regarding the cost of HCPCS code C2637 

to hospitals. This payment policy would 

resemble our policy regarding the APC 

assignment of not otherwise classified 

codes, which are assigned to the lowest 

level APC in their clinically compatible 

series. However, HCPCS code C2637 is 

a specifically defined brachytherapy 

source, and such a payment rate would 

not recognize the clinical distinctions 

among brachytherapy sources, including 

their differences in isotopes, activity 

levels, and clinical uses in low dose rate 

(LDR) versus HDR brachytherapy. The 

solid brachytherapy source with the 

lowest proposed median cost for CY 

2007 is HCPCS code C2634, for High 

Activity Iodine-125, with a median cost 

of $25.77 per source, which is 

implanted in LDR brachytherapy. 

A third option would be to assign 

HCPS code C2637 to its own APC or to 

a New Technology APC with a payment 

rate established at or near the proposed 

payment rate for HCPCS code C1717, 

which describes HDR Iridium-192. Like 

HCPCS code C2637, HCPCS code C1717 

is used for HDR brachytherapy, and 

HCPCS code C1717 is the most 

commonly used source for HDR 

brachytherapy under the OPPS. 

However, this approach would not take 

into consideration significant 

differences in the two sources, 

including their radioactive isotopes and 

energy levels. 

The fourth option would be to assign 

HCPCS code C2637 to its own APC or 

to a New Technology APC with a 

prospective payment rate based on 

external data provided to us regarding 

the expected cost of the source to 

hospitals. If we were provided reliable 

and relevant cost information for the 

source, we could establish its payment 

rate based on that information and our 

review of other pertinent 

considerations, as we do for new 

technology services under the OPPS. 

Under this option, in the absence of 

external cost information, we would not 

recognize HCPCS code C2637 under the 

OPPS for CY 2007 until we received 

such information and could establish a 

payment rate in a quarterly OPPS 

update. CMS provided the 

brachytherapy source Ytterbium-169 a 

HCPCS code in CY 2005 at the 

manufacturer’s request, based on the 

belief that the source would be 

marketed shortly. However, the product 

has not yet been marketed. Therefore, 

we currently have a recognized HCPCS 

code for an item that is not currently 

available to hospitals. We do not 

typically issue and maintain as payable 

a HCPCS code for an item that is not 

marketed. Under this option, if the 

source were marketed mid-quarter in CY 

2007 and cost information was provided 

to us, there would be no payment 

available for the source until the next 

OPPS quarterly update, which would 

establish the payment rate for HCPCS 

code C2637 and its effective date. 

After weighing the above options, we 

are proposing the second option 

discussed, that is, to assign C2637 to its 

own APC or a New Technology APC 

with a payment rate set at or near the 

lowest proposed payment rate for any 


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source of brachytherapy paid on a per 

source basis. This option resembles our 

policy regarding the APC assignment of 

not otherwise classified codes, in the 

absence of any data currently available. 

Once we have claims data, or obtain 

external data, we can consider 

movement to another APC, if warranted. 

However, as we indicate below, we are 

interested in the public’s comments on 

the four options we have presented. 

We are specifically inviting comments 

on how we should establish the CY 

2007 payment amount for Ytterbium169 (HCPCS code C2637), especially 

with consideration of the four options 

discussed above, and on how we should 

generally proceed on setting payment 

amounts for established or new 

brachytherapy sources eligible for 

separate payment under section 

1833(t)(2)(H) of the Act, for which we 

have no claims-based cost data in the 

future. Note that under option 4, for a 

future new source we would need cost 

information regarding the source in 

order to establish a code for which we 

could set an appropriate OPPS payment 

rate. We intend to avoid routinely 

establishing HCPCS codes for 

brachytherapy sources which hospitals 

could not be using, and, therefore, for 

which payments would not be 

necessary. 

As we have consistently done in the 

past, we are inviting the public to 

submit recommendations for new codes 

to describe new brachytherapy sources 

in a manner reflecting the number, 

isotope, and radioactive intensity of the 

sources. We are requesting that 

commenters provide a detailed rationale 

to support recommended new sources 

and send recommendations to us. We 

will continue our endeavor to add new 

brachytherapy source codes and 

descriptors to our systems for payment 

on a quarterly basis. Such 

recommendations should be directed to 

the Division of Outpatient Care, Mail 

Stop C4–05–17, Centers for Medicare & 

Medicaid Services, 7500 Security 

Boulevard, Baltimore, MD 21244. 

We have considered the definition of 

the term ‘‘brachytherapy source’’ in the 

context of current medical practice, and 

in light of the language in section 

1833(t)(2)(H) of the Act. We are 

proposing to define a device of 

brachytherapy eligible for separate 

payment under the OPPS as a ‘‘seed or 

seeds (or radioactive source)’’ as 

indicated in section 1833(t)(2)(H) of the 

Act, which refers to sources that are 

themselves radioactive, meaning that 

the sources contain a radioactive 

isotope. Therefore, for example, we do 

not consider specific devices that do not 

utilize radioactive isotopes to deliver 

radiation to be radioactive sources as 

envisioned by the statute. While the 

public may recommend any item that it 

wishes us to consider as a 

brachytherapy source, we remind the 

public of our interpretation of a device 

of brachytherapy eligible for separate 

payment under section 1833(t)(2)(H) of 

the Act. 

VIII. Proposed Changes to OPPS Drug 

Administration Coding and Payment 

for CY 2007 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Drug Administration’’ at 

the beginning of your comment.) 

A. Background 

From the start of the OPPS until the 

end of CY 2004, three HCPCS codes 

were used to bill drug administration 

services provided in the hospital 

outpatient department: 

• Q0081 (Infusion therapy, using 

other than chemotherapeutic drugs, per 

visit) 

• Q0083 (Chemotherapy 

administration by other than infusion 

technique only, per visit) 

• Q0084 (Chemotherapy 

administration by infusion technique 

only, per visit). 

A fourth OPPS drug administration 

HCPCS code, Q0085 (Administration of 

chemotherapy by both infusion and 

another route, per visit), was active from 

the beginning of the OPPS through the 

end of CY 2003. 

Each of these four HCPCS codes 

mapped to an APC (that is, Q0081 

mapped to APC 0120, Q0083 mapped to 

APC 0116, Q0084 mapped to APC 0117, 

and Q0085 mapped to APC 0118), and 

the APC payment rates for these codes 

were made on a per-visit basis. The pervisit payment included payment for all 

hospital resources (except separately 

payable drugs) associated with the drug 

administration procedures. For CY 

2004, we discontinued using HCPCS 

code Q0085 to identify drug 

administration services and moved to a 

combination of HCPCS codes Q0083 

and Q0084 that allowed more accurate 

calculations when determining OPPS 

payment rates. 

In CY 2005, in response to the 

recommendations made by commenters 

and the hospital industry, OPPS 

transitioned to the use of CPT codes for 

drug administration services. These CPT 

codes allowed for more specific 

reporting of services, especially 

regarding the number of hours for an 

infusion, and provided consistency in 

coding between Medicare and other 

payers. However, we did not have any 

data to revise the CY 2005 per-visit APC 

payment structure for infusion services. 

In order to collect data for future 

ratesetting purposes, we implemented 

claims processing logic that collapsed 

payments for drug administration 

services and paid a single APC amount 

for those services for each visit, unless 

a modifier was used to identify drug 

administration services provided in a 

separate encounter on the same day. 

Hospitals were instructed to bill all 

applicable CPT codes for drug 

administration services provided in a 

hospital outpatient department, without 

regard to whether or not the CPT code 

would receive a separate APC payment 

during OPPS claims processing. 

While hospitals were just adopting 

CPT codes for outpatient drug 

administration services in CY 2005, 

physicians paid under the Medicare 

Physician Fee Schedule were using 

HCPCS G-codes in CY 2005 to report 

office-based drug administration 

services. These G-codes were developed 

in anticipation of substantial revisions 

to the drug administration CPT codes by 

the CPT Editorial Panel that were 

expected for CY 2006. 

In CY 2006, as anticipated, the CPT 

Editorial Panel revised its coding 

structure for drug administration 

services, incorporating new concepts 

such as initial, sequential, and 

concurrent services into a structure that 

previously distinguished services based 

on type of administration 

(chemotherapy/nonchemotherapy), 

method of administration (injection/ 

infusion/push), and for infusion 

services, first hour and additional hours. 

For CY 2006, we proposed a crosswalk 

that mapped the expected CY 2006 CPT 

codes (represented by CY 2005 G-codes 

used in the physician office setting, the 

closest proxy at the time) to the APC 

payment structure implemented in CY 

2005. Our crosswalk was reviewed by 

the APC Panel at both the February and 

August 2005 meetings, and was 

included in the CY 2006 OPPS proposed 

rule. During the proposed rule comment 

period, we received a number of 

comments that prompted several 

revisions to our proposed crosswalk, 

including the development of complex 

claims processing logic to assign correct 

payment for certain drug administration 

services that would vary based on other 

drug administration services provided 

during the same patient visit. These 

revisions were a result of the growing 

understanding, facilitated by the 

preview of CPT drug administration 

coding guidelines developed by the CPT 

Editorial Panel, in the hospital 

community of the multiple implications 

associated with adopting the newly 


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introduced CPT concepts of initial, 

sequential, and concurrent services. 

Upon review of the completed 

revisions to our proposed CY 2006 

methodology, and following 

comprehensive assessment of all public 

comments, we implemented 20 of the 33 

CY 2006 drug administration CPT codes 

that did not reflect the concepts of 

initial, sequential, and concurrent 

services, and we created 6 new HCPCS 

C-codes that generally paralleled the CY 

2005 CPT codes for the same services. 

We chose not to implement the full set 

of CY 2006 CPT codes because of our 

concerns regarding the interface 

between the complex claims processing 

logic required for correct payments and 

hospitals’ challenges in correctly coding 

their claims to receive accurate 

payments for these services. In addition, 

numerous commenters indicated that 

implementing certain CPT codes in a 

fashion consistent with the code 

descriptors would present hospitals 

with difficult operational and 

administrative challenges because 

concepts integral to the codes were 

inconsistent with the clinical patterns of 

drug administration services provided 

in hospital outpatient departments. In 

addition to coding changes, CY 2006 

payment rates for drug administration 

services were updated based upon CY 

2004 claims, and we continued the 

claims processing logic that required 

hospitals providing drug administration 

services to report all applicable drug 

administration HCPCS codes, despite 

some codes being collapsed into one 

APC for payment purposes. 

B. Proposed CY 2007 Drug 

Administration Coding Changes 

For the CY 2007 OPPS, we are 

proposing to continue the CY 2006 

OPPS drug administration coding 

structure, which combines CPT codes 

with several C-codes. However, we 

welcome comments from hospitals 

regarding their experiences in 

implementing, for purposes of reporting 

to other payers, the CY 2006 CPT codes 

that incorporate the concepts of initial, 

sequential, and concurrent drug 

administration services. While we are 

not proposing to transition to the full set 

of CPT codes in CY 2007, we retain this 

as an option for the future. 

In addition, because of the 

discrepancies between APC payments 

(based on per-visit hospital claims data) 

and per-service CPT/HCPCS coding, we 

provided special instructions to 

hospitals in CY 2005 and CY 2006 

regarding modifier 59 in order to ensure 

proper OPPS payments, consistent with 

our claims processing logic. As we do 

not expect any changes to our coding 

structure for CY 2007 and because we 

have updated service-specific claims 

data from CY 2005, we no longer have 

the need for specific drug 

administration instructions regarding 

modifier 59. Instead, for CY 2007 we are 

proposing that hospitals apply modifier 

59 to drug administration services using 

the same correct coding principles that 

they generally use for other OPPS 

services. 

C. Proposed CY 2007 Drug 

Administration Payment Changes 

CY 2007 is the first year that we have 

more detailed claims data to inform our 

ratesetting process. Through CY 2006, 

payment for additional hours of drug 

infusion has always been packaged, 

although separate codes for reporting 

these hours have been used under the 

OPPS since CY 2005. Specifically, 

hospitals began reporting more precise 

CPT codes in CY 2005 that included 

separate coding for the first hour of 

infusion versus additional hours of 

infusion. In order to analyze these data, 

because we expected that additional 

hours of infusion codes would always 

be reported with codes for the first hour 

of infusion, thereby resulting in 

multiple bills for the additional hours of 

infusion CPT codes, we added the 

following three CY 2005 drug 

administration CPT codes to the bypass 

list utilized to create ‘‘pseudo’’ single 

claims: CPT codes 90781 (Intravenous 

infusion for therapy/diagnosis, 

administered by physician or under 

direct supervision of physician; each 

additional hour, up to eight (8) hours); 

96412 (Chemotherapy administration, 

intravenous; infusion technique, one to 

8 hours, each additional hour); and 

96423 (Chemotherapy administration, 

intra-arterial; infusion technique, one to 

8 hours, each additional hour). The 

standard OPPS methodology, as 

described in section II.A. of this 

proposed rule, was used to calculate 

HCPCS medians for these three drug 

administration codes. We then mapped 

all the data for the three additional 

hours of infusion CPT codes from the 

single and ‘‘pseudo’’ single claims to the 

APCs to which we are proposing to 

assign the CY 2005 claims data for these 

codes for purposes of calculating APC 

median costs. 

While bypassing these three CPT 

codes and developing additional ‘‘per 

unit’’ claims provide a methodology to 

calculate median costs for these 

previously packaged drug 

administration services and to attribute 

all of their cost data to their assigned 

APCs, we note that this methodology 

allocates all packaging on the claim 

related to drug administration to the 

associated first hour drug 

administration code. Because these 

additional hours of infusion codes are 

not reported alone in conjunction with 

other separately payable nondrug 

administration services, we would not 

expect that the packaging related to 

additional hours of infusion would be 

inappropriately assigned to nondrug 

administration services. While we 

realize that there are some packaged 

costs that truly are clinically related to 

the second and subsequent hours of 

infusion, especially for infusions of 

packaged drugs that span several hours, 

and would, therefore, be most 

appropriately allocated to the additional 

hours of infusion codes, we are not able 

at this time to accurately assign 

representative portions of packaging 

costs to multiple different services at 

this time due to the limitations of our 

claims data. We believe this proposed 

methodology takes into account all of 

the packaging on claims for drug 

administration services and provides a 

reasonable framework for developing 

median costs for drug administration 

services that are often provided in 

combination with one another. 

Upon review of the HCPCS median 

costs for all drug administration 

services, including injections and 

antigen therapy services, we created a 

comprehensive set of new APC 

groupings of CY 2005 HCPCS codes for 

drug administration services, with our 

assignments based both upon hospital 

resources utilized as reflected in HCPCS 

median costs and clinical coherence. 

The result of this analysis was the 

development of six proposed drug 

administration APC levels for the 

proposed CY 2007 payment rates, as 

shown in Table 30–1. 


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As shown above, the placement of 

HCPCS codes into the proposed six 

levels follows logical, clinically 

coherent principles and is consistent 

with both expected and observed 

differences in hospital resource costs, 


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both across levels and within each level. 

For example, the first hour of 

chemotherapy infusion is assigned to 

proposed Level VI, while additional 

hours of chemotherapy infusion are 

assigned to proposed Level III. This 

proposed structure is mirrored by the 

nonchemotherapy codes that show the 

first hour of nonchemotherapy infusion 

assigned to proposed Level V, while 

additional hours of nonchemotherapy 

infusion are assigned to proposed Level 

II. 

Using this structure as a base, the CY 

2006 OPPS drug administration codes 

were assigned to the proposed 6-level 

APC structure based on their clinical 

and expected hospital resource 

characteristics, as seen in Table 30–2. 

This proposed structure was 

presented to the APC Panel during the 

March 2006 meeting. The Panel 

recommended using the bypass 

methodology as described above for the 

three additional hours of infusion codes 

to develop their median costs and 

supported separate payment for each 

additional hour of infusion for CY 2007, 

as shown in Table 30–2. 


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We are accepting the APC Panel’s 

recommendation for CY 2007 to use the 

bypass and ‘‘per unit’’ methodology as 

described in proposing a drug 

administration payment structure that 

includes a methodology to pay for 


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infusion services by the hour. Therefore, 

we are proposing to assign HCPCS codes 

for CY 2007 to six new drug 

administration APCs, as listed in Table 

30–2, with payment rates based on 

median costs for the APCs from CY 2005 

claims data as assigned in Table 30–1. 

For CY 2007, the APC Panel also 

recommended that CMS reevaluate 

payment for IVIG administration, 

especially considering the resource 

intensity of IVIG infusions. We are 

accepting this APC Panel 

recommendation and believe that our 

proposed CY 2007 drug administration 

payment policy that would provide 

specific payment for each hour of 

infusion would provide more accurate 

and appropriate payment for lengthy 

infusions, including the administration 

of IVIG. IVIG administration in the 

outpatient hospital setting typically 

occurs over 3–6 hours, and under our 

proposal hospitals would receive 

separate payment for the first hour of 

infusion, along with payments for each 

of the additional 2–5 hours generally 

required for the IVIG infusion. 

Considerable hospital resources are 

used throughout the infusion period, 

including significant clinical staff time 

to monitor and adjust infusions based 

on patients’ evolving conditions, so we 

believe separate payment for each 

additional hour is appropriate. With 

respect to separate payment for IVIG 

preadministration-related services, the 

APC Panel recommended that CMS 

maintain separate payment as long as it 

remains appropriate. For CY 2006 only, 

we created the temporary G-code G0332 

(Preadministration-related services for 

intravenous infusion of 

immunoglobulin, per infusion 

encounter). We are accepting this APC 

Panel recommendation and have 

considered whether separate payment 

for IVIG preadministration-related 

services remains appropriate. Based 

upon our ongoing review of the IVIG 

marketplace and our CY 2007 proposed 

payment policies for items and services 

under the OPPS, we believe that 

separate payment for preadministrationrelated services specific to IVIG 

infusions would not be necessary in CY 

2007 to ensure Medicare beneficiary 

access to IVIG. 

Hospitals’ cooperation during CY 

2005 in reporting all drug 

administration services, whether or not 

separate payments were made for all 

such services, has allowed us to develop 

robust median costs for individual 

services so that we have sufficient 

information to propose this more 

specific APC payment structure for drug 

administration services for CY 2007. We 

believe that this proposed structure 

would make appropriate payments for 

the hospital resources required to 

provide drug administration services, as 

we have large numbers of claims for 

many specific drug administration 

services that reveal significant and 

differential costs. In particular, using 

this proposed APC structure should 

allow us to make more accurate 

payments to hospitals for complex and 

lengthy drug administration services 

furnished to Medicare beneficiaries for 

many medical conditions, while also 

providing accurate payments for 

individual services when they are 

provided alone. 

IX. Proposed Hospital Coding and 

Payments for Visits 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Visits’’ at the beginning of your 

comment.) 

A. Background 

Currently, CMS instructs hospitals to 

use the CY 2006 CPT codes used by 

physicians and listed in Table 31 to 

report clinic and emergency department 

visits and critical care services on 

claims paid under the OPPS. 

TABLE 31.—CY 2006 CPT CODES

USED TO REPORT CLINIC AND

EMERGENCY DEPARTMENT VISITS

AND CRITICAL CARE SERVICES

CPT code Descriptor 

CPT Evaluation and Management Codes 

99201 .......... Office or other outpatient visit 

for the evaluation and management of a new patient 

(Level 1). 

99202 .......... Office or other outpatient visit 

for the evaluation and management of a new patient 

(Level 2). 

99203 .......... Office or other outpatient visit 

for the evaluation and management of a new patient 

(Level 3). 

99204 .......... Office or other outpatient visit 

for the evaluation and management of a new patient 

(Level 4). 

99205 .......... Office or other outpatient visit 

for the evaluation and management of a new patient 

(Level 5). 

99211 .......... Office or other outpatient visit 

for the evaluation and management of an established 

patient (Level 1). 

99212 .......... Office or other outpatient visit 

for the evaluation and management of an established 

patient (Level 2). 

TABLE 31.—CY 2006 CPT CODES

USED TO REPORT CLINIC AND

EMERGENCY DEPARTMENT VISITS

AND CRITICAL CARE SERVICES—

Continued 

CPT code Descriptor 

99213 .......... Office or other outpatient visit 

for the evaluation and management of an established 

patient (Level 3). 

99214 .......... Office or other outpatient visit 

for the evaluation and management of an established 

patient (Level 4). 

99215 .......... Office or other outpatient visit 

for the evaluation and management of an established 

patient (Level 5). 

99241 .......... Office consultation for a new 

or established patient (Level 

1). 

99242 .......... Office consultation for a new 

or established patient (Level 

2). 

99243 .......... Office consultation for a new 

or established patient (Level 

3). 

99244 .......... Office consultation for a new 

or established patient (Level 

4). 

99245 .......... Office consultation for a new 

or established patient (Level 

5). 

Emergency Department Visit CPT Codes 

99281 .......... Emergency department visit 

for the evaluation and management of a patient (Level 

1). 

99282 .......... Emergency department visit 

for the evaluation and management of a patient (Level 

2). 

99283 .......... Emergency department visit 

for the evaluation and management of a patient (Level 

3). 

99284 .......... Emergency department visit 

for the evaluation and management of a patient (Level 

4). 

99285 .......... Emergency department visit 

for the evaluation and management of a patient (Level 

5). 

Critical Care Services CPT Codes 

99291 .......... Critical care, evaluation and 

management of the critically 

ill or critically injured patient; 

first 30–74 minutes. 

99292 .......... Each additional 30 minutes. 

The majority of CPT code descriptors 

are applicable to both physician and 

facility resources associated with 

specific services. However, we have 

acknowledged from the beginning of the 

OPPS that we believe that CPT 

Evaluation and Management (E/M) 


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codes were defined to reflect the 

activities of physicians and do not 

describe well the range and mix of 

services provided by hospitals during 

visits of clinic and emergency 

department patients and critical care 

encounters. Presently, CPT indicates 

that office or other outpatient visit codes 

are used to report E/M services provided 

in the physician’s office or in an 

outpatient or other ambulatory facility. 

For OPPS purposes, we refer to these as 

clinic visit codes. CPT also indicates 

that emergency department visit codes 

are used to report E/M services provided 

in the emergency department, defined 

as an ‘‘organized hospital-based facility 

for the provision of unscheduled 

episodic services to patients who 

present for immediate medical 

attention. The facility must be available 

24 hours a day.’’ For OPPS purposes, we 

refer to these as emergency visit codes. 

CPT defines critical care services as the 

‘‘direct delivery by a physician(s) of 

medical care for a critically ill or 

critically injured patient.’’ It also states 

that ‘‘critical care is usually, but not 

always, given in a critical care area, 

such as * * * the emergency care 

facility.’’

In the April 7, 2000 OPPS final rule 

(65 FR 18434), CMS instructed hospitals 

to report facility resources for clinic and 

emergency department visits using CPT 

E/M codes and to develop internal 

hospital guidelines to determine what 

level of visit to report for each patient. 

While awaiting the development of a 

national set of facility-specific codes 

and guidelines, we have advised that 

each hospital’s internal guidelines 

should follow the intent of the CPT code 

descriptors, in that the guidelines 

should be designed to reasonably relate 

the intensity of hospital resources to the 

different levels of effort represented by 

the codes. 

During the January 2002 APC Panel 

meeting, the APC Panel recommended 

that CMS adopt the American College of 

Emergency Physicians (ACEP) 

intervention-based guidelines for 

facility coding of emergency department 

visits and develop guidelines for clinic 

visits that are modeled on the ACEP 

guidelines. 

In the August 9, 2002 OPPS proposed 

rule, we proposed 10 new G-codes 

(Levels 1–5 Facility Emergency Services 

and Levels 1–5 Facility Clinic Services) 

for use in the OPPS to report hospital 

visits. We also asked for public 

comments regarding national guidelines 

for hospital coding of emergency and 

clinic visits. We discussed various types 

of models, reflecting on the advantages 

and disadvantages of each. We reviewed 

in detail the considerations around 

various discrete types of specific 

guidelines, including guidelines based 

on staff interventions, based upon staff 

time spent with the patient, based on 

resource intensity point scoring, and 

based on severity acuity point scoring 

related to patient complexity. We note 

below our analysis of the various 

models. 

1. Guidelines Based on the Number or 

Type of Staff Interventions 

Under this model, the level of service 

reported would be based on the number 

and/or type of interventions performed 

by nursing or ancillary staff. In the 

intervention model, baseline care 

(including registration, triage, initial 

nursing assessment, periodic vital signs 

as appropriate, simple discharge 

instructions, and exam room set up/ 

clean up) and possibly a single minor 

intervention (for example, suture 

removal, rapid strep test, or visual 

acuity) would be reported by the lowest 

level of service. Higher levels of service 

would be reported as the number and/ 

or complexity of staff interventions 

increased. 

The most commonly recommended 

intervention-based guidelines were the 

facility-coding guidelines developed by 

the ACEP. The ACEP model uses 

examples of interventions to illustrate 

appropriate coding. Coders extrapolate 

from these examples to determine the 

correct level of service to report. The 

ACEP model uses the types of 

interventions rather than the number of 

interventions to determine the 

appropriate level of service. This means 

that the single most complex 

intervention determines the level of 

service, whether it was the only service 

provided (in addition to baseline care), 

whether other similarly complex 

interventions were also provided, or 

whether other interventions of less 

complexity were also provided. The 

intervention model is based on 

emergency department/clinic resource 

use, is simple, reflects the care given to 

the patient, and does not require 

additional facility documentation. 

However, we expressed concern that the 

intervention model may provide an 

incentive to provide unnecessary 

services and that it is susceptible to 

upcoding. In addition, it is not 

particularly focused on measuring and 

appropriately reporting a code reflecting 

total hospital resources used in a visit. 

Furthermore, the ACEP model requires 

extrapolation from a set of examples 

that could make it prone to variability 

across hospitals. 

2. Guidelines Based on the Time Staff 

Spent With the Patient 

Under this model, the level of service 

would be determined based on the 

amount of time hospital staff spent with 

a patient. The underlying assumption is 

that staff time spent with the patient is 

an appropriate proxy for total hospital 

resource consumption. In this model, if 

only baseline care (as described above) 

were provided, a Level 1 service would 

be reported. Higher levels of service 

would be reported based on increments 

of staff time beyond baseline care. For 

example, Level 2 could be reported for 

11 to 20 minutes beyond baseline care, 

and Level 3 could be reported for 21 to 

30 minutes beyond baseline care. This 

model is simple, correlates with total 

hospital resource use, and provides an 

objective standard for all hospitals to 

follow. However, we observed that this 

model would require additional, 

potentially burdensome documentation 

of staff time, could provide an incentive 

to work slowly or use less efficient 

personnel, and has the potential for 

upcoding and gaming. 

3. Guidelines Based on a Point System 

Where a Certain Number of Points Are 

Assigned to Each Staff Intervention 

Based on the Time, Intensity, and Staff 

Type Required for the Intervention 

In this model, points or weights are 

assigned to each facility service and/or 

intervention provided to a patient in the 

clinic or emergency department. The 

level of service is determined by the 

sum of the points for all services/ 

interventions provided. Commenters to 

the August 9, 2002 proposed rule 

recommended various approaches to a 

point system, including point systems 

that assigned points based on the 

amount of staff time spent with the 

patient, the number of activities 

performed during the visit, and a 

combination of patient condition and 

activities performed. A point system 

would correlate with facility resource 

consumption and provide an objective 

standard. In addition, it is not as easily 

gamed because time-based interventions 

can be assigned a set number of points. 

However, we noted that a point system 

could present a significant burden for 

hospitals in terms of requiring 

additional, clinically unnecessary 

documentation. Point systems that are 

complex could require dedicated staff to 

monitor and maintain them. 

4. Guidelines Based on Patient 

Complexity 

Several variations were recommended 

in comments to the August 9, 2002 

proposed rule, including assignment of 


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levels of service based on ICD–9–CM 

(International Classification of Diseases, 

Ninth Edition, Clinical Modification) 

diagnosis codes, based on complexity of 

medical decision making, or based on 

presenting complaint or medical 

problem. The premise for these 

guideline systems is that many 

emergency departments follow 

established protocols based on patients’

presenting complaints and/or diagnoses. 

Therefore, assigning a level of service 

based on patient diagnosis should 

correlate with facility resource 

consumption. These systems may 

require the use of a coding ‘‘grid,’’

which lists more than 100 examples of 

patient conditions and diagnoses and 

assigns a level of service to each 

example. When the patient presents 

with a condition that does not appear on 

the grid, the coder must extrapolate 

from the grid to the individual patient. 

We expressed concern that these 

systems are extremely complex, demand 

significant interpretive work on the part 

of the coder (who may not have clinical 

experience), and are subject to 

variability across hospitals. While no 

clinically unnecessary documentation 

would be required because the system is 

based on diagnoses that are already 

reported on claims, there is a significant 

potential for upcoding and gaming. 

In the August 9, 2002 OPPS proposed 

rule, we also stated that we were 

concerned about counting separately 

paid services (for example, intravenous 

infusions, x-rays, electrocardiograms, 

and lab tests) as ‘‘interventions’’ or 

including their associated ‘‘staff time’’

in determining the level of service. We 

believed that the level of service should 

be determined by resource consumption 

that is not otherwise captured in 

payments for other separately payable 

services. We are now reconsidering this 

perspective and will discuss this further 

in section IX.D. of the preamble of this 

proposed rule. 

In the November 1, 2002 OPPS final 

rule, we specified that we would not 

create new codes to replace existing 

CPT E/M codes for reporting hospital 

visits until national guidelines have 

been developed, in response to 

commenters who were concerned about 

implementing code definitions without 

national guidelines. We noted that an 

independent panel of experts would be 

an appropriate forum to develop codes 

and guidelines that are simple to 

understand and implement, and that are 

compliant with the HIPAA 

requirements. We explained that 

organizations such as the American 

Hospital Associations (AHA) and the 

American Health Information 

Management Association (AHIMA) had 

such expertise and would be capable of 

creating hospital visit guidelines and 

providing ongoing education of 

providers. We also articulated a set of 

principles that any national guidelines 

for facility visit coding should satisfy, 

including that coding guidelines should 

be based on facility resources, should be 

clear to facilitate accurate payments and 

be usable for compliance purposes and 

audits, should meet the HIPAA 

requirements, should only require 

documentation that is clinically 

necessary for patient care, and should 

not facilitate upcoding or gaming. We 

stated that the distribution of codes 

should result in a normal curve. We 

concluded that we believed the most 

appropriate forum for development of 

code definitions and guidelines was an 

independent expert panel that would 

makes recommendations to CMS. 

The AHA and AHIMA originally 

supported the ACEP model for 

emergency visit coding, but we 

expressed concern that the ACEP 

guidelines allowed counting of 

separately payable services in 

determining a service level, which 

could result in the double counting of 

hospital resources in establishing visit 

payment rates and payment rates for 

those separately payable services. 

Subsequently, on their own initiative, 

the AHA and AHIMA formed an 

independent expert panel, the Hospital 

Evaluation and Management Coding 

Panel, comprised of members with 

coding, health information management, 

documentation, billing, nursing, 

finance, auditing, and medical 

experience. This panel included 

representatives from the AHA, AHIMA, 

ACEP, Emergency Nurses Association, 

and American Organization of Nurse 

Executives. CMS and AMA 

representatives observed the meetings. 

On June 24, 2003, the AHA and AHIMA 

submitted their recommended 

guidelines, hereafter referred to as the 

AHA/AHIMA guidelines, for reporting 

three levels of hospital clinic and 

emergency visits and a single level of 

critical care services to CMS, with the 

hope that CMS would publish the 

guidelines in the CY 2004 proposed 

rule. The AHA and AHIMA 

acknowledged that ‘‘continued 

refinement will be required as in all 

coding systems. The Panel * * * looks 

forward to working with CMS to 

incorporate any recommendations 

raised during the public comment 

period’’ (AHA/AHIMA guidelines 

report, page 9). The AHA and AHIMA 

indicated that the guidelines were fieldtested several times by panel members 

at different stages of their development. 

The guidelines are based on an 

intervention model, where the levels are 

determined by the numbers and types of 

interventions performed by nursing or 

ancillary hospital staff. Higher levels of 

services are reported as the number and/ 

or complexity of staff interventions 

increase. 

Although we did not publish the 

guidelines, the AHA and AHIMA 

released the guidelines through their 

Web sites. Consequently, we received 

numerous comments from providers 

and associations, some in favor and 

some opposed to the guidelines. We 

undertook a critical review of the 

recommendations from the AHA and 

AHIMA and made some modifications 

to the guidelines based on comments we 

received from outside hospitals and 

associations on the AHA/AHIMA 

guidelines, clinical review, and 

changing payment policies in the OPPS 

regarding some separately payable 

services. 

In an attempt to validate the modified 

AHA/AHIMA guidelines and examine 

the distribution of services that would 

result from their application to hospital 

clinic and emergency visits paid under 

the OPPS, we contracted a study that 

began in September 2004 and concluded 

in September 2005 to retrospectively 

code, under the modified AHA/AHIMA 

guidelines, hospital visits by reviewing 

hospital visit medical chart 

documentation gathered through the 

Comprehensive Error Rate Testing 

(CERT) work. While a review of 

documentation and assignment of visit 

levels based on the modified AHA/ 

AHIMA guidelines to 12,500 clinic and 

emergency visits was initially planned, 

the study was terminated after a pilot 

review of only 750 visits. The contractor 

identified a number of elements in the 

guidelines that were difficult for coders 

to interpret, poorly defined, nonspecific, 

or regularly unavailable in the medical 

records. The contractor’s coders were 

unable to determine any level for about 

25 percent of the clinic cases and about 

20 percent of the emergency cases 

reviewed. The only agreement observed 

between the levels reported on the 

claims and levels according to the 

modified AHA/AHIMA guidelines was 

the classification of Level 1 services, 

where the review supported the level on 

the claims 54–70 percent of the time. In 

addition, the vast majority of the clinic 

and emergency visits reviewed were 

assigned to Level 1 during the review. 

Based on these findings, we believed 

that it was not necessary to review 

additional records after the initial 

sample. The contractor advised that 

multiple terms in the guidelines 

required clearer definition and believed 


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that more examples would be helpful. 

Although we believe that all of the visit 

documentation for each case was 

available for the contractor’s review, we 

were unable to determine definitively 

that this was the case. Thus, there is 

some possibility that the contractor’s 

assignments would have differed if 

additional documentation from the 

medical records was available for the 

visits. In summary, while testing of the 

modified AHA/AHIMA guidelines was 

helpful in illuminating areas of the 

guidelines that would benefit from 

refinement, we were unable to draw 

conclusions about the relationship 

between the distribution of current 

hospital reporting of visits using CPT E/ 

M codes that are assigned according to 

each hospital’s internal guidelines and 

the distribution of coding under the 

AHA/AHIMA guidelines, nor were we 

able to demonstrate a normal 

distribution of visit levels under the 

modified AHA/AHIMA guidelines. 

B. CY 2007 Proposed Coding 

As discussed above, the majority of all 

CPT code descriptors are applicable to 

both physician and facility resources 

associated with specific services. 

However, we believe that CPT E/M 

codes were defined to reflect the 

activities of physicians and do not 

describe well the range and mix of 

services provided by hospitals during 

visits of clinic and emergency 

department patients and critical care 

encounters. While awaiting the 

development of a national set of facilityspecific codes and guidelines, we have 

advised that each hospital’s internal 

guidelines should follow the intent of 

the CPT code descriptors, in that the 

guidelines should be designed to 

reasonably relate the intensity of 

hospital resources to the different levels 

of effort represented by the codes. 

In the November 1, 2002 OPPS final 

rule, we specified that we would not 

create new codes to replace existing 

CPT E/M codes for reporting hospital 

visits until national guidelines have 

been developed, in response to 

commenters who were concerned about 

implementing code definitions without 

national guidelines. While we do not yet 

have a formal set of guidelines that we 

believe may be appropriately applied 

nationally to report different levels of 

hospital clinic and emergency 

department visit and to report critical 

care services, we have made significant 

progress in developing potential 

guidelines and, therefore, are proposing 

for CY 2007 the establishment of HCPCS 

codes to describe hospital clinic and 

emergency department visits and 

critical care services. Prior to our 

implementation of national guidelines 

for the new hospital visit HCPCS codes, 

we are proposing that hospitals may 

continue to use their existing internal 

guidelines to determine the visit levels 

to be reported with these codes. We 

anticipate that many providers would 

choose to use their existing guidelines 

for reporting visits with CPT codes. We 

do not expect a substantial workload for 

a provider that chooses to adjust its 

guidelines to reflect our proposed 

policies. 

We acknowledge that it can be 

burdensome for providers to bill Gcodes rather than CPT codes. In this 

case, because current CPT E/M codes do 

not describe hospital visit resources, we 

have no alternative other than to create 

new G-codes. CPT has not yet created 

clinic and emergency department visit 

and critical care services codes that 

describe hospital resource utilization. It 

is important to note that G-codes may be 

recognized by other payers. 

1. Clinic Visits 

For clinic visits, we are proposing five 

new codes, to replace hospitals’

reporting of the CPT clinic visit E/M 

codes for new and established patients 

and consultations listed in Table 31. 

Providers have been reporting five 

levels of CPT codes through CY 2006, 

and we believe that it should be fairly 

easy to crosswalk current internal 

hospital guidelines to these five 

proposed new codes. Commenters to 

prior rules have stated that the hospital 

resources used for new and established 

patients to provide a specific level of 

service are very similar, and that it is 

unnecessary and burdensome from a 

coding perspective to distinguish 

between the two types of visits. The 

new codes are proposed in Table 32 

below. 

TABLE 32.—PROPOSED CY 2007 HCPCS CODES TO BE USED TO REPORT CLINIC VISITS

HCPCS code Short descriptor Long descriptor 

Gxxx1 .......... Level 1 hosp clinic visit ............................................................... Level 1 hospital clinic visit. 

Gxxx2 .......... Level 2 hosp clinic visit ............................................................... Level 2 hospital clinic visit. 

Gxxx3 .......... Level 3 hosp clinic visit ............................................................... Level 3 hospital clinic visit. 

Gxxx4 .......... Level 4 hosp clinic visit ............................................................... Level 4 hospital clinic visit. 

Gxxx5 .......... Level 5 hosp clinic visit ............................................................... Level 5 hospital clinic visit. 

2. Emergency Department Visits 

As described above, CPT defines an 

emergency department as ‘‘an organized 

hospital-based facility for the provision 

of unscheduled episodic services to 

patients who present for immediate 

medical attention. The facility must be 

available 24 hours a day.’’ Under the 

OPPS, we have restricted the billing of 

emergency department CPT codes to 

services furnished at facilities that meet 

this CPT definition. Facilities open less 

than 24 hours a day should not use the 

emergency department codes. 

Sections 1866(a)(1)(I), 1866(a)(1)(N), 

and 1867 of the Act impose specific 

obligations on Medicare-participating 

hospitals and critical access hospitals 

that offer emergency services. These 

obligations concern individuals who 

come to a hospital’s dedicated 

emergency department (DED) and 

request examination or treatment for 

medical conditions, and apply to all of 

these individuals, regardless of whether 

or not they are beneficiaries of any 

program under the Act. Section 1867(h) 

of the Act specifically prohibits a delay 

in providing required screening or 

stabilization services in order to inquire 

about the individual’s payment method 

or insurance status. Section 1867(d) of 

the Act provides for the imposition of 

civil monetary penalties on hospitals 

and physicians responsible for failing to 

meet the provisions listed above. These 

provisions, taken together, are 

frequently referred to as the Emergency 

Medical Treatment and Labor Act 

(EMTALA). EMTALA was passed in 

1986 as part of the Consolidated 

Omnibus Budget Reconciliation Act of 

1985 Pub. L. 99–272 (COBRA). 

Section 489.24 of the EMTALA 

regulations defines ‘‘dedicated 

emergency department’’ as any 

department or facility of the hospital, 

regardless of whether it is located on or 

off the main hospital campus, that meets 

at least one of the following 

requirements: (1) It is licensed by the 

State in which it is located under 

applicable State law as an emergency 

room or emergency department; (2) It is 


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held out to the public (by name, posted 

signs, advertising, or other means) as a 

place that provides care for emergency 

medical conditions on an urgent basis 

without requiring a previously 

scheduled appointment; or (3) During 

the calendar year immediately 

preceding the calendar year in which a 

determination under this section is 

being made, based on a representative 

sample of patient visits that occurred 

during that calendar year, it provides at 

least one-third of all of its outpatient 

visits for the treatment of emergency 

medical conditions on an urgent basis 

without requiring a previously 

scheduled appointment. 

We believe that every emergency 

department that meets the CPT 

definition of emergency department also 

qualifies as a dedicated emergency 

department under EMTALA. However, 

we are aware that there are some 

departments or facilities of hospitals 

that meet the definition of a DED under 

the EMTALA regulations but that do not 

meet the more restrictive CPT definition 

of an emergency department. For 

example, a hospital department or 

facility that meets the definition of a 

DED may not be available 24 hours a 

day, 7 days a week. Nevertheless, 

hospitals with such departments or 

facilities incur EMTALA obligations 

with respect to an individual who 

presents to the department and requests, 

or has requested on his or her behalf, 

examination or treatment for an 

emergency medical condition. However, 

because they do not meet the CPT 

requirements for reporting emergency 

visit E/M codes, these facilities must bill 

clinic visit codes for the services they 

furnish. We have no way to distinguish 

in our hospital claims data the costs of 

visits provided in DEDs that do not meet 

the CPT definition of emergency 

department from the costs of clinic 

visits. 

Some hospitals have requested that 

they be permitted to bill emergency visit 

codes under the OPPS for services 

furnished in a facility that meets CPT’s 

definition for reporting emergency visit 

E/M codes, except that they are not 

available 24 hours a day. These 

hospitals believe that their resource 

costs are more similar to those of 

emergency departments that meet the 

CPT definition than they are to the 

resource costs of clinics. 

Representatives of such facilities have 

argued that emergency department visit 

payments are more appropriate, on the 

grounds that their facilities treat 

patients with emergency conditions 

whose costs exceed the resources 

reflected in the clinic visit APC 

payments, even though these emergency 

departments are not available 24 hours 

per day. In addition, these hospital 

representatives indicated that their 

facilities have EMTALA obligations and 

should, therefore, be able to receive 

emergency visit payments. While these 

emergency departments may provide a 

broader range and intensity of hospital 

services and require significant 

resources to assure their availability and 

capabilities in comparison with typical 

hospital outpatient clinics, the fact that 

they do not operate with all capabilities 

full-time suggests that hospital 

resources associated with visits to 

emergency departments or facilities 

available less than 24 hours a day may 

not be as great as the resources 

associated with emergency departments 

or facilities that are available 24 hours 

a day and that fully meet the CPT 

definition. 

To determine whether visits to 

emergency departments or facilities 

(referred to as Type B emergency 

departments) that incur EMTALA 

obligations but do not meet more 

prescriptive expectations that are 

consistent with the CPT definition of an 

emergency department (referred to as 

Type A emergency departments) have 

different resource costs than visits to 

either clinics or Type A emergency 

departments, for CY 2007 we are 

proposing a set of five G-codes for use 

by all entities that meet the definition of 

a DED under the EMTALA regulations 

in § 489.24 but that are not Type A 

emergency departments, as described in 

Table 33 below. These codes will be 

called ‘‘Type B emergency visit codes.’’

TABLE 33.—PROPOSED CY 2007 HCPCS CODES TO BE USED TO REPORT EMERGENCY VISITS PROVIDED IN TYPE B 

EMERGENCY DEPARTMENTS

HCPCS code Short descriptor Long descriptor 

Gzzz1 .......... Lev 1 hosp type B ED 

visit.

Level 1 hospital emergency department visit provided in a Type B emergency department. (The ED 

must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; (2) It is held 

out to the public (by name, posted signs, advertising, or other means) as a place that provides 

care for emergency medical conditions on an urgent basis without requiring a previously scheduled 

appointment; or (3) During the calendar year immediately preceding the calendar year in which a 

determination under this section is being made, based on a representative sample of patient visits 

that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for 

the treatment of emergency medical conditions on an urgent basis without requiring a previously 

scheduled appointment). 

Gzzz2 .......... Lev 2 hosp type B ED 

visit.

Level 2 hospital emergency department visit provided in a Type B emergency department. (The ED 

must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; (2) It is held 

out to the public (by name, posted signs, advertising, or other means) as a place that provides 

care for emergency medical conditions on an urgent basis without requiring a previously scheduled 

appointment; or (3) During the calendar year immediately preceding the calendar year in which a 

determination under this section is being made, based on a representative sample of patient visits 

that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for 

the treatment of emergency medical conditions on an urgent basis without requiring a previously 

scheduled appointment). 


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TABLE 33.—PROPOSED CY 2007 HCPCS CODES TO BE USED TO REPORT EMERGENCY VISITS PROVIDED IN TYPE B 

EMERGENCY DEPARTMENTS—Continued 

HCPCS code Short descriptor Long descriptor 

Gzzz3 .......... Lev 3 hosp type B ED 

visit.

Level 3 hospital emergency department visit provided in a Type B emergency department. (The ED 

must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; (2) It is held 

out to the public (by name, posted signs, advertising, or other means) as a place that provides 

care for emergency medical conditions on an urgent basis without requiring a previously scheduled 

appointment; or (3) During the calendar year immediately preceding the calendar year in which a 

determination under this section is being made, based on a representative sample of patient visits 

that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for 

the treatment of emergency medical conditions on an urgent basis without requiring a previously 

scheduled appointment). 

Gzzz4 .......... Lev 4 hosp type B ED 

visit.

Level 4 hospital emergency department visit provided in a Type B emergency department. (The ED 

must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; (2) It is held 

out to the public (by name, posted signs, advertising, or other means) as a place that provides 

care for emergency medical conditions on an urgent basis without requiring a previously scheduled 

appointment; or (3) During the calendar year immediately preceding the calendar year in which a 

determination under this section is being made, based on a representative sample of patient visits 

that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for 

the treatment of emergency medical conditions on an urgent basis without requiring a previously 

scheduled appointment). 

Gzzz5 .......... Lev 5 hosp type B ED 

visit.

Level 5 hospital emergency department visit provided in a Type B emergency department. (The ED 

must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; (2) It is held 

out to the public (by name, posted signs, advertising, or other means) as a place that provides 

care for emergency medical conditions on an urgent basis without requiring a previously scheduled 

appointment; or (3) During the calendar year immediately preceding the calendar year in which a 

determination under this section is being made, based on a representative sample of patient visits 

that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for 

the treatment of emergency medical conditions on an urgent basis without requiring a previously 

scheduled appointment). 

For CY 2007, we also are proposing to 

create five G-codes to be reported by the 

subset of provider-based emergency 

departments or facilities of the hospital, 

called Type A emergency departments, 

that are available to provide services 24 

hours a day, 7 days per week and meet 

one or both of the following 

requirements related to the EMTALA 

definition of DED, specifically: (1) It is 

licensed by the State in which it is 

located under the applicable State law 

as an emergency room or emergency 

department; or (2) It is held out to the 

public (by name, posted signs, 

advertising, or other means) as a place 

that provides care for emergency 

medical conditions on an urgent basis 

without requiring a previously 

scheduled appointment. These codes 

will be called ‘‘Type A emergency visit 

codes’’ and would replace hospitals’

current reporting of the CPT emergency 

department visit E/M codes listed in 

Table 33. Our intention is to allow 

hospital-based emergency departments 

or facilities that are currently 

appropriately reporting CPT emergency 

department visit E/M codes to bill these 

new Type A emergency visit codes. We 

believe that this proposed definition of 

Type A emergency departments will 

neither narrow nor broaden the group of 

emergency departments or facilities that 

may bill the Type A emergency visit 

codes in comparison with those that are 

currently correctly billing CPT 

emergency department visit E/M codes. 

Rather, we are refining and clarifying 

the definition for use in the hospital 

context. We believe that because the 

concepts employed in the definition of 

a DED for EMTALA purposes are 

already familiar to hospitals, it is 

appropriate to employ those concepts, 

rather than the concepts employed in 

the CPT definition of emergency 

department, for purposes of defining 

these new G-codes. As we have 

previously noted, the CPT codes were 

defined to reflect the activities of 

physicians and do not always describe 

well the range and mix of services 

provided by hospitals during visits of 

emergency department patients. We 

believe that these new codes that we are 

proposing for reporting emergency visits 

to Type A emergency departments are 

more specific to the hospital context. 

For example, one feature that 

distinguishes Type A hospital 

emergency departments from other 

departments of the hospital is that Type 

A emergency departments do not 

generally provide scheduled care, but 

rather regularly operate to provide 

immediately available unscheduled 

services. 

The new codes that we are proposing 

for CY 2007 are listed in Table 34 

below. 


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TABLE 34.—PROPOSED CY 2007 HCPCS CODES TO BE USED TO REPORT EMERGENCY VISITS PROVIDED IN TYPE A 

EMERGENCY DEPARTMENTS

HCPCS code Short descriptor Long descriptor 

Gyyy1 .......... Lev 1 hosp type A ED 

visit.

Level 1 hospital emergency visit provided in a Type A hospital-based facility or department. (The facility or department must be open 24 hours a day, 7 days a week and meets at least one of the 

following requirements: (1) It is licensed by the State in which it is located under applicable State 

law as an emergency room or emergency department; or (2) It is held out to the public (by name, 

posted signs, advertising, or other means) as a place that provides care for emergency medical 

conditions on an urgent basis without requiring a previously scheduled appointment). 

Gyyy2 .......... Lev 2 hosp type A ED 

visit.

Level 2 hospital emergency visit provided in a Type A hospital-based facility or department. (The facility or department must be open 24 hours a day, 7 days a week and meets at least one of the 

following requirements: (1) It is licensed by the State in which it is located under applicable State 

law as an emergency room or emergency department; or (2) It is held out to the public (by name, 

posted signs, advertising, or other means) as a place that provides care for emergency medical 

conditions on an urgent basis without requiring a previously scheduled appointment). 

Gyyy3 .......... Lev 3 hosp type A ED 

visit.

Level 3 hospital emergency visit provided in a Type A hospital-based facility or department. (The facility or department must be open 24 hours a day, 7 days a week and meets at least one of the 

following requirements: (1) It is licensed by the State in which it is located under applicable State 

law as an emergency room or emergency department; or (2) It is held out to the public (by name, 

posted signs, advertising, or other means) as a place that provides care for emergency medical 

conditions on an urgent basis without requiring a previously scheduled appointment). 

Gyyy4 .......... Lev 4 hosp type A ED 

visit.

Level 4 hospital emergency visit provided in a Type A hospital-based facility or department. (The facility or department must be open 24 hours a day, 7 days a week and meets at least one of the 

following requirements: (1) It is licensed by the State in which it is located under applicable State 

law as an emergency room or emergency department; or (2) It is held out to the public (by name, 

posted signs, advertising, or other means) as a place that provides care for emergency medical 

conditions on an urgent basis without requiring a previously scheduled appointment). 

Gyyy5 .......... Lev 5 hosp type A ED 

visit.

Level 5 hospital emergency visit provided in a Type A hospital-based facility or department. (The facility or department must be open 24 hours a day, 7 days a week and meets at least one of the 

following requirements: (1) It is licensed by the State in which it is located under applicable State 

law as an emergency room or emergency department; or (2) It is held out to the public (by name, 

posted signs, advertising, or other means) as a place that provides care for emergency medical 

conditions on an urgent basis without requiring a previously scheduled appointment). 

3. Critical Care Services 

For critical care services, we are 

proposing two new codes, to replace 

hospitals’ reporting of the CPT E/M 

critical care codes listed in Table 31. 

Providers have been reporting two CPT 

codes through CY 2006, and we believe 

that it should be fairly easy to crosswalk 

current internal hospital guidelines to 

these two new proposed codes. The 

proposed new codes are listed in Table 

35 below. 

TABLE 35.—PROPOSED CY 2007 HCPCS CODES TO BE USED TO REPORT CRITICAL CARE SERVICES

HCPCS code Short descriptor Long descriptor 

Gccc1 ........... Hosp critical care, 30–74 min ................... Hospital critical care services, first 30–74 minutes. 

Gccc2 ........... Hosp critical care, add 30 min .................. Hospital critical care services, each additional 30 minutes. 

C. CY 2007 Proposed Payment Policy 

Since the implementation of the 

OPPS, outpatient visits provided by 

hospitals have been paid at three 

payment levels for both clinic and 

emergency department visits, even 

though hospitals have been reporting 

five resource-based coding levels of 

clinic and emergency department visits 

using CPT E/M codes. Critical care 

services have been paid at one level, 

with separate payment for the first 30 to 

74 minutes of care and bundling of 

payment for all additional 30 minute 

increments of critical care services into 

payment for the first 30–74 minutes. If 

the critical care service is less than 30 

minutes in duration, then it is to be 

billed as either a clinic visit or an 

emergency visit CPT code. Because the 

three payment rates for clinic and 

emergency department visits are based 

on five levels of CPT codes as listed in 

Table 31, in general the two lowest 

levels of CPT codes (1 and 2) are 

assigned to the low-level visit APCs and 

the two highest levels of CPT codes (4 

and 5) are assigned to the high-level 

visit APCs, with the single middle CPT 

level CPT code (3) assigned to the midlevel visit APCs. Hospital claims data 

indicate that the cost of providing a visit 

of the same level is generally 

significantly higher for emergency visits 

in comparison with clinic visits, with 

the differential increasing at higher 

levels of services. 

Based upon CY 2005 claims data 

processed through December 31, 2005, 

the median costs of clinic visit, 

emergency visit, and critical care APCs 

as configured for CY 2006 are listed 

below. 


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TABLE 36.—MEDIAN COSTS OF CLINIC AND EMERGENCY VISIT AND CRITICAL CARE APCS AS CONFIGURED FOR CY 2006 

APC title APC 

median Levels of CPT codes assigned to APC 

Clinic Visits 

Low Level Clinic Visits ............................... $53.94 Level 1 Clinic Visit, Level 2 Clinic Visit. 

Mid Level Clinic Visits ................................ 63.73 Level 3 Clinic Visit. 

High Level Clinic Visits .............................. 91.27 Level 4 Clinic Visit, Level 5 Clinic Visit. 

Emergency Department Visits 

Low Level Emergency Visits ...................... 76.43 Level 1 ED Visit, Level 2 ED Visit. 

Mid Level Emergency Visits ....................... 133.98 Level 3 ED Visit. 

High Level Emergency Visits ..................... 237.17 Level 4 ED Visit, Level 5 ED Visit. 

Critical Care Services 

Critical Care ............................................... 495.16 Critical care, first hour. 

Historical hospitals claims data, 

however, have generally reflected 

significantly different median costs for 

the two levels of services assigned to the 

low and high level visit APCs. While the 

median costs of these services do not 

violate the 2 times rule within their 

assigned APCs, this may not be the most 

accurate method of payment for these 

very common hospital levels of visits 

which clearly demonstrate differential 

hospital resources. In particular, 

because of the relatively low volume of 

the highest levels of services in the 

clinic and emergency department, our 

payment rates may be especially low. 

Therefore, we are proposing five 

payment levels for clinic and emergency 

visits and one payment level for critical 

care services. 

As discussed in the previous section, 

we are proposing to create 17 new Gcodes to replace the CPT E/M codes that 

hospitals are currently billing to report 

visits and critical care services. To 

determine appropriate payment rates for 

the new G-codes, we are proposing to 

map the data from the CY 2005 CPT E/ 

M codes and other HCPCS codes 

currently assigned to the clinic visit 

APCs to 11 new APCs, 5 for clinic visits, 

5 for emergency visits, and 1 for critical 

care services as shown in Table 37 to 

develop median costs for these APCs. 

We mapped the CPT E/M codes and 

other HCPCS codes to the new APCs 

based on median costs and clinical 

considerations. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

In the case of the CPT E/M codes for 

emergency visits, the assignment of data 

from a single visit code to the new Type 

A Emergency Visit APC of the same 

level was straightforward. Similarly, the 

assignment of data from the only 

separately payable critical care CPT 

code to the new APC for critical care 

services was clear-cut. However, in 

some cases of the data for CPT clinic 

visit E/M codes, we assigned a code to 


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an appropriate clinic visit APC level 

based upon resource and clinical 

homogeneity considerations, and that 

APC assignment did not correspond to 

the visit level described by the code. For 

example, CPT 99213 is a level 3 clinic 

visit code for an established patient, 

which would seem to logically map to 

the Level 3 Clinic Visit APC. However, 

because CPT 99213 has a median cost of 

$63.04, it maps more appropriately to 

the Level 2 Clinic Visit APC, which has 

an overall median cost of $62.12. In 

general, CPT codes for established 

patient visits had lower median costs 

than new patient visit or consultation 

codes of the same E/M level, and that 

variability is reflected in their respective 

proposed APC data assignments for CY 

2007. We believe that in CY 2007, when 

hospitals utilize their own internal 

guidelines to report clinic visits, 

without codes that differentiate among 

new, established, or consultation visits, 

they will report G-code levels that 

reflect their resources used. We expect 

that payments provided for G-codes of 

each level, based upon the CY 2005 

claims data assignments as listed in 

Table 38, would provide appropriate 

resource-based payments for visits 

reported at each level. 

After the CY 2005 CPT E/M codes and 

other HCPCS codes were mapped to an 

appropriate new APC as shown in Table 

38, the next step required was to assign 

an APC to each new G-code for which 

no data were available. We assigned 

these 16 new separately payable Gcodes to an appropriate APC level based 

on the code level alone as shown in 

Table 38. For example, both the Level 1 

Hospital Clinic Visit and Level 1 

Hospital Type B ED visit codes are 

mapped to the Level 1 Hospital Clinic 

Visit APC, 0604. Similarly, the Level 1 

Hospital Type A ED visit code is 

mapped to the Level 1 Type A 

Emergency Visit APC, 0609. We expect 

that this configuration would provide 

appropriate resource-based payments 

for visits reported at each level. We are 

proposing to assign status indicator ‘‘B’’

to the CPT E/M codes for CY 2007, with 

no APC assignment, because we are 

proposing new G-codes for the OPPS for 

CY 2007, as delineated in Table 38. 

Table 38 also removes codes that were 

deleted by CPT for CY 2007, and only 

includes codes that would be effective 

under the OPPS for CY 2007. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

We are proposing to map the five new 

clinic visit G-codes to the five new 

Clinic Visit APCs, 0604, 0605, 0606, 

0607, and 0608. We are proposing to 

assign the five new Type A emergency 

visit codes for services provided in a 

Type A emergency department to the 

five new Type A Emergency Visit APCs, 

0609, 0613, 0614, 0615, and 0616. For 

CY 2007, we are proposing to assign the 

five new Type B emergency visit codes 

for services provided in a Type B 

emergency department to the five new 

Clinic Visit APCs, 0604, 0605, 0606, 

0607, and 0608. 

This payment policy for Type B 

emergency visits is similar to our 

current policy which requires services 

furnished in emergency departments 

that have an EMTALA obligation but do 

not meet the CPT definition of 

emergency department to be reported 

using CPT clinic visit E/M codes, 

resulting in payments based upon clinic 

visit APCs. As mentioned above, CPT 

requires an emergency department to be 

open 24 hours per day in order for it to 

be eligible to bill emergency department 

E/M codes. While maintaining the same 

payment policy for Type B emergency 

department visits in CY 2007, the 

reporting of specific G-codes for 

emergency visits provided in Type B 

emergency departments will permit us 

to specifically collect and analyze the 

hospital resource costs of visits to these 

facilities in order to determine in the 

future whether a proposal of an 

alternative payment policy may be 

warranted. This approach to more 

refined data collection is similar to our 

approach to drug administration 

services under the OPPS over the past 

several years. We collected hospital 

claims data for specific detailed services 

using CPT and HCPCS codes for CYs 

2005 and 2006, while making payments 

based on claims data available to us for 

the less specific HCPCS codes billed by 

hospitals prior to CY 2005. We 

recognize that reporting specific drug 

administration services for which 

hospitals received no separate or 


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additional payments created some 

additional administrative burden on 

hospitals for a period of time, but the 

resource information collected through 

the claims submissions has been critical 

to the development of our proposal of 

more refined drug administration 

payment policies. The hospital claims 

data based upon the CY 2005 drug 

administration coding structure now 

form the foundation of our CY 2007 

proposal for drug administration 

services as described in section VIII.C. 

of the preamble to this proposed rule. 

Although we believe that our 

proposed payment policy for CY 2007 

for Type B emergency department visits 

is consistent with our past policy 

regarding visits to emergency 

departments that do not meet the CPT 

definition of an emergency department, 

we are interested in public comments 

regarding this policy. The OPPS 

rulemaking cycle for CY 2009 will be 

the first year that we will have cost data 

for these new Type B emergency 

department HCPCS codes available for 

analysis. In the interim, we are 

particularly concerned with ensuring 

that necessary emergency department 

services are available to rural Medicare 

beneficiaries. We recognize that rural 

emergency departments may be 

disproportionately likely to offer 

essential emergency department 

services less than 24 hours per day, 7 

days a week because of the limited 

demand for those services and the high 

costs and inefficiencies associated with 

providing full emergency department 

availability during times when few 

patients are present for emergency care. 

We believe that our OPPS payment 

policies for Type A and Type B 

emergency visits should support the 

ability of hospitals to provide their 

communities with essential and 

appropriate emergency department 

services efficiently and effectively. We 

also believe that the payment policies 

should present no payment incentive for 

hospitals to provide necessary 

emergency services less than 24 hours 

per day, 7 days per week, which could 

result in limited access to emergency 

services for Medicare beneficiaries, 

thereby leading to adverse effects on 

their health. 

We are proposing to map code Gccc1, 

the new proposed hospital critical care 

services code for the first 30–74 minutes 

of care, to the proposed new Critical 

Care APC 0617. We are proposing to 

assign status indicator ‘‘N’’ to proposed 

HCPCS code Gccc2, to indicate that the 

code is packaged, as the predecessor 

code to Gccc2 was also packaged. 

D. CY 2007 Proposed Treatment of 

Guidelines 

1. Background 

As described in section IX.A. of the 

preamble of this proposed rule, since 

April 7, 2000 we have instructed 

hospitals to report facility resources for 

clinic and emergency department 

outpatient hospital visits using the CPT 

E/M codes and to develop internal 

hospital guidelines for reporting the 

appropriate visit level. In the CY 2003 

OPPS final rule with comment period, 

we noted that an independent panel of 

experts would be an appropriate forum 

to develop codes and guidelines. In that 

final rule with comment period, we also 

articulated a set of principles that any 

national guidelines for facility visit 

coding should satisfy, including that 

coding guidelines should be based on 

facility resources, should be clear to 

facilitate accurate payments and be 

usable for compliance purposes and 

audits, should meet the HIPAA 

requirements, should only require 

documentation that is clinically 

necessary for patient care, and should 

not facilitate upcoding or gaming. We 

stated that the distribution of codes 

should result in a normal curve. 

Subsequently, as described above, the 

AHA and AHIMA formed an 

independent expert panel, the Hospital 

Evaluation and Management Coding 

Panel, and submitted the AHA/AHIMA 

guidelines for reporting three levels of 

hospital clinic and emergency visits and 

a single level of critical care services to 

CMS. The guidelines are based on an 

intervention model, where the levels are 

determined by the numbers and types of 

interventions performed by nursing or 

ancillary hospital staff. We undertook a 

critical review of the recommendations 

and made some modifications to the 

guidelines based on comments we 

received from outside hospitals and 

associations, clinical review, and 

changing payment policies in the OPPS 

regarding some separately payable 

services. In addition, as previously 

stated, we contracted a study to 

retrospectively code, under the 

modified AHA/AHIMA guidelines, 

hospital visits by reviewing hospital 

visit medical chart documentation 

gathered through CERT work. In 

summary, while the testing of the 

modified AHA/AHIMA guidelines was 

helpful in illuminating areas of the 

guidelines that would benefit from 

refinement, we were unable to draw 

conclusions about the relationship 

between the distribution of current 

hospital reporting of visits using CPT E/ 

M codes that are assigned according to 

each hospital’s internal guidelines and 

the distribution of code levels under the 

AHA/AHIMA guidelines, nor were we 

able to demonstrate a normal 

distribution of visit levels under the 

modified AHA/AHIMA guidelines. 

Despite the inconclusive findings 

from the validation study, after 

reviewing the AHA/AHIMA guidelines, 

as well as approximately a dozen other 

guidelines for outpatient visits 

submitted by various hospitals and 

hospital associations, we believe that 

the AHA/AHIMA guidelines are the 

most appropriate and well-developed 

guidelines for use in the OPPS of which 

we are aware. Our particular interest in 

these guidelines is based upon the 

broad-based input into their 

development, the need for CMS to move 

definitively to promulgate national 

outpatient hospital visit coding 

guidelines in the near future, and full 

consideration of the characteristics of 

alternative types of guidelines. We also 

think that hospitals will react favorably 

to guidelines developed and supported 

by the AHA and AHIMA, national 

organizations that have great interest in 

hospital coding and payment issues and 

possess significant medical, technical 

and practical expertise due to their 

broad membership, which includes 

hospitals and health information 

management professionals. Anecdotally, 

we have been told that a number of 

hospitals are successfully utilizing the 

AHA/AHIMA guidelines to report levels 

of hospital visits. However, other 

organizations have expressed concern 

that the AHA/AHIMA guidelines may 

result in a significant redistribution of 

hospital visits to higher levels, reducing 

the ability of the OPPS to discriminate 

among the hospital resources required 

for various different levels of visits. We, 

too, remain concerned about the 

potential redistributive effect on OPPS 

payments for other services or among 

levels of hospital visits when national 

guidelines for outpatient visit coding are 

adopted. We recognize that there may be 

difficulty crosswalking historical 

hospital claims data from current CPT 

E/M codes reported based on individual 

internal hospital guidelines to payments 

for any new coding system developed, 

in order to provide appropriate payment 

levels for hospital visits reported based 

on national guidelines in the future. 

There are several types of problems 

with the AHA/AHIMA guidelines that 

have been identified based upon 

extensive staff review and contractor 

use of the guidelines during the 

validation study. We believe the AHA/ 

AHIMA guidelines require short-term 

refinement prior to their full adoption 

by the OPPS, as well as continued 

refinement over time after their 


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implementation. Our modified version 

of the AHA/AHIMA guidelines provides 

some possibilities for addressing certain 

issues. Our eight general areas of 

concern regarding the AHA/AHIMA 

model are listed below. In addition, we 

have posted to the CMS Web site both 

the original AHA/AHIMA guidelines 

and our modified draft version, and we 

are seeking public input before we 

adopt national guidelines. We continue 

to commit that we will provide a 

minimum of 6–12 months notice to 

hospitals prior to implementation of 

national guidelines to provide sufficient 

time for providers to make the necessary 

systems changes and educate their staff. 

2. Outstanding Concerns With the AHA/ 

AHIMA Guidelines 

a. Three Versus Five Levels of Codes 

The AHA/AHIMA guidelines describe 

three levels of codes for clinic and 

emergency visits, rather than the five 

levels of codes that we are proposing for 

clinic and Type A and Type B 

emergency visits. It would be 

impossible to pay at five levels using 

these guidelines, unless the guidelines 

were revised. As discussed above, our 

claims data indicate that five payment 

levels are justified for both clinic and 

Type A emergency visits, and, therefore, 

we are proposing five levels of G-codes 

so that providers may code at five visit 

levels and receive payments at five 

levels as well. In fact, the materials 

explaining the AHA/AHIMA guidelines 

state that one of the reasons that the 

model includes only three coding levels 

is because CMS only paid at three 

payment levels. We are now proposing 

to pay at five payment levels, and if our 

proposed CY 2007 payment policy is 

finalized, the AHA/AHIMA guidelines 

may need to be revised to reflect five 

visit levels. 

b. Lack of Clarity for Some Interventions 

Some interventions are vague, 

unclear, or nonspecific, without 

sufficient examples of documentation in 

the medical record that may support 

those interventions. For instance, it is 

unclear what documentation for the 

intervention stated as ‘‘Patient 

registration, room set up, patient use of 

room, room cleaning’’ and assigned in 

the AHA/AHIMA guidelines to a lowlevel clinic visit would be necessary to 

support all aspects of that intervention. 

In another case, the intervention 

‘‘Frequent monitoring/assessment as 

evidenced by two sets of vital sign 

measurements or assessments’’ that is 

attributable to a mid-level emergency 

visit in the guidelines explains that this 

may include assessment of 

cardiovascular, pulmonary, or 

neurological status. However, it is 

unclear exactly what coders should look 

for in the medical record to support this 

intervention and whether narrative 

hospital staff descriptions of patient 

status would be considered to be 

assessments. These examples, and 

others, were identified by the contractor 

engaged in medical chart reviews as part 

of the guidelines validation study. The 

AHA/AHIMA guidelines may benefit 

from revisions to clarify some 

interventions and/or provide additional 

examples based upon questions that 

arose during field testing of the 

guidelines or that are raised by hospitals 

reviewing the AHA/AHIMA guidelines 

and the modified version posted on our 

Web site. 

c. Treatment of Separately Payable 

Services 

CMS and the APC Panel stated that 

separately payable services should be 

excluded from the guidelines because of 

their concern over the potential for 

double payment for hospital resources 

attributed to visit services when those 

resources were actually used to provide 

the separately payable services. 

Consistent with this policy, at the time 

of their development the AHA/AHIMA 

guidelines excluded all services 

separately payable under the OPPS from 

the list of interventions. For policy 

consistency, in our modified draft 

version of the guidelines, we removed 

interventions that have now become 

separately payable under the OPPS 

through CY 2006, such as bladder 

catheterizations and some wound care 

services. However, upon further 

reflection as we move forward to 

implement national guidelines, we are 

open to reconsidering whether the 

inclusion of some separately payable 

services in guidelines to determine visit 

levels could serve as a proxy for the 

resources that the patient will consume 

and that should be attributable to the 

hospital visit, not the separately payable 

services. In such cases, consideration of 

separately payable services in reporting 

visit levels may not result in double 

payment for components of those 

separately payable services. There may 

be hospital resources used in visits that 

are not captured in the AHA/AHIMA 

guidelines’ limited number of 

interventions that are not separately 

payable. We believe that, in general, a 

patient with high medical acuity will 

consume more hospital resources in the 

visit than a patient with moderate 

acuity. However, when separately 

payable interventions are removed from 

the model, it may be difficult for the 

limited interventions remaining in the 

guidelines for each visit level to capture 

the acuity level of the patient. In 

addition, the list of HCPCS codes that 

are packaged can change annually. For 

example, in the CY 2006 OPPS, bladder 

catheterization services, which had been 

packaged in prior years, were first made 

separately payable. If the guidelines 

strictly excluded all separately payable 

services, then the guidelines could also 

change from year to year, possibly 

requiring additional education of 

hospital staff on an annual basis. An 

extremely ill emergency department 

patient who may need a significant 

number of separately payable 

procedures, but only one or two minor 

interventions that are not separately 

payable, may require significant time 

and attention from hospital staff that is 

unrelated to the hospital resources 

generally required for the separately 

payable procedures. The guidelines may 

indicate that a low level emergency 

department visit code should be billed, 

while in fact the patient may require 

significantly more hospital resources 

than a mildly ill patient who received 

the same two minor interventions. We 

are open to further discussion and 

welcome public comments on the 

exclusion of separately payable services 

from the national visit guidelines and 

whether their inclusion could pose a 

risk of attributing the same hospital 

resources to both visits and separately 

payable services, potentially resulting in 

duplicate payments for those resources. 

d. Some Interventions Appear 

Overvalued 

Several interventions that we believe 

may be minor are valued at a high level 

in the guidelines. This could result in 

visits with relatively less resource 

intensive interventions being coded as 

high level visits, leading to an overall 

visit distribution that was skewed 

toward the high end. Claims data then 

would fail to reflect the differential 

hospital resources associated with 

hospital visits of five levels. For 

example, the AHA/AHIMA guidelines 

consider oxygen administration, 

described as initiation and/or 

adjustment from a baseline oxygen 

regimen, to be a mid level emergency 

department intervention, while we 

believe that the associated hospital 

resources could be more consistent with 

its characterization as a low level 

emergency department intervention. In 

another example, the AHA/AHIMA 

guidelines consider specimen 

collection(s), other than venipuncture 

and other separately payable services, to 

be a mid level clinic intervention, while 

we believe this may be more consistent 

with other low level clinic 


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interventions, depending upon the 

numbers and types of different 

specimens collected. We encourage 

specific comments on the levels 

assigned to various interventions in the 

guidelines, with the goal of 

differentiating five levels of services in 

a normal distribution, based on their 

respective hospital resources. 

e. Concerns of Specialty Clinics 

The AHA/AHIMA guidelines are 

unlikely to sufficiently address the 

concerns of various specialty clinics (for 

example, pain management clinics, 

oncology clinics, and wound care 

centers). Anecdotally, we have heard 

that the interventions listed in the AHA/ 

AHIMA guidelines do not include many 

of the interventions commonly 

performed in specialty clinics and that 

some of the interventions in the 

guidelines would never be performed in 

certain types of clinics. Currently, each 

provider has its own set of guidelines, 

and we believe that some specialty 

clinics have customized guidelines to 

facilitate coding their visits at different 

levels based upon the specific hospital 

resources commonly used in visits to 

their clinics. While we prefer to have 

one model that can be applied 

nationally to each level of clinic visit 

code for which we make a specific 

OPPS payment, we are unsure as to 

whether one model can adequately 

characterize visit levels for all types of 

clinics. For example, we have been told 

that the most appropriate proxy for 

facility resource consumption in cancer 

care is staff time due to the intensive 

staff interactions required to care for 

patients with cancer, regardless of the 

reasons for their clinic visits. We are 

interested in comments regarding the 

feasibility of applying national 

guidelines to specialty clinic visits 

while ensuring appropriate OPPS 

payments for those services and 

suggestions for revisions to the 

guideline models posted that could 

improve their utility in reporting such 

visits. 

f. Americans With Disabilities Act 

We are concerned that the AHA/ 

AHIMA guidelines’ intervention related 

to the special needs of certain patients 

may be in violation of the Americans 

with Disabilities Act, as it may increase 

the visit level reported, thereby 

increasing a patient’s copayment. Even 

if additional hospital resources are 

required to treat patients with 

disabilities, patients must not have 

additional financial liability for those 

services based on their disabilities. 

g. Differentiation Between New and 

Established Patients, and Between 

Standard Visits and Consultations 

The AHA/AHIMA guidelines do not 

differentiate between new versus 

established patients or consultations 

versus standard visits for clinic visits. 

During the summer 2002 APC Panel 

meeting, the APC Panel recommended 

that CMS not differentiate among visit 

types, specifically new, established, and 

consultation visits, for the purposes of 

clinic visit facility coding. Therefore, in 

the August 9, 2002 OPPS proposed rule, 

we proposed to accept the APC Panel’s 

recommendation to create five new Gcodes to replace the CPT new and 

established clinic visit and consultation 

E/M codes. We did not finalize the 

codes for CY 2003 because of concerns 

then about creating new G-codes 

without national guidelines. 

During CY 2006 and earlier, there has 

not been a payment difference between 

new and established patient visits of the 

same level, as generally both were 

mapped to the same APC. The 

information describing the AHA/ 

AHIMA guidelines indicates that only 

one set of guidelines was developed for 

five levels of codes for clinic visits, 

regardless of a patient’s status as a new 

or established patient or the provision of 

a consultation visit. This approach may 

have been related to the lack of a 

payment differential for different types 

of clinic visits of the same level under 

the OPPS when those guidelines were 

developed. However, several years of 

hospital claims data regarding the 

median costs of the specific CPT clinic 

visit E/M codes consistently indicate 

that new patients generally are more 

resource intensive than existing patients 

across all visit levels, and that 

consultations are more resource 

intensive than standard visits. For 

example, based upon CY 2005 claims 

used by the OPPS for CY 2007 

ratesetting, CPT code 99213, the level 3 

clinic visit code for established patients, 

has a median cost of $63.04. CPT code 

99203, the level 3 clinic visit code for 

new patients, has a median cost of 

$74.12. CPT code 99243, the level 3 

consultation visit code, has a median 

cost of $84.14. Finally, CPT code 99273, 

the level 3 confirmatory consultation 

visit code which was deleted for CY 

2006, had a median cost of $100.77. We 

encourage public comments that discuss 

the potential differences in hospital 

clinic resource consumption for new 

patient visits, established patient visits, 

and consultations. If there are 

significant additional hospital resources 

required to provide new patient visits or 

consultations, we are unsure whether 

the interventions in the AHA/AHIMA 

guidelines would reliably capture these 

additional resources. 

h. Distinction Between Type A and 

Type B Emergency Departments 

There are no AHA/AHIMA guidelines 

for the reporting of visits to Type B 

emergency departments that meet the 

EMTALA definition of a DED, but do 

not meet the proposed definition of a 

Type A emergency department, as 

discussed above. When the AHA and 

AHIMA created these guidelines, 

emergency departments that did not 

meet the CPT definition of emergency 

department were instructed to bill CPT 

clinic visit E/M codes. There was no 

distinction in reporting between 

emergency departments that, as DEDs, 

had an EMTALA obligation but did not 

meet the CPT definition of emergency 

department and outpatient hospital 

clinics that did not provide emergency 

services. If we finalize our proposal to 

create new G-codes for CY 2007 for 

Type B emergency departments to use 

in reporting visits, in the short run 

hospitals will use internal guidelines to 

determine their visit levels for Type B 

emergency department visits, as they 

will for visits to both clinics and Type 

A emergency departments. However, 

with the implementation of national 

hospital visit guidelines we will need to 

specify those guidelines to be used for 

the purposes of Type B emergency visit 

reporting. The AHA and AHIMA have 

not yet had the opportunity to consider 

the issue of Type B emergency visit 

reporting in their guidelines, and we 

welcome public comments to provide 

additional perspectives on the 

appropriate guidelines for reporting 

visit levels in these Type B emergency 

departments. 

The public comments that we receive 

on this guidelines section of this 

proposed rule will be publicly available 

to the AHA and AHIMA and their 

expert panel, along with comments that 

we receive on the two versions of the 

guidelines posted on our Web site. We 

hope to receive input from them over 

the upcoming months to address the 

eight areas of concern that are discussed 

above, as well as other issues brought to 

our attention by the public. We 

understand that some issues will not be 

able to be fully addressed by their 

expert panel until we finalize our CY 

2007 payment policies for visits in the 

OPPS. We plan to communicate 

progress on the development of OPPS 

visit guidelines through updates to the 

OPPS Web site, and we may post other 

versions of draft guidelines in order to 

solicit additional public input during 

CY 2007. When we post additional 


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materials to the web for purposes of 

providing information or soliciting 

further comments regarding national 

guidelines, we will update the public 

through all means practically available 

to us, including communications with 

professional associations, list-serves, 

etc. While we understand the interest of 

some hospitals in our moving quickly to 

promulgate national guidelines that will 

assure standardized reporting of 

outpatient hospital visit levels, we 

believe that the issues we have 

identified and others that may arise are 

important and require serious 

consideration prior to the 

implementation of national guidelines. 

Because of our commitment to provide 

hospitals with 6–12 months notice prior 

to implementation of national 

guidelines, we expect that we will not 

implement national guidelines prior to 

CY 2008. We acknowledge that, once 

implemented, the guidelines will 

require periodic review and updating 

based on factors such as changing 

medical practices, hospital experiences 

in reporting the codes, new payment 

policies under the OPPS, and median 

costs for levels of services calculated 

from claims data. We are hopeful that 

the information received from the AHA, 

AHIMA and others on such reviews 

would permit us to effectively, and in a 

timely manner, address emerging 

guideline implementation issues, as 

well as develop desirable future 

modifications to the guidelines based on 

hospitals’ experiences reporting 

commonly provided visits. We believe 

that this ongoing system should provide 

the most successful approach to 

ensuring that OPPS national visit 

guidelines continue to facilitate 

consistent and standardized reporting of 

outpatient hospital visits, in a manner 

that is resource-based and supportive of 

appropriate OPPS payments for the 

efficient and effective provision of visits 

in hospital outpatient settings. 

X. Proposed Payment for Blood and 

Blood Products 

A. Background 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Blood and Blood Products’’ at 

the beginning of your comment.) 

Since the implementation of the OPPS 

in August 2000, separate payments have 

been made for blood and blood products 

through APCs rather than packaging 

them into payments for the procedures 

with which they were administered. 

Hospital payments for the costs of blood 

and blood products, as well as the costs 

of collecting, processing, and storing 

blood and blood products, are made 

through the OPPS payments for specific 

blood product APCs. On April 12, 2001, 

CMS issued the original billing 

guidance for blood products to hospitals 

(Program Transmittal A–01–50). In 

response to requests for clarification of 

these instructions, CMS issued Program 

Transmittal 496 on March 4, 2005. The 

comprehensive billing guidelines in the 

Program Transmittal also addressed 

specific concerns and issues related to 

billing for blood-related services, which 

the public had brought to our attention. 

In the CY 2000 OPPS, payments for 

blood and blood products were 

established based on external data 

provided by commenters due to limited 

Medicare claims data. From the CY 2000 

OPPS to the CY 2002 OPPS, payment 

rates for blood and blood products were 

updated for inflation. For the CY 2003 

OPPS, as described in the November 1, 

2002 final rule with comment period (67 

FR 66773), we applied a special 

adjustment methodology to blood and 

blood products that had significant 

reductions in payment rates from the CY 

2002 OPPS to the CY 2003 OPPS, when 

median costs were first calculated from 

hospital claims. Using the adjustment 

methodology, we limited the decrease in 

payment rates for blood and blood 

products to approximately 15 percent. 

For the CY 2004 OPPS, as recommended 

by the APC Panel, we froze payment 

rates for blood and blood products at CY 

2003 levels as we studied concerns 

raised by commenters and presenters at 

the August 2003 and February 2004 

APC Panel meetings. 

For the CY 2005 OPPS, we established 

new APCs that allowed each blood 

product to be assigned to its own 

separate APC, as several of the previous 

blood product APCs contained multiple 

blood products with no clinical 

homogeneity or whose product-specific 

median costs may not have been similar. 

Some of the blood product HCPCS 

codes were reassigned to the new APCs 

(Table 34 of the November 15, 2004 

final rule with comment period (69 FR 

65819)). 

We also noted in the November 15, 

2004 final rule with comment period, 

that public comments on previous OPPS 

rules had stated that the CCRs that were 

used to adjust charges to costs for blood 

products in past years were too low. 

Past commenters indicated that this 

approach resulted in an 

underestimation of the true hospital 

costs for blood and blood products. In 

response to these comments and APC 

Panel recommendations from its 

February 2004 and September 2004 

meetings, we conducted a thorough 

analysis of the CY 2003 claims (used to 

calculate the CY 2005 APC payment 

rates) to compare CCRs between those 

hospitals reporting a blood-specific cost 

center and those hospitals defaulting to 

the overall hospital CCR in the 

conversion of their blood product 

charges to costs. As a result of this 

analysis, we observed a significant 

difference in CCRs utilized for 

conversion of blood product charges to 

costs for those hospitals with and 

without blood-specific cost centers. The 

median hospital blood-specific CCR was 

almost two times the median overall 

hospital CCR. As discussed in the 

November 15, 2004 final rule with 

comment period, we applied a 

methodology for hospitals not reporting 

a blood-specific cost center, which 

simulated a blood-specific CCR for each 

hospital that we then used to convert 

charges to costs for blood products. 

Thus, we developed simulated medians 

for all blood and blood products based 

on CY 2003 hospital claims data (69 FR 

65816). 

For the CY 2005 OPPS, we also 

identified a subset of blood products 

that had less than 1,000 units billed in 

CY 2003. For these low-volume blood 

products, we based the CY 2005 OPPS 

payment rate on a 50/50 blend of the CY 

2004 OPPS product-specific OPPS 

median costs and the CY 2005 OPPS 

simulated medians based on the 

application of blood-specific CCRs to all 

claims. We were concerned that, given 

the low frequency in which these 

products were billed, a few occurrences 

of coding or billing errors may have led 

to significant variability in the median 

calculation. The claims data may not 

have captured the complete costs of 

these products to hospitals as fully as 

possible. This low-volume adjustment 

methodology also allowed us to further 

study the issues raised by commenters 

and by presenters at the September 2004 

APC Panel meeting, without putting 

beneficiary access to these low-volume 

blood products at risk. 

Overall, median costs from CY 2003 

(used for the 2005 OPPS) to CY 2004 

(used for the 2006 OPPS) were relatively 

stable, with a few significant increases 

and decreases from the CY 2005 

adjusted median costs for some specific 

blood products. For the CY 2006 OPPS, 

we adopted a payment adjustment 

policy that limited significant decreases 

in APC payment rates for blood and 

blood products from the CY 2005 OPPS 

to the CY 2006 OPPS to not more than 

5 percent. We applied this adjustment to 

11 blood and blood product APCs for 

the CY 2006 OPPS, which we identified 

in Table 33 of the CY 2006 OPPS final 

rule with comment period. For the CY 

2006 OPPS we set the final median costs 

for blood and blood products at the 


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greater of: (1) The simulated median 

costs calculated from the CY 2004 

claims data; or (2) 95 percent of the CY 

2005 OPPS adjusted median costs for 

these products, as reflected in Table 33 

published in the CY 2006 OPPS final 

rule with comment period. 

B. Proposed Policy Changes for CY 2007 

For the CY 2007 OPPS, we are 

proposing to establish payment rates for 

blood and blood products by using the 

same simulation methodology described 

in the November 15, 2004 final rule 

with comment period (69 FR 65816), 

which utilized hospital-specific actual 

or simulated CCRs for blood cost centers 

to convert hospital charges for blood 

and blood products to costs. We 

continue to believe that using bloodspecific CCRs applied to hospital claims 

data will result in payments that more 

fully reflect hospitals’ true costs of 

providing blood and blood products 

than our general methodology of 

defaulting to the overall hospital CCR 

when more specific CCRs are 

unavailable. 

The median costs for blood and blood 

products in this proposed rule are 

derived from the CY 2005 claims data 

and have the benefit of reflecting, in 

part, the clarifications about reporting 

that were provided through CMS 

Program Transmittal 496, which we 

issued on March 4, 2005. This 

instruction articulated and clarified 

many questions that had been raised by 

hospitals and others about how 

hospitals should report charges for 

blood and blood products. These 

instructions went into effect for services 

furnished on or after July 1, 2005, and 

therefore were in effect for the last 6 

months of CY 2005. Thus, we expect 

that the reporting of charges and units 

for blood and blood products in CY 

2005 has improved over past years, 

especially with respect to hospitals’

inclusion of all charges related to the 

acquisition, processing, and handling of 

blood and blood products as specifically 

described in each of the relevant P-code 

descriptors. We believe that the median 

costs for blood and blood products from 

the CY 2005 claims data reflect this 

improved reporting of charges and units 

for these products, particularly with 

regard to the most commonly furnished 

blood and blood products. 

Of the 34 blood products, median 

costs per unit (calculated using the 

simulated blood CCR methodology) rise 

for 23 of them compared to the CY 2006 

final rule with comment period 

unadjusted median unit costs. These 23 

products account for 92.4 percent of all 

units of blood products furnished in our 

CY 2005 claims data. As has been the 

case in the past, the low volume 

products (which we define as fewer 

than 1,000 units) show the most 

volatility. Of the 12 low volume 

products, 6 products have increases in 

their unit costs compared to their CY 

2006 unadjusted median unit costs, and 

6 products show decreases in their 

median unit costs compared to their CY 

2006 unadjusted median unit costs. The 

low-volume products for which the 

medians decline compared to their 

unadjusted median costs in CY 2006 

represent only 0.29 percent of the total 

units of blood products furnished in the 

CY 2005 OPPS claims data. 

Fewer blood products increased in 

projected costs from CY 2006 to the 

proposed median costs for CY 2007 

because we adjusted the CY 2006 

median costs for blood and blood 

products. Of the 34 blood products, 

median costs rise for 19 of them 

compared to the CY 2006 OPPS adjusted 

median costs on which the CY 2006 

payments were based (and which were 

adjusted to no less than 95 percent of 

the CY 2005 payment medians). These 

19 products accounted for 91.6 percent 

of all units of blood products furnished 

in our CY 2005 claims data. Of the 12 

low-volume products, 4 show increases 

in their median unit costs compared to 

the CY 2006 OPPS adjusted median unit 

costs, and 8 show decreases compared 

to their CY 2006 OPPS adjusted median 

unit costs. The low-volume products 

that show a decline in medians 

compared to their CY 2006 adjusted 

median costs represent only 0.4 percent 

of the total units of blood products 

reflected in the CY 2005 claims data. 

We are proposing to set the payment 

rates for blood and blood products for 

CY 2007 based on the unadjusted 

median costs for blood and blood 

products which are derived from the CY 

2005 claims data as we have described. 

We believe that, in most cases, the 

unadjusted unit costs developed by this 

process are valid reflections of the 

estimated median costs of furnishing 

these specific blood products, and that 

no adjustment is required to result in 

appropriate payments for blood and 

blood products in CY 2007. Under this 

proposed policy, based on the CY 2005 

claims data, the projected payments 

would rise for approximately 92 percent 

of the blood product units paid under 

OPPS if patterns of furnishing blood 

products in CY 2007 were similar to 

those in CY 2005. The low-volume 

products whose median costs decline 

compared to their CY 2006 unadjusted 

median costs are furnished very rarely 

and by very few providers because, in 

part, more commonly available products 

may be used for similar clinical 

indications. We have no reason to 

believe that the median costs for lowvolume products are not valid 

reflections of the costs of furnishing 

these low-volume services, particularly 

given that so few providers furnish them 

and it is their claims data that is used 

to develop the medians. We note, as 

well, that the median costs of several 

low-volume blood products show a 

significant increase for CY 2007. We 

welcome public comments on this issue. 

Displayed in Table 39 is the list of 

blood product HCPCS codes with their 

proposed CY 2007 payment medians. 

TABLE 39.—PROPOSED CY 2007 PAYMENT MEDIANS FOR BLOOD AND BLOOD PRODUCTS

HCPCS 

code SI APC Short description 

Proposed 

CY 2007 

units 

Proposed 

CY 2007 

OPPS median unit 

cost 

CY 2006 

unadjusted 

median cost 

CY 2006 

adjusted 

median cost 

P9010 .... K ....... 0950 Whole blood for transfusion, per unit ........................... 2060 $134.80 $117.91 $117.91 

P9011 .... K ....... 0967 Blood split unit, specify amount .................................... 136 136.42 82.50 82.50 

P9012 .... K ....... 0952 Cryoprecipitate each unit .............................................. 4155 52.94 40.33 47.10 

P9016 .... K ....... 0954 RBC leukocytes reduced, each unit ............................. 556100 177.51 163.16 163.16 

P9017 .... K ....... 9508 Plasma 1 donor frz w/in 8 hr, each unit ....................... 40113 72.12 70.40 70.40 

P9019 .... K ....... 0957 Platelets, each unit ....................................................... 25796 60.49 51.50 51.50 

P9020 .... K ....... 0958 Platelet rich plasma unit ............................................... 657 156.49 277.42 277.42 

P9021 .... K ....... 0959 Red blood cells unit ...................................................... 145507 129.99 121.48 121.48 

P9022 .... K ....... 0960 Washed red blood cells unit ......................................... 2455 216.35 172.40 189.22 

P9023 .... K ....... 0949 Frozen plasma, pooled, sd, each unit .......................... 388 55.96 60.38 76.15 


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49620 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

TABLE 39.—PROPOSED CY 2007 PAYMENT MEDIANS FOR BLOOD AND BLOOD PRODUCTS—Continued 

HCPCS 

code SI APC Short description 

Proposed 

CY 2007 

units 

Proposed 

CY 2007 

OPPS median unit 

cost 

CY 2006 

unadjusted 

median cost 

CY 2006 

adjusted 

median cost 

P9031 .... K ....... 1013 Platelets leukocytes reduced, each unit ....................... 19368 94.61 98.30 98.30 

P9032 .... K ....... 9500 Platelets, irradiated, each unit ...................................... 4579 129.45 73.46 86.55 

P9033 .... K ....... 0968 Platelets leukoreduced irrad, each unit ........................ 4802 130.89 102.18 150.58 

P9034* ... K ....... 9507 Platelets, pheresis, each unit ........................................ 9292 465.60 434.01 434.01 

P9035 .... K ....... 9501 Platelet pheresis leukoreduced, each unit .................... 40933 490.51 493.12 493.12 

P9036 .... K ....... 9502 Platelet pheresis irradiated, each unit .......................... 1476 413.58 317.43 325.87 

P9037 .... K ....... 1019 Plate pheresis leukoredu irrad, each unit ..................... 17766 616.68 581.01 581.01 

P9038 .... K ....... 9505 RBC irradiated, each unit ............................................. 4130 201.36 147.47 147.47 

P9039 .... K ....... 9504 RBC deglycerolized, each unit ..................................... 818 352.72 343.44 343.44 

P9040 .... K ....... 0969 RBC leukoreduced irradiated, each unit ....................... 57857 228.76 218.04 218.04 

P9043 .... K ....... 0956 Plasma protein fract, 5%, 50ml .................................... 430 24.81 67.94 67.94 

P9044 .... K ....... 1009 Plasma, cryoprecipitate reduced, each unit ................. 5868 80.23 74.52 74.52 

P9048 .... K ....... 0966 Plasma protein fract, 5%, 250ml .................................. 398 193.39 127.36 315.70 

P9050 .... K ....... 9506 Granulocytes, pheresis unit .......................................... 495 253.43 245.14 994.64 

P9051 .... K ....... 1010 Blood, l/r, cmv-neg, each unit ....................................... 3364 135.83 207.72 207.72 

P9052 .... K ....... 1011 Platelets, hla-m, l/r, unit ................................................ 1809 649.06 609.48 609.48 

P9053 .... K ....... 1020 Plt, pher, l/r cmv-neg, irr, each unit .............................. 895 722.82 654.13 654.13 

P9054 .... K ....... 1016 Blood, l/r, froz/degly/wash, each unit ............................ 493 89.33 89.73 261.93 

P9055 .... K ....... 1017 Plt, aph/pher, l/r, cmv-neg, each unit ........................... 534 379.91 526.00 526.00 

P9056 .... K ....... 1018 Blood, l/r, irradiated, each unit ...................................... 3720 134.43 162.42 178.37 

P9057 .... K ....... 1021 RBC, frz/deg/wsh, l/r, irrad, each unit .......................... 71 427.35 345.53 345.53 

P9058 .... K ....... 1022 RBC, l/r, cmv-neg, irrad, each unit ............................... 1965 264.47 256.76 266.89 

P9059 .... K ....... 0955 Plasma, frz between 8–24hour, each unit .................... 3118 73.28 74.70 74.70 

P9060 .... K ....... 9503 Fr frz plasma donor retested, each unit ....................... 283 73.60 94.72 94.72 

*After removal of two claims with grossly excessive units. 

XI. Proposed OPPS Payment for 

Observation Services 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS: Observation Services’’

at the beginning of your comment.) 

Observation care is a well-defined set 

of specific, clinically appropriate 

services that include ongoing short-term 

treatment, assessment, and 

reassessment, before a decision can be 

made regarding whether patients will 

require further treatment as hospital 

inpatients or if they are able to be 

discharged from the hospital. 

Observation status is commonly 

assigned to patients with unexpectedly 

prolonged recovery after surgery and to 

patients who present to the emergency 

department and who then require a 

significant period of treatment or 

monitoring before a decision is made 

concerning their next placement. 

For CY 2006, we adopted two coding 

changes that affect how observation 

services are reported, and we made 

changes in the OCE to shift from 

individual providers to the OPPS claims 

processing systems the determination of 

whether or not observation services are 

separately payable or packaged. 

Observation services reported using 

HCPCS code G0378 (Hospital 

observation services, per hour) that are 

eligible for separate payment map to 

APC 0339 (Observation). The CY 2006 

payment rate for APC 0339 is $425.08. 

The proposed CY 2007 median cost for 

APC 0339 is $442.16, reflecting relative 

stability in hospital costs for separately 

payable observation care. Direct 

admission to observation (G0379), when 

separately payable, is currently assigned 

for payment to APC 0600 (Low Level 

Clinic Visit) with a CY 2006 payment 

rate of $52.37. As discussed below, for 

CY 2007 we are proposing to assign 

direct admission to observation, when 

separately payable, to APC 0604 (Low 

Level Clinic Visit). The CY 2007 

proposed median cost for APC 0604 is 

$49.93. 

As we stated in the November 10, 

2005 OPPS final rule with comment 

period (70 FR 68688), the changes that 

we adopted for CY 2006 were intended 

to ensure more consistent hospital 

billing for observation services in order 

to guide our future analyses of payment 

for observation care and to simplify how 

observation services are reported and 

paid. We refer readers to the CY 2006 

OPPS final rule with comment period 

for a detailed discussion of the G-codes 

for observation services and the OCE 

logic changes implemented for CY 2006 

(70 FR 68688), and to Program 

Transmittal 787, issued on December 

16, 2005, in which we updated Chapter 

4, Section 290 of the Medicare Claims 

Processing Manual (Pub. 100–04) to 

reflect the CY 2006 changes and to 

provide additional guidance to 

contractors and hospitals. 

During the APC Panel’s March 2006 

meeting, the Observation Subcommittee 

did not make any recommendations to 

the Panel other than to request its 

review of additional data on observation 

services at the Panel’s 2007 winter 

meeting. The APC Panel adopted the 

Observation Subcommittee’s report and 

recommended no changes to the criteria 

for separate payment for observation 

services or to the coding and payment 

methodology for observation services. 

Therefore, for CY 2007, we are 

proposing to continue applying the 

criteria for separate payment for 

observation services and the coding and 

payment methodology for observation 

services that were implemented in CY 

2006, with one exception. In section IX. 

of this preamble, we are proposing 

changes in coding and payment for 

clinic and emergency room visits. As 

part of these proposed changes, low 

level clinic visits would move from APC 

0600 to APC 0604, with a CY 2007 

proposed median cost of $49.93. Under 

the circumstances where direct 

admission to observation is separately 

payable, we are proposing to assign 

HCPCS code G0379 to APC 0604 

consistent with its CY 2006 placement 

in the APC for Low Level Clinic Visits. 

As we stated in Program Transmittal 

A–02–129 released in January 2003, we 


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will continue to include in the October 

quarterly update of the OPPS any 

changes to the list of ICD–9–CM codes 

required for separate payment of HCPCS 

code G0378 resulting from the October 

1 annual update of ICD–9–CM codes. 

The currently applicable ICD–9–CM 

codes are listed in Table 34 of the CY 

2006 OPPS final rule with comment 

period (70 FR 68692), and any changes 

to that list will be included in the CY 

2007 OPPS final rule with comment 

period. 

XII. Proposed Procedures That Will Be 

Paid Only as Inpatient Procedures 

A. Background 

Section 1833(t)(1)(B)(i) of the Act 

gives the Secretary broad authority to 

determine the services to be covered 

and paid for under the OPPS. Before 

implementation of the OPPS in August 

2000, Medicare paid reasonable costs for 

services provided in the outpatient 

department. The claims submitted were 

subject to medical review by the fiscal 

intermediaries to determine the 

appropriateness of providing certain 

services in the outpatient setting. We 

did not specify in regulations those 

services that were appropriate to 

provide only in the inpatient setting and 

that, therefore, should be payable only 

when provided in that setting. 

In the April 7, 2000 final rule with 

comment period, we identified 

procedures that are typically provided 

only in an inpatient setting and, 

therefore, would not be paid by 

Medicare under the OPPS (65 FR 

18455). These procedures comprise 

what is referred to as the ‘‘inpatient 

list.’’ The inpatient list specifies those 

services that are only paid when 

provided in an inpatient setting because 

of the nature of the procedure, the need 

for at least 24 hours of postoperative 

recovery time or monitoring before the 

patient can be safely discharged, or the 

underlying physical condition of the 

patient. As we discussed in the April 7, 

2000 final rule with comment period (65 

FR 18455) and the November 30, 2001 

final rule (66 FR 59856), we use the 

following criteria when reviewing 

procedures to determine whether or not 

they should be moved from the 

inpatient list and assigned to an APC 

group for payment under the OPPS: 

• Most outpatient departments are 

equipped to provide the services to the 

Medicare population. 

• The simplest procedure described 

by the code may be performed in most 

outpatient departments. 

• The procedure is related to codes 

that we have already removed from the 

inpatient list. 

In the November 1, 2002 final rule 

with comment period (67 FR 66741), we 

removed 43 procedures from the 

inpatient list for payment under OPPS. 

We also added the following criteria for 

use in reviewing procedures to 

determine whether they should be 

removed from the inpatient list and 

assigned to an APC group for payment 

under the OPPS: 

• We have determined that the 

procedure is being performed in 

numerous hospitals on an outpatient 

basis; or 

• We have determined that the 

procedure can be appropriately and 

safely performed in an ambulatory 

surgical center (ASC) and is on the list 

of approved ASC procedures or 

proposed by us for addition to the ASC 

list. 

We believe that these additional 

criteria help us to identify procedures 

that are appropriate for removal from 

the inpatient list. 

B. Proposed Changes to the Inpatient 

Only List 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Inpatient Only Procedures’’ at 

the beginning of your comment.) 

For CY 2007 OPPS, we used the same 

methodology as described in the 

November 15, 2004 final rule with 

comment period (69 FR 65835) to 

identify a subset of procedures currently 

on the inpatient list that are being 

widely performed on an outpatient 

basis. These procedures were then 

clinically reviewed for possible removal 

from the inpatient list. We solicited 

input from the APC Panel on the 

appropriateness of the removal of seven 

procedures from the inpatient list at the 

March 1, 2006 APC Panel meeting. 

During CY 2006, we have received no 

other candidate HCPCS codes for 

removal from the OPPS inpatient list 

based on recommendations from the 

public. The APC Panel recommended 

that one of the procedures (CPT code 

21181, Reconstruction by contouring of 

benign tumor of cranial bones, 

extracranial) be removed from the list 

and that we solicit approval from the 

relevant physician specialty societies 

prior to proposing removal of the other 

procedures. 

Consistent with our established policy 

for removing procedures from the 

inpatient list, we rely on our utilization 

data and clinical staff input in 

determining which procedures are 

candidates for removal. We believe that 

our policy of proposing the procedures 

for removal and soliciting comments 

from the public, which includes 

physician specialty societies, is the most 

appropriate process to receive input 

from the public on this issue. Rather 

than solicit approval from a select group 

(for example, specific physician 

specialty societies), we believe that 

solicitation of comments from all 

interested parties is more consistent 

with meeting our obligation to the 

public regarding outpatient services 

provided by hospitals. The utilization 

data and clinical review findings for the 

eight procedures support our proposal 

to remove them from the inpatient list, 

and therefore, we are proposing to 

remove these procedures from the 

inpatient list and to assign them to 

clinically appropriate APCs, as shown 

in Table 40. The changes to the 

inpatient list would be effective for 

services furnished on or after January 1, 

2007. 

TABLE 40.—PROPOSED PROCEDURE CODES TO REMOVE FROM INPATIENT LIST AND PROPOSED APC ASSIGNMENTS, 

EFFECTIVE JANUARY 1, 2007 

HCPCS code Long descriptor 

Proposed 

new APC 

assignment 

Current 

status 

indicator 

Proposed 

new status 

indicator 

16035 .......... Escharotomy; initial incision ............................................................................................... 0016 C T 

21181 .......... Reconstruction by contouring of benign tumor of cranial bones, extracranial .................. 0254 C T 

22851 .......... Apply spine prosth device .................................................................................................. 0049 C T 

57292 .......... Construction of artificial vagina; with graft ......................................................................... 0195 C T 

57335 .......... Vaginoplasty for intersex state .......................................................................................... 0195 C T 

61720 .......... Creation of lesion by stereotactic method, including burr holes and localizing and recording techniques, single of multiple stages; globus pallidus or thalamus.0221 C T 

62000 .......... Elevation of depressed skull fracture; simple extradural ................................................... 0254 C T 


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TABLE 40.—PROPOSED PROCEDURE CODES TO REMOVE FROM INPATIENT LIST AND PROPOSED APC ASSIGNMENTS, 

EFFECTIVE JANUARY 1, 2007—Continued 

HCPCS code Long descriptor 

Proposed 

new APC 

assignment 

Current 

status 

indicator 

Proposed 

new status 

indicator 

64804 .......... Sympathectomy, cervicothoracic ....................................................................................... 0220 C T 

C. Proposed CY 2007 Payment for 

Ancillary Outpatient Services When 

Patient Expires (–CA Modifier) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Ancillary Outpatient Services’’

at the beginning of your comment.) 

1. Background 

In the November 1, 2002 final rule 

with comment period (67 FR 66798), we 

discussed the creation of a new HCPCS 

modifier –CA to address situations 

where a procedure on the OPPS 

inpatient list must be performed to 

resuscitate or stabilize a patient (whose 

status is that of an outpatient) with an 

emergent, life-threatening condition, 

and the patient dies before being 

admitted as an inpatient. In Transmittal 

A–02–129, issued on January 3, 2003, 

we instructed hospitals on the use of 

this modifier when submitting a claim 

on bill type 13x for a procedure that is 

on the inpatient list and assigned the 

payment status indicator (SI) ‘‘C’’ (to 

indicate inpatient services that are not 

paid under the OPPS). Conditions to be 

met for hospital payment for a claim 

reporting a service billed with modifier 

–CA include a patient with an emergent, 

life-threatening condition on whom a 

procedure on the inpatient list is 

performed on an emergency basis to 

resuscitate or stabilize the patient. For 

CY 2003, a single payment for otherwise 

payable outpatient services billed on a 

claim with a procedure appended with 

this new –CA modifier was made under 

APC 0977 (New Technology Level VIII, 

$1,000–$1,250), due to the lack of 

available claims data to establish a 

payment rate based on historical 

hospital costs. 

As discussed in the November 7, 2003 

final rule with comment period, we 

created APC 0375 (Ancillary Outpatient 

Services When Patient Expires) to pay 

for services furnished on the same date 

as a procedure with SI ‘‘C’’ and billed 

with the modifier –CA (68 FR 63467) 

because we were concerned that 

payment under a New Technology APC 

would not result in an appropriate 

payment. Payment under a New 

Technology APC is a fixed amount that 

does not have a relative payment weight 

and, therefore, is not subject to 

recalibration based on hospital costs. In 

the absence of hospital claims data to 

determine costs, the clinical APC 0375 

payment rate for CY 2004 was set at 

$1,150, which was the payment amount 

for the newly structured New 

Technology APC that replaced APC 

0977. 

For CYs 2005 and 2006, the payment 

rates for APC 0375 for services billed on 

the same date as a ‘‘C’’ status procedure 

appended with modifier -CA were 

established in accordance with the same 

methodology we followed to set 

payment rates for the other procedural 

APCs in those years, based on the 

relative payment weight calculated for 

APC 0375. For APC 0375 specifically, 

we calculated the relative payment 

weight from all claims reporting a ‘‘C’’

status procedure appended with 

modifier –CA, using charge data from 

the relevant calendar year claims for 

line items with a HCPCS code and 

status indicator ‘‘V,’’ ‘‘S,’’ ‘‘T,’’ ‘‘X,’’

‘‘N,’’ ‘‘K,’’ ‘‘G,’’ and ‘‘H,’’ in addition to 

charges for revenue codes without a 

HCPCS code. We continued to make one 

payment in CYs 2005 and 2006 under 

APC 0375 for the services that met the 

specific conditions discussed in 

previous rules for using modifier –CA. 

In the CY 2006 final rule with 

comment period (70 FR 68700) we 

discussed our concern about the large 

increase in the volume of hospital 

claims billed with modifier –CA from 

CY 2003 to CY 2004, growing from 18 

to 300 claims over that 1-year time 

period. We acknowledged that because 

modifier –CA was first introduced for 

CY 2003, the use of the modifier in CYs 

2003 and 2004 may have reflected such 

an increase due to hospitals’ learning 

curve with respect to the modifier’s 

appropriate use on claims for services 

payable under the OPPS. We also 

expressed some concern that numerous 

claims reflected unanticipated examples 

of ‘‘C’’ status procedures reported with 

modifier –CA that may not have been 

provided to patients with emergency life 

threatening conditions, where the 

inpatient procedure was performed on 

an emergency basis to resuscitate or 

stabilize the patient. We promised to 

monitor CY 2005 claims data for similar 

increases. 

Our review of the CY 2005 claims 

data revealed a decrease in the use of 

modifier –CA in comparison with CY 

2004 claims. In CY 2005 there were only 

210 claims submitted reporting modifier 

–CA. Because of the diverse individual 

clinical scenarios where modifier –CA 

may be appropriately reported, we 

expect some variation from year to year 

in the number of OPPS claims reporting 

the modifier. It would appear that the 

hospital learning curve regarding use of 

modifier –CA may have been completed 

over the past 3 year period, and that we 

may expect relatively consistent 

reporting of this modifier in future 

years. We wish to particularly note that 

not only was there no increase in the 

number of claims reporting modifier 

–CA in CY 2005, but there were also far 

fewer apparently inappropriate 

instances of use. Our CY 2005 claims 

data show the majority of reporting of 

modifier –CA was in association with 

what were likely to have been urgent 

interventions, including the insertion of 

intra-aortic balloon assist devices and 

exploratory laparotomies. We believe 

that the data support our speculation 

that much of the increase in reporting of 

the modifier observed in CY 2004 data 

was a result of hospitals’ learning curve 

regarding the appropriate use of the 

modifier. 

2. Proposed Policy for CY 2007 

We do not propose any change to our 

policies regarding reporting of modifier 

–CA for CY 2007, or to our payment 

policy regarding APC 0375. Therefore, 

for CY 2007, we are proposing that 

hospitals continue reporting modifier 

–CA only under circumstances 

described in section VI. of Transmittal 

A–02–129, which provided specific 

billing guidance for the use of modifier 

-CA. In addition, we are proposing to 

continue to make one payment under 

APC 0375 for the services that meet the 

specific conditions discussed in 

previous rules for using modifier –CA, 

based on calculation of the relative 

payment weight for APC 0375 as 

described above. We applaud hospitals’

improved billing practices and as 

before, will continue to monitor use of 

modifier –CA. The CY 2007 proposed 

APC 0375 median cost is $3,539, 

significantly increased from the $2,527 


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median cost proposed in the CY 2006 

proposed rule. This variation in median 

costs, however, is expected because the 

specific cases that populate the claims 

data for APC 0375 likely exhibit only 

limited clinical and resource 

homogeneity among all the claims 

attributable to that APC in a given year 

and across different years for the same 

APC. The cost variation of APC 0375 

from year to year could be expected 

because APC 0375 is unique in the 

OPPS and, by its definition, should 

always be limited in its use. 

XIII. Proposed Nonrecurring Policy 

Changes 

A. Removal of Comprehensive 

Outpatient Rehabilitation Facility 

(CORF) Services From the List of 

Services Paid under the OPPS 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘CORF Services’’ at the 

beginning of your comment.) 

We are proposing to make a technical 

change to the regulations at 42 CFR 

419.21(d) to remove from the list of 

services paid under the OPPS certain 

services furnished by a comprehensive 

outpatient rehabilitation facility (CORF) 

when they are provided outside the 

patient’s plan of care (for example, 

hepatitis B vaccine). Section 1834(k) of 

the Act, as added by section 4541(a) of 

Pub. L. 105–33 (BBA), requires that 

CORF services be paid using the lesser 

of actual charges or a fee schedule 

amount. We instructed fiscal 

intermediaries to use the Medicare 

Physician Fee Schedule (MPFS) for 

payments to CORFs. We have not 

required CORF cost reports, or paid 

CORFs under the OPPS, since 2001. The 

proposed revision of the regulation to 

delete certain CORF services from the 

list of specified services paid under the 

OPPS is necessary to conform the 

regulations to the statutory requirement. 

B. Addition of Ultrasound Screening for 

Abdominal Aortic Aneurysms (AAAs) 

(Section 5112 of Pub. 109–171 (DRA)) 

(If you choose to comment on the 

issues in this section, please include the 

caption ‘‘AAA Screening’’ at the 

beginning of your comment.) 

1. Background 

Section 5112 of the Deficit Reduction 

Act of 2005, Pub. L. 109–171 (DRA), 

amended section 1861 and related 

provisions of the Act to provide for 

coverage under Part B of ultrasound 

screening for abdominal aortic 

aneurysms (AAAs), effective for services 

furnished on or after January 1, 2007, 

subject to certain eligibility and other 

limitations. The proposed rule 

governing this new Part B coverage will 

be established through a separate 

document, specifically the CY 2007 

Medicare Physician Fee Schedule 

proposed rule. We refer readers to that 

document for a full and complete 

explanation of this coverage provision. 

2. Proposed Assignment of New HCPCS 

Code for Payment of Ultrasound 

Screening for Abdominal Aortic 

Aneurysm (AAA) (Section 5112) 

There is no current CPT code that 

specifically describes an ultrasound 

screening for AAA. Therefore, we are 

proposing to establish the following 

new HCPCS code, GXXXX (Ultrasound, 

B-scan and or real time with image 

documentation; for abdominal aortic 

aneurysm (AAA) screening) to be used 

to bill for the new service under both 

the Medicare Physician Fee Schedule 

and the OPPS. As required by the 

statute, Medicare will allow payment for 

a one-time only screening examination, 

and this screening test will be available 

even if the qualifying patient does not 

present signs or symptoms of disease or 

illness. In addition, this code does not 

include any other preventive services 

that are currently separately covered 

and paid under the Medicare Part B 

screening benefits. When these other 

preventive services are performed, they 

should be reported using the existing 

appropriate codes. 

We are proposing to base the payment 

for GXXXX on equivalent hospital 

resources and intensity to those 

contained in CPT code 76775, which is 

assigned to APC 0266 (Level II 

Diagnostic and Screening Ultrasound) 

under the OPPS for CY 2007. We believe 

that the hospital costs associated with 

the screening study are very similar to 

those of the limited retroperitoneal 

ultrasound diagnostic examination and, 

therefore, that the screening and 

diagnostic studies should be assigned to 

the same clinical APC for reasons of 

clinical and resource homogeneity. 

Thus, we are proposing to assign 

GXXXX to APC 0266 with a median cost 

of $98.59 for CY 2007. 

3. Handling of Comments Received in 

Response to This Proposal 

We noted previously that ultrasound 

screening for AAAs is also addressed in 

detail in our proposed rule to update the 

Medicare Physician Fee Schedule for 

CY 2007. We will respond to all 

comments regarding the proposed 

elements required for the ultrasound 

screening for AAA, whether the 

examination is performed in a 

physician’s office or an outpatient 

hospital setting, and the exception from 

the Part B annual deductible, in the 

final rule implementing the Medicare 

Physician Fee Schedule for CY 2007. 

We will respond to all comments 

regarding payment for GXXXX under 

the OPPS in the CY 2007 OPPS final 

rule. 

XIV. Emergency Medical Screening in 

Critical Access Hospitals (CAHs) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘CAHs: Emergency Medical 

Screening’’ at the beginning of your 

comment.) 

A. Background 

Section 1820 of the Act, as amended 

by section 4201 of the Balanced Budget 

Act of 1997, provides for the 

establishment of Medicare Rural 

Hospital Flexibility Programs 

(MRHFPs), under which individual 

States may designate certain facilities as 

critical access hospitals (CAHs). 

Facilities that are so designated and 

meet the CAH conditions of 

participations (CoPs) under 42 CFR Part 

485, Subpart F, will be certified as 

CAHs by CMS. The MRHFP replaced 

the Essential Access Community 

Hospital (EACH)/Rural Primary Care 

Hospital (RPCH) program. 

B. Proposed Policy Change 

Existing regulations governing CAHs 

at § 485.618(d) require on-call doctors 

and nonphysician practitioners who 

may be attending to urgent/acute 

medical problems in other areas of the 

CAH or outside the CAH to report to the 

CAH’s emergency room within 30 

minutes (60 minutes if the CAH is 

located in a frontier or remote area or 

permissible under the State’s rural 

health care plan) to see a patient in the 

emergency room of a CAH. Often, these 

patients do not have emergency medical 

conditions. With changes to the 

regulations at § 489.24 that implement 

the Emergency Medical Treatment and 

Labor Act (EMTALA) over the past few 

years, some practitioners have noted to 

CMS that the requirements regarding 

who should respond to calls to see 

patients who present to the emergency 

department of a CAH are more stringent 

than for general hospitals. 

The provider community recently 

requested that we change the emergency 

on-call personnel requirements for 

CAHs to conform to the regulatory 

changes published in the FY 2005 IPPS 

final rule (69 FR 49271). In response to 

this request, we are proposing to revise 

the current CAH CoPs to align the 

emergency medical screening 

requirements in CAHs with those 

applicable to acute care hospitals. The 


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proposed change would allow registered 

nurses, in addition to the personnel 

currently required at § 485.618(d), to 

serve as qualified medical personnel to 

screen individuals who present to the 

CAH emergency room if the nature of 

the patient’s request is within the 

registered nurse’s scope of practice 

under State law and such screening is 

permitted by the CAH’s bylaws. This 

proposed change would effectively 

eliminate the need for a doctor or midlevel practitioner to report to the 

emergency department to attend to a 

nonemergent request for medical care if 

a registered nurse is on site at the CAH 

and has made a determination that the 

care needed is of a non-emergent nature. 

The EMTALA statute at section 1867 

of the Act states that a hospital in this 

context must provide an appropriate 

(suitable for the symptoms presented) 

medical screening examination within 

the capability of the hospital’s 

emergency department to determine 

whether or not an emergency medical 

condition exists (section 1866(a)(1)(I) of 

the Act imposes the section 1867 

requirements on a CAH). The EMTALA 

regulations at § 489.24(a) state that the 

examination must be conducted by 

qualified medical personnel. These 

qualified medical personnel designated 

to perform medical screening 

examinations must be determined 

qualified by the hospital’s bylaws or 

rules and regulations and must be 

practicing within the scope of practice 

under State law. 

The regulations at § 489.24(c) relating 

to the use of dedicated emergency 

department for nonemergency services 

were added in September 2003 (68 FR 

53262) to state that if an individual goes 

to a hospital’s dedicated emergency 

department to request medical 

treatment, and the nature of the request 

makes it clear that the medical 

condition is not of an emergency nature, 

the hospital is required only to perform 

such screening as would be appropriate 

to determine that the individual does 

not have an emergency medical 

condition. 

Although EMTALA also applies to 

CAHs, the CoP for CAH emergency 

services (§ 485.618(d)) states that a 

physician, a physician assistant, a nurse 

practitioner, or a clinical nurse 

specialist with training or experience in 

emergency care must be on call and 

available onsite at a CAH within a 

specified timeframe. These are the CAH 

personnel who would be available to 

conduct an emergency medical 

screening under § 489.24(c). In contrast, 

the emergency services CoP for acute 

care hospitals at § 482.55 does not 

specify the type of personnel who must 

be available to provide emergency 

services and who would, therefore, 

perform assessments and screenings. 

The regulation states only that the 

services must be organized and 

supervised under the direction of a 

qualified member of the medical staff. 

Therefore, an acute care hospital may, if 

it chooses, have protocols that permit a 

registered nurse to conduct specific 

emergency medical screenings if the 

nature of the individual’s request for 

examination and treatment is within the 

scope of practice of a registered nurse. 

For emergencies that are outside of a 

registered nurse’s scope of practice, 

another qualified medical personnel 

(operating within his or her scope of 

practice under State law) would 

conduct the emergency medical 

screening. 

We are proposing to revise the CAH 

standard at § 485.618(d) to allow a CAH, 

if applicable, the flexibility of including 

a registered nurse, with training and 

experience in emergency care and who 

is on site at the CAH, as one of the 

qualified medical personnel available 

for emergency services, particularly 

emergency medical screenings, if the 

nature of the individual’s request makes 

clear that the medical condition is not 

of an emergency nature and the 

individual’s request for examination 

and treatment is within the registered 

nurse’s scope of practice under State 

law. If the registered nurse begins the 

emergency medical screening and 

determines that the nature of the 

individual’s conditions is outside his or 

her scope of practice under State law, 

the physician, physician assistant, nurse 

practitioner or a clinical nurse specialist 

must be contacted to see the patient 

within 30 or 60 minutes to conduct the 

emergency medical screening and 

provide stabilizing treatment. If the 

registered nurse knows initially that the 

medical screening for the presenting 

complaint is outside the applicable 

scope of practice under State law, the 

physician or other nonphysician 

practitioner must see the individual 

within the 30 or 60 minute timeframes 

(as currently specified in 

§ 485.618(d)(1)). 

We recognize that not all CAHs will 

be able to utilize this flexibility. Some 

State licensure boards have stated that 

it is not within the authorized scope of 

practice for a registered nurse to 

independently perform an appropriate 

emergency medical screening for the 

purpose of determining if an emergency 

medical condition exists. However, the 

licensure boards in these States further 

maintain that it is within the scope of 

practice for a registered nurse to assess 

the health status of an individual to 

determine a nonemergent condition and 

to provide nursing care or to refer the 

individual to appropriate medical 

resources. Therefore, based on State 

law, some CAHs will not be able to 

designate registered nurses as qualified 

medical personnel under our proposed 

revision to the regulations governing 

CAHs. However, as we wish to provide 

flexibility to CAHs and to be consistent 

with existing EMTALA policy, we are 

proposing the revision to the regulation 

at § 485.618(d). 

XV. Proposed OPPS Payment Status 

and Comment Indicators 

A. Proposed CY 2007 Status Indicator 

Definitions 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS Status Indicator’’ at the 

beginning of your comment.) 

The OPPS payment status indicators 

(SIs) that we assign to HCPCS codes and 

APCs play an important role in 

determining payment for services under 

the OPPS. They indicate whether a 

service represented by a HCPCS code is 

payable under the OPPS or another 

payment system and also whether 

particular OPPS policies apply to the 

code. Our proposed CY 2007 status 

indicator assignments for APCs and 

HCPCS codes are shown in Addendum 

A and Addendum B, respectively. We 

are proposing to use the status 

indicators and definitions that are listed 

in Addendum D1, which we discuss 

below in greater detail: 

1. Proposed Payment Status Indicators 

To Designate Services That Are Paid 

Under the OPPS 

Indicator Item/code/service OPPS payment status 

G .................. Pass-Through Drugs and Biologicals .......................................... Paid under OPPS; Separate APC payment includes passthrough amount. 

H .................. (1) Pass-Through Device Categories .......................................... (1) Separate cost-based pass-through payment; Not subject to 

coinsurance. 

(2) Radiopharmaceutical Agents ................................................. (2) Separate cost-based non-pass-through payment. 


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Indicator Item/code/service OPPS payment status 

K .................. (1) Non-Pass-Through Drugs and Biologicals ............................ (1) Paid under OPPS; Separate APC payment. 

(2) Brachytherapy Sources ......................................................... (2) Paid under OPPS; Separate APC payment. 

K .................. (3) Blood and Blood Products ..................................................... (3) Paid under OPPS; Separate APC payment. 

N .................. Items and Services Packaged into APC Rates .......................... Paid under OPPS; Payment is packaged into payment for 

other services, including outliers. Therefore, there is no separate APC payment. 

P .................. Partial Hospitalization .................................................................. Paid under OPPS; Per diem APC payment. 

Q .................. Packaged Services Subject to Separate Payment Under OPPS 

Payment Criteria.

Paid under OPPS; Addendum B displays APC assignments 

when services are separately payable. 

(1) Separate APC payment based on OPPS payment criteria. 

(2) If criteria are not met, payment is packaged into payment 

for other services, including outliers. Therefore, there is no 

separate APC payment. 

S .................. Significant Procedure, Not Discounted when Multiple ................ Paid under OPPS; Separate APC payment. 

T .................. Significant Procedure, Multiple Reduction Applies ..................... Paid under OPPS; Separate APC payment.

V .................. Clinic or Emergency Department Visit ........................................ Paid under OPPS; Separate APC payment. 

X .................. Ancillary Services ........................................................................ Paid under OPPS; Separate APC payment. 

2. Proposed Payment Status Indicators 

To Designate Services That Are Paid 

Under a Payment System Other Than 

the OPPS 

Indicator Item/code/service OPPS payment status 

A .................. Services furnished to a hospital outpatient that are paid under 

a fee schedule or payment system other than OPPS, for example.

Not paid under OPPS. Paid by fiscal intermediaries under a 

fee schedule or payment system other than OPPS. 

• Ambulance Services.

• Clinical Diagnostic Laboratory Services.

• Non-Implantable Prosthetic and Orthotic Devices.

• EPO for ESRD Patients.

• Physical, Occupational, and Speech Therapy.

• Routine Dialysis Services for ESRD Patients Provided in a 

Certified Dialysis Unit of a Hospital.

• Diagnostic Mammography.

• Screening Mammography.

C .................. Inpatient Procedures ................................................................... Not paid under OPPS. Admit patient. Bill as inpatient. 

F .................. Corneal Tissue Acquisition; Certain CRNA Services; and Hepatitis B Vaccines.Not paid under OPPS. Paid at reasonable cost. 

L ................... Influenza Vaccine; Pneumococcal Pneumonia Vaccine ............. Not paid under OPPS. Paid at reasonable cost; Not subject to 

deductible or coinsurance. 

M .................. Items and Services Not Billable to the Fiscal Intermediary ........ Not paid under OPPS. 

Y .................. Non-Implantable Durable Medical Equipment ............................. Not paid under OPPS. All institutional providers other than 

home health agencies bill to DMERC. 

3. Proposed Payment Status Indicators 

To Designate Services That Are Not 

Recognized Under the OPPS but That 

May Be Recognized by Other 

Institutional Providers 

Indicator Item/code/service OPPS payment status 

B .................. Codes that are not recognized by OPPS when submitted on an 

outpatient hospital Part B bill type (12x,13x, and 14x).

Not paid under OPPS. 

• May be paid by intermediaries when submitted on a different 

bill type, for example, 75x (CORF), but not paid under 

OPPS. 

• An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x, 13x, 

and 14x) may be available. 

4. Proposed Payment Status Indicators 

to Designate Services That Are Not 

Payable by Medicare 


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Indicator Item/code/service OPPS payment status 

D .................. Discontinued Codes .................................................................... Not paid under OPPS or any other Medicare payment system. 

E .................. Items, Codes, and Services: ....................................................... Not paid under OPPS or any other Medicare payment system. 

• That are not covered by Medicare based on statutory exclusion.

• That are not covered by Medicare for reasons other than 

statutory exclusion.

• That are not recognized by Medicare but for which an alternate code for the same item or service may be available.

• For which separate payment is not provided by Medicare.

To make it more relevant to the 

proposed update of the OPPS, we are 

displaying in Addendum B of this 

proposed rule those HCPCS codes that 

describe items or services that are 

payable under the OPPS as well as 

nonpayable codes for which we are 

proposing a change in status. Status 

indicators for items and services that are 

payable under the OPPS are listed in 

section XV.A.1 of this preamble. 

A complete listing of HCPCS codes 

with OPPS payment status indicators 

and APC assignments proposed for CY 

2007 is available electronically on the 

CMS Web site. 

B. Proposed CY 2007 Comment 

Indicator Definitions 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS Comment Indicator’’ at 

the beginning of your comment.) 

In the November 15, 2004 final rule 

with comment period (69 FR 65827 and 

65828), we made final our policy to use 

three comment indicators to identify in 

an OPPS final rule the assignment status 

of a specific HCPCS code to an APC and 

the timeframe when comments on the 

HCPCS APC assignment will be 

accepted. These three comment 

indicators are listed below: 

• ‘‘NF’’—New code, final APC 

assignment; Comments were accepted 

on a proposed APC assignment in the 

Proposed Rule; APC assignment is no 

longer open to comment. 

• ‘‘NI’’—New code, interim APC 

assignment; Comments will be accepted 

on the interim APC assignment for the 

new code. 

In the November 10, 2005 final rule 

with comment period (70 FR 68702 and 

68703), we adopted a new comment 

indicator: 

• ‘‘CH’’—Active HCPCS codes in 

current and next calendar year; status 

indicator and/or APC assignment have 

changed. 

We implemented comment indicator 

‘‘CH’’ to designate a change in payment 

status indicator and/or APC assignment 

for HCPCS codes in Addendum B of the 

CY 2006 final rule with comment 

period. We also stated that codes flagged 

with the ‘‘CH’’ indicator in that final 

rule would not be open to comment 

because the changes were previously 

subject to comment during the proposed 

rule comment period. We are proposing 

to continue that policy in the CY 2007 

OPPS final rule. When used in an OPPS 

final rule, the ‘‘CH’’ indicator is only 

intended to facilitate the public’s review 

of changes made from one calendar year 

to another. We are proposing to use the 

‘‘CH’’ indicator in the CY 2007 final rule 

to indicate HCPCS codes for which the 

status indicator and/or APC assignment 

will change in CY 2007. However, only 

HCPCS codes with comment indicator 

‘‘NI’’ in the CY 2007 OPPS final rule 

would be subject to comment during the 

final rule comment period. 

We also are proposing to use the 

‘‘CH’’ indicator to call attention to 

changes in payment status indicator 

and/or APC assignment in this proposed 

rule to update the OPPS for CY 2007. 

We believe that using the ‘‘CH’’

indicator in this proposed rule will 

facilitate the public’s review of the 

changes that we are proposing to make 

final in CY 2007. Use of the ‘‘CH’’

indicator in the proposed rule is 

significant because it highlights changes 

that are subject to comment during the 

proposed rule comment period. 

The three comment indicators that we 

are proposing to implement in CY 2007 

and their definitions are listed in 

Addendum D2 of this proposed rule. 

XVI. OPPS Policy and Payment 

Recommendations 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Policy and Payment 

Recommendations’’ at the beginning of 

your comment.) 

A. MedPAC Recommendations 

The Medicare Payment Advisory 

Commission (MedPAC) submits reports 

to Congress in March and June that 

summarize payment policy 

recommendations. The March 2006 

MedPAC report included the following 

recommendation relating specifically to 

the hospital OPPS: 

Recommendation 2A: The Congress 

should increase payment rates for the 

acute inpatient and outpatient 

prospective payment systems in 2007 by 

the projected increase in the hospital 

market basket index less half of the 

Commission’s expectation for 

productivity growth. A discussion 

regarding updates to the market basket 

is included in section II.C. (‘‘Proposed 

OPPS Conversion Factor Update for 

2007’’) of this preamble. 

B. APC Panel Recommendations 

Recommendations made by the APC 

Panel are discussed in sections of this 

preamble that correspond to topics 

addressed by the APC Panel. Minutes of 

the APC Panel’s March 1–2, 2006 

meeting are available online at http:// 

www.cms.hhs.gov/FACA/05_Advisory

PanelonAmbulatory

PaymentClassificationGroups.asp. 

C. GAO Recommendations 

A discussion of the October 31, 2005 

GAO letter of comment on proposed 

2006 specified covered outpatient drug 

(SCOD) rates (GAO–06–17R ‘‘Comments 

on Proposed 2006 SCOD Rates’’) is 

contained in section V.3.B.a. of this 

preamble. 

A discussion of the April 2006 GAO 

report entitled ‘‘Medicare Hospital 

Pharmaceuticals: Survey Shows Price 

Variation and Highlights Data Collection 

Lessons and Outpatient Rate-setting 

Challenges for CMS’’ (GAO–06–372) is 

contained in section V.3.B.a. of this 

preamble. 

XVII. Proposed Policies Affecting 

Ambulatory Surgical Centers (ASCs) for 

CY 2007 

A. ASC Background 

1. Legislative History 

Section 1832(a)(2)(F)(i) of the Act 

provides that benefits under the 

Medicare Supplementary Medical 

Insurance program (Part B) include 

payment for facility services furnished 

in connection with surgical procedures 

the Secretary specifies which are 

performed in an ASC. To participate in 

the Medicare program as an ASC, a 


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facility must meet the standards 

specified in section 1832(a)(2)(F)(i) of 

the Act; in 42 CFR 416, subpart B of our 

regulations, which sets forth general 

conditions and requirements for ASCs; 

and in 42 CFR 416, subpart C of our 

regulations, which provides specific 

conditions for coverage for ASCs. 

The ASC services benefit was enacted 

by Congress through the Omnibus 

Reconciliation Act of 1980 (Pub. L. 96–

499). For a detailed discussion of the 

legislative history related to ASCs, we 

refer readers to the June 12, 1998 

proposed rule (63 FR 32291). 

Section 626(b) of Pub. L. 108–173, 

repealed the requirement formerly 

found in section 1833(i)(2)(A) of the Act 

that the Secretary conduct a survey of 

ASC costs for purposes of updating ASC 

payment rates and, instead, requires the 

Secretary to implement a revised ASC 

payment system, to be effective not later 

than January 1, 2008. Section XVIII. of 

this proposed rule contains our proposal 

for a revised ASC payment system that 

would be implemented on January 1, 

2008. 

Section 5103 of Pub. L. 109–171, 

amended section 1833(i)(2) of the Act by 

adding a new subparagraph (E) to place 

a limitation on payments for surgical 

procedures in ASCs. If the standard 

overhead amount under section 

1833(i)(2)(A) of the Act for a facility 

service for such procedure, without 

application of any geographic 

adjustment exceeds the Medicare OPPS 

payment amount for the service for that 

year, without application of any 

geographic adjustment, the Secretary 

shall substitute the OPPS payment 

amount for the ASC standard overhead 

amount. This provision applies to 

surgical procedures furnished in ASCs 

on or after January 1, 2007, and before 

the effective date of the revised ASC 

payment system. 

We discuss in section XVII.C. of this 

preamble, the regulatory changes that 

we are proposing for our current ASC 

payment system. In section XVII.D. of 

this proposed rule, we are addressing 

the changes in payment to ASCs 

mandated by section 5103 of Pub. L. 

109–171, as well as additions to and 

deletions from the list of Medicareapproved ASC procedures to be 

implemented January 1, 2007, prior to 

implementation of the revised ASC 

payment system. In addition, in section 

XVII.E. of this preamble, we are 

proposing changes in the process to 

review payment adjustments for 

insertion of new technology intraocular 

lenses (NTIOLs). The CY 2007 OPPS 

final rule that we issue in the fall of 

2006 will implement changes to the 

ASC list that will go into effect 

January 1, 2007. In section XVIII. of this 

preamble, we are proposing a revised 

payment system for ASCs to be 

implemented effective January 1, 2008, 

including revisions to the ASC list for 

CY 2008, the ratesetting method, and 

the applicable ASC regulations to 

incorporate the requirements and 

payments for ASC facility services 

under the proposed revised ASC system. 

We expect that a final rule 

implementing the revised ASC payment 

system will be published separately in 

the spring of 2007. 

2. Current Payment Method 

There are two primary elements in the 

total cost of performing a surgical 

procedure: (a) The cost of the 

physician’s professional services to 

perform the procedure and (b) the cost 

of items and services furnished by the 

facility where the procedure is 

performed (for example, surgical 

supplies, equipment, and nursing 

services). Payment for the first element 

is made under the Medicare physician 

fee schedule. This proposed rule 

addresses the second element, the 

payment of facility fees for ASC 

services. This proposed rule also 

addresses coverage of ASC services. 

Under the current ASC facility 

services payment system, the ASC 

payment rate is a standard overhead 

amount established on the basis of our 

estimate of a fee that takes into account 

the costs incurred by ASCs generally in 

providing facility services in connection 

with performing a specific procedure. 

The report of the Conference Committee 

accompanying section 934 of the 

Omnibus Reconciliation Act of 1980 

(ORA), Pub. L. 96–499, which enacted 

the ASC benefit in December 1980, 

states that this overhead amount is 

expected to be calculated on a 

prospective basis using sample survey 

data and similar techniques to establish 

reasonable estimated overhead 

allowances, which take into account 

volume (within reasonable limits), for 

each of the listed procedures. (H.R. Rep. 

No. 96–1479, at 134–35 (1980)). 

To establish those reasonable 

estimated allowances for services 

furnished prior to implementation of the 

revised ASC payment system, section 

626(b)(1) of Pub. L. 108–173 amended 

section 1833(i)(2)(A)(i) of the Act to 

require us to take into account the 

audited costs incurred by ASCs to 

perform a procedure, in accordance 

with a survey. Payment for ASC facility 

services is subject to the usual Medicare 

Part B deductible and coinsurance 

requirements and the amounts paid by 

Medicare must be 80 percent of the 

standard fee. 

Section 1833(i)(1) of the Act requires 

us to specify, in consultation with 

appropriate medical organizations, 

surgical procedures that are 

appropriately performed on an inpatient 

basis in a hospital but that can be safely 

performed in an ASC and to review and 

update the list of ASC procedures at 

least every 2 years. 

Section 141(b) of the Social Security 

Act Amendments of 1994, Pub. L. 103–

432, requires us to establish a process 

for reviewing the appropriateness of the 

payment amount provided under 

section 1833(i)(2)(A)(iii) of the Act for 

intraocular lenses (IOLs) for a class of 

NTIOLs. That process was the subject of 

a separate final rule entitled 

‘‘Adjustment in Payment Amounts for 

New Technology Intraocular Lenses 

Furnished by Ambulatory Surgical 

Centers,’’ published in the June 16, 1999 

Federal Register (64 FR 32198). As 

stated earlier, in section XVII.E. of this 

proposed rule, we discuss the changes 

that we are proposing to that process. 

A summary of changes to ASC 

payment rates made prior to CY 1998 

may be found in the June 12, 1998 

proposed rule (63 FR 32292). The 1998 

rule proposed to rebase the ASC 

payment rates using cost, charge, and 

utilization data collected by a 1994 

survey of ASCs. In that proposed rule, 

we also proposed to refine the 

ratesetting methodology that was 

implemented in the February 8, 1990 

Federal Register (55 FR 4577). However, 

the changes that were proposed for the 

ratesetting methodology were not 

implemented because of a combination 

of circumstances resulting in the 

delayed publication of a final rule. 

Those circumstances included several 

extensions to the comment period 

which ended July 30, 1999, Year 2000 

(Y2K) Medicare systems compliancy 

considerations, and legislative changes 

required by the Medicare, Medicaid, 

and SCHIP Balanced Budget Refinement 

Act of 1999 (BBRA), Pub. L. 106–113 

and the Medicare, Medicaid, and SCHIP 

Benefits Improvement and Protection 

Act of 2000 (BIPA), Pub. L. 106–554. 

Readers may refer to the March 28, 2003 

ASC List Update final rule (68 FR 

15269) for a detailed discussion of these 

circumstances and the legislative 

changes. 

3. Published Changes to the ASC List 

Section 1833(i)(1)(A) of the Act 

requires the Secretary to specify surgical 

procedures that, although appropriately 

performed in an inpatient hospital 

setting, can also be performed safely on 

an ambulatory basis in an ASC, a CAH, 

or a hospital outpatient department. The 

report accompanying the legislation 


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explained that the Congress intended 

procedures currently performed on an 

ambulatory basis in a physician’s office 

that do not generally require the more 

elaborate facilities of an ASC not be 

included in the list of ASC covered 

procedures (H.R. Rep. No. 96–1167, at 

390–91, reprinted in 1980 U.S.C.C.A.N. 

5526, 5753–54). In a final rule published 

August 5, 1982, in the Federal Register 

(47 FR 34082), we established 

regulations that included criteria for 

specifying which surgical procedures 

were to be included for purposes of 

implementing the ASC facility benefit. 

Section 416.65(a) of the regulations 

specifies general standards for 

procedures on the ASC list. ASC 

procedures are those surgical and other 

medial procedures that are—

• Commonly performed on an 

inpatient basis but may be safely 

performed in an ASC; 

• Not of a type that are commonly 

performed or that may be safely 

performed in physicians’ offices; 

• Limited to procedures requiring a 

dedicated operating room or suite and 

generally requiring a post-operative 

recovery room or short term (not 

overnight) convalescent room; and 

• Not otherwise excluded from 

Medicare coverage. 

Specific standards in § 416.65(b) limit 

covered ASC procedures to those that 

do not generally exceed 90 minutes 

operating time and a total of 4 hours 

recovery or convalescent time. If 

anesthesia is required, the anesthesia 

must be local or regional anesthesia, or 

general anesthesia of not more than 90 

minutes duration. 

Section 416.65(b)(3) of the regulations 

excludes from the ASC list procedures 

that generally result in extensive blood 

loss, that require major or prolonged 

invasion of body cavities, that directly 

involve major blood vessels, or that are 

generally emergency or life-threatening 

in nature. 

A detailed history of published 

changes to the ASC list and ASC 

payment rates may be found in the June 

12, 1998 proposed rule (63 FR 32292). 

Subsequently, in accordance with 

§ 416.65(c), we published updates of the 

ASC list in the Federal Register on 

March 28, 2003 (68 FR 15268) and May 

4, 2005 (70 FR 23690). 

During years when we have not 

updated the ASC list in the Federal 

Register, we have revised the list to be 

consistent with annual calendar year 

changes to HCPCS and CPT codes. 

These annual coding updates have been 

implemented through program 

instructions to the carriers that process 

ASC claims. The most recent update to 

the list to conform with CPT and HCPCS 

coding changes was published in 

Transmittal R–720–CP, Change Request 

4082, on October 21, 2005. It may be 

found on our Web site at: http:// 

www.cms.hhs.gov/Transmittals/. 

B. Proposed ASC List Update Effective 

for Services Furnished On or After 

January 1, 2007 

1. Criteria for Additions to or Deletions 

From the ASC List 

In April 1987, we adopted 

quantitative criteria for identifying 

procedures that were commonly 

performed either in a hospital inpatient 

setting or in a physician’s office. 

Collectively, commenters responding to 

a notice published on February 16, 1984 

in the Federal Register (49 FR 6023) had 

recommended that virtually every 

surgical CPT code be included on the 

ASC list. Consulting with other 

specialist physicians and medical 

organizations as appropriate, our 

medical staff reviewed the 

recommended additions to the list to 

determine which code or series of codes 

were appropriately performed on an 

ambulatory basis within the framework 

of the regulatory criteria in § 416.65. 

However, when we arrayed the 

proposed procedures by the site where 

they were most frequently performed 

according to our claims payment data 

files (1984 Part B Medicare Data 

(BMAD)), we found that many 

procedures were not commonly 

performed on an inpatient basis or were 

performed in a physician’s office the 

majority of the time, and, thus, would 

not meet the standards in our 

regulations. Therefore, we decided that 

if a procedure was performed on an 

inpatient basis 20 percent of the time or 

less, or in a physician’s office 50 percent 

of the time or more, it would be 

excluded from the ASC list. (April 21, 

1987 (52 FR 13176)). 

At the time, we believed that these 

utilization thresholds best reflected the 

legislative objectives of moving 

procedures from the more expensive 

hospital inpatient setting to the less 

expensive ASC setting without 

encouraging the migration of procedures 

from the generally less expensive 

physician’s office setting to the ASC. We 

applied these quantitative standards not 

only to codes proposed for addition to 

the ASC list, but also to the codes that 

were currently on the list, to delete 

codes that did not meet the thresholds. 

The trend towards performing surgery 

on an ambulatory or outpatient basis 

grew steadily and, by 1995, we 

discovered that a number of procedures 

that were on the ASC list at the time fell 

short of the 20 percent and 50 percent 

thresholds even though the procedures 

were obviously appropriate in the ASC 

setting. The most notable of these was 

cataract extraction with intraocular lens 

insertion that were already being 

performed predominately in outpatient 

settings by the early 1990s, although 

more than 20 percent were also 

performed as inpatient procedures. The 

thresholds would also have excluded 

from the ASC list certain newer 

procedures, such as CPT code 66825 

(Repositioning of intraocular lens 

prosthesis, requiring an incision 

(separate procedure)), that were rarely 

performed on a hospital inpatient basis 

but that were appropriate for the ASC 

setting. Strict adherence to the same 20 

percent and 50 percent thresholds both 

to add and remove procedures did not 

provide latitude for minor fluctuations 

in utilization across settings or errors 

that could occur in the site-of-service 

data drawn from the National Claims 

History File that we were then using for 

analysis. 

In an effort to avoid these anomalies 

but still retain a relatively objective 

standard for determining which 

procedures should comprise the ASC 

list, we adopted in the Federal Register 

notice with comment period published 

on January 26, 1995 (60 FR 5185), a 

modified standard for deleting 

procedures already on the list. We 

deleted from the list only those 

procedures whose combined inpatient, 

hospital outpatient, and ASC site-ofservice volume was less than 46 percent 

of the procedure’s total volume and that 

were either performed 50 percent of the 

time or more in the physician’s office or 

10 percent of the time or less in an 

inpatient hospital setting. We retained 

the 20 percent and 50 percent standard 

to determine which procedures would 

be appropriate additions to the ASC list. 

We are not proposing changes to the 

criteria for adding or deleting items 

from the ASC list effective January 1, 

2007. However, please see section 

XVIII.B. of this proposed rule for a 

discussion of proposed changes in the 

context of developing a revised ASC 

payment system to be effective January 

1, 2008. The proposed changes to the 

criteria result in the addition for CY 

2008 of many procedures that do not 

meet the current criteria for addition to 

the list. 

2. Response to Comments to May 4, 

2005 Interim Final Rule for the ASC 

Update 

In accordance with section 1833(i)(1) 

of the Act, in this proposed rule, we are 

proposing to update the list of 

procedures that are covered when 

furnished in an ASC, effective January 


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1, 2007. In the process of determining 

which procedures to add to the list, we 

focused on requests we received from 

the public in their comments on our 

May 4, 2005 interim final rule (70 FR 

23690). We evaluated codes for which 

we received requests from the public. 

The public comments include requests 

for addition and deletion of specific 

procedures and for assignment to higher 

payment groups for specific procedures. 

3. Procedures Proposed for Addition to 

the ASC List 

Using the current criteria as described 

in section XVII.B.1. of this preamble, we 

identified 14 procedures that we are 

proposing to add to the ASC list 

effective January 1, 2007. The 

procedures would be assigned to one of 

the nine existing ASC payment groups 

as indicated in Table 41. 

TABLE 41.—PROCEDURES PROPOSED FOR ADDITION TO THE ASC LIST EFFECTIVE JANUARY 1, 2007 

CPT Short descriptor 

ASC payment 

group 

13102 ................ Repair wound/lesion add-on ......................................................................................................................................... 1 

13122 ................ Repair wound/lesion add-on ......................................................................................................................................... 1 

13133 ................ Repair wound/lesion add-on ......................................................................................................................................... 1 

19297 ................ Place breast cath for rad .............................................................................................................................................. 9 

21356 ................ Treat cheek bone fracture ............................................................................................................................................ 3 

22520 ................ Percutaneous vertebroplasty, thor ................................................................................................................................ 9 

22521 ................ Percutaneous vertebroplasty, lumb .............................................................................................................................. 9 

22522 ................ Percutaneous vertebroplasty, add’l .............................................................................................................................. 1 

35476 ................ Repair venous blockage ............................................................................................................................................... 9 

36818 ................ AV fuse, upper arm, cephalic ....................................................................................................................................... 3 

37205 ................ Transcath IV stent, percutaneous ................................................................................................................................ 9 

37206 ................ Transcath IV stent/perc, add’l ....................................................................................................................................... 1 

43761 ................ Reposition gastrostomy tube ........................................................................................................................................ 1 

46946 ................ Ligation of hemorrhoids ................................................................................................................................................ 1 

4. Suggested Additions Not Accepted 

There are a number of procedures for 

which we received requests for 

additions to the ASC list that we are not 

proposing to add to the ASC list because 

they do not meet the criteria set forth in 

section 416.65 of the CFR. Those 

procedures are listed in Tables 42 and 

43 below. Our medical advisors believe 

that the procedures listed in Tables 42 

and 43 may be of a type that: 

• Are performed predominantly in 

the hospital inpatient or physician 

office setting; 

• Require an overnight or inpatient 

stay; 

• Require a total of 90 minutes of 

operating time or 4 hours or more of 

recovery time; 

• Require major or prolonged 

invasion of body cavities or involve 

major blood vessels; 

• Are generally emergent or lifethreatening; or 

• Are of a type that result in extensive 

blood loss. 

We are not proposing to add 19 

procedures for which we received 

requests for addition to the ASC list 

because they are procedures that are 

furnished predominantly in the 

physician office setting and according to 

the current criteria are not eligible for 

inclusion on the list. Those procedures 

are displayed in Table 42. 

One request was made that we add 

CPT code 66990 (Use of ophthalmic 

endoscope) to the list. As we stated in 

our May 5, 2005 interim final rule (70 

FR 23704), this code is used to 

recognize the use of equipment that is 

integral to a surgical procedure and is 

not a surgical procedure. For this 

reason, we do not believe that it is an 

appropriate addition to the list. 

TABLE 42.—PROCEDURES NOT PROPOSED FOR ADDITION TO 2007 ASC 

LIST BECAUSE THEY ARE PREDOMINANTLY PERFORMED IN THE PHYSICIAN’S OFFICE

CPT Short descriptor 

31040 ..... Exploration behind upper jaw. 

45300 ..... Proctosigmoidoscopy dx. 

45303 ..... Proctosigmoidoscopy dilate. 

45330 ..... Diagnostic sigmoidoscopy. 

46221 ..... Ligation of hemorrhoid(s). 

46604 ..... Anoscopy and dilation. 

46614 ..... Anoscopy, control bleeding. 

46900 ..... Destruction, anal lesion(s). 

46910 ..... Destruction, anal lesion(s). 

46916 ..... Destruction, anal lesion(s). 

62367 ..... Analyze spine infusion pump. 

62368 ..... Analyze spine infusion pump. 

67028 ..... Injection eye drug. 

67105 ..... Repair detached retina. 

67110 ..... Repair detached retina. 

67145 ..... Treatment of retina. 

67210 ..... Treatment of retinal lesion. 

67221 ..... Ocular photodynamic ther. 

67228 ..... Treatment of retinal lesion. 

We are proposing not to add to the 

ASC list 14 procedures for which we 

received requests because our medical 

advisors determined that those 

procedures do not meet the clinical 

criteria (§ 416.65) for addition. That is, 

the procedures either require more than 

4 hours of recovery time, or may result 

in excessive blood loss, etc., making 

them ineligible for addition to the list of 

ASC procedures. Those procedures are 

displayed in Table 43. 

TABLE 43.—PROCEDURES NOT ADDED

TO THE ASC LIST BECAUSE THEY

DO NOT MEET CURRENT CLINICAL

CRITERIA FOR ADDITION TO THE

ASC LIST

CPT Short descriptor 

27412 ..... Autochondrocyte implant knee. 

27415 ..... Osteochondral knee allograft. 

29866 ..... Autgrft implnt, knee w/scope. 

29867 ..... Allgrft implnt, knee w/scope. 

29868 ..... Meniscal trnspl, knee w/scpe. 

35470 ..... Repair arterial blockage. 

35475 ..... Repair arterial blockage. 

47562 ..... Laparoscopic cholecystectomy. 

47563 ..... Laparo cholecystectomy/graph. 

47564 ..... Laparo cholecystectomy/explr. 

63030 ..... Low back disk surgery. 

63035 ..... Spinal disk surgery add-on. 

63042 ..... Laminotomy, single lumbar. 

63047 ..... Removal of spinal lamina. 

5. Rationale for Payment Assignment 

Currently, procedures on the ASC list 

are assigned to one of nine payment 

groups based on our estimate of the 

costs incurred by the facility to perform 

the procedure. We are proposing no 

changes to those nine payment groups 

and are proposing to assign the 

additional procedures to one of those 

existing payment groups. The payment 


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group to which we propose each 

addition to the ASC list be classified is 

based on the payment group, which our 

medical advisors judged to be similar in 

terms of time and resource inputs to 

procedures currently on the list. The 

proposed list of procedures eligible for 

Medicare payment of a facility fee and 

the proposed rates are displayed in 

Addendum AA of this proposed rule. 

The procedures that are effected by the 

payment limit required by section 5103 

of Pub. L. 109–171 are identified in that 

addendum along with their proposed 

rates. 

6. Other Comments on the May 4, 2005 

Interim Final Rule 

In the May 4, 2005 interim final rule 

(70 FR 23690), we also invited public 

comments on the payment assignments 

for specific procedure codes that we 

added to the ASC list in that rule that 

had not been proposed for addition to 

the ASC list in the November 26, 2004 

proposed rule (69 FR 69178). We 

received comments on 14 of those 

newly-added procedures. A summary of 

those comments and our proposed 

treatment of them for CY 2007 is 

discussed below. 

Several comments requested that we 

delay adding to the ASC list CPT codes 

33212 (Insertion or replacement of 

pacemaker pulse generator only; single 

chamber, atrial or ventricular), 33213 

(Insertion or replacement of pacemaker 

pulse generator only; dual chamber), 

and 33233 (Removal of permanent 

pacemaker pulse generator) until we 

implement the new ASC payment 

system. 

We added these procedures to the 

ASC list in response to a request from 

a commenter. Our medical advisors 

evaluated the request and determined 

that these were appropriate procedures 

for performance in the ASC setting. We 

continue to believe that the procedures 

are appropriate for performance in the 

ASC and see no reason to remove them 

from the list at this time. Therefore, we 

are proposing to make no change in the 

ASC assignments for these three 

procedures. 

Two commenters requested that we 

reassign CPT codes 57155 (Insertion of 

uterine tandems and/or vaginal ovoids 

for clinical brachytherapy) and 58346 

(Insertion of Heyman capsules for 

clinical brachytherapy) to the highest 

ASC payment group. The commenters 

believe that payment at a higher level is 

necessary in order to cover the costs of 

the equipment and supplies used in 

performing the procedures. 

We reviewed the OPPS cost data for 

these procedures and found that the 

median cost for CPT code 57155 is $506 

and that for CPT code 58346 is $364. We 

do not have median cost data for the 

procedures performed in the ASC but 

the ASC payment amount for both 

services is $446, which is within the 

range of the median costs for those 

procedures in the generally more costly 

hospital outpatient setting. This leads us 

to believe that the $446 payment in the 

ASC is quite adequate. We are not 

proposing to assign the procedures to 

higher ASC payment groups. 

Several commenters wrote regarding 

CPT codes 36475 (Endovenous ablation 

therapy of incompetent vein, extremity, 

inclusive of all imaging guidance and 

monitoring, percutaneous, 

radiofrequency; first vein); 36476 

(Endovenous ablation therapy of 

incompetent vein, extremity, inclusive 

of all imaging guidance and monitoring, 

percutaneous, radiofrequency; second 

and subsequent veins in single 

extremity, each through separate access 

sites); 36478 (Endovenous ablation 

therapy of incompetent vein, extremity, 

inclusive of all imaging guidance and 

monitoring, percutaneous, laser; first 

vein); and 36479 (Endovenous ablation 

therapy of incompetent vein, extremity, 

inclusive of all imaging guidance and 

monitoring, percutaneous, laser; second 

and subsequent veins treated in a single 

extremity, each through separate access 

sites). The commenters requested that 

we remove these procedures from the 

ASC list, and suggested that if we were 

unwilling to remove them from the list, 

that we assign the procedures to a 

higher payment group. They believe that 

these procedures require significantly 

more facility resources than other 

procedures with which they are 

currently grouped in payment level 3. 

The commenters explained that if the 

procedures were excluded from the list, 

more adequate payments would be 

made to physicians under the Medicare 

physician fee schedule for the required 

resources. 

We added these procedures to the list 

in response to public comments. We 

initially assigned the codes to ASC 

payment group 3, consistent with other 

procedures with similar clinical 

indications. We continue to believe that 

these procedures are appropriate for 

performance in the ASC setting and will 

not remove them from the list. However, 

we agree with the commenters’ point 

that these procedures require 

significantly more facility resources 

than traditional vein removal 

procedures, and, therefore, we are 

proposing to reassign them to ASC 

payment group 9. We believe that this 

is an appropriate payment level that 

takes into consideration the costs of the 

required equipment and supplies. 

Two comments requested that we 

assign CPT code 46947 

(Hemorrhoidopexy by stapling) to a 

higher ASC payment group. The 

commenters stated that due to the cost 

of the stapler used in the procedure, the 

resources required for this procedure are 

not similar to the other surgical 

procedures for the treatment of 

hemorrhoids that are also assigned to 

ASC payment group 3. The commenters 

suggested that it would be more 

appropriate to assign this procedure to 

ASC payment group 7. 

We agree with the commenters and 

are proposing to reassign this procedure 

to ASC payment group 7 for CY 2007. 

One commenter raised concern about 

payment for CPT code 49419 (Insertion 

of intraperitoneal cannula or catheter, 

with subcutaneous reservoir, 

permanent). The commenter reported 

that the catheter that is used in 

performing this procedure is billed 

separately under the DMEPOS fee 

schedule, and that Medicare carriers 

have discretion over whether or not to 

allow that payment. According to the 

commenter, in some areas, separate 

payment is not made for the catheter 

that is integral to the procedure. 

We believe that the commenter may 

be misinformed, because cannulas and 

catheters are not considered durable 

medical equipment, and they are not 

paid under the DMEPOS fee schedule. 

Rather, they are considered to be 

supplies. Payment for supplies 

furnished by an ASC in connection with 

a surgical procedure is bundled into the 

payment for the surgical procedure for 

which the supplies are required. 

One commenter requested that we 

allow separate payment for the material 

used as the sling in the procedure 

described by CPT code 51992 

(Laparoscopy, surgical; sling operation 

for stress incontinence (e.g., fascia or 

synthetic)). The commenter stated that 

without separate payment for the sling 

material, the Medicare payment for 

performing the procedure is inadequate 

to cover the service. The commenter 

also stated that there is no specific 

HCPCS code to use for billing the 

synthetic sling material. 

We added CPT code 51992 to the ASC 

list in the last update in response to 

comments. We assigned CPT code 

51992 to ASC payment group 5, the 

same ASC payment group to which 

other procedures to treat stress 

incontinence are assigned. We realize 

that the synthetic material for the sling 

may be costly, but there is no 

identifiable HCPCS code available for 

use in ASCs to report the material, and 

such material is not eligible for separate 

payment from Medicare in the ASC or 


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in any other setting. Further, CPT code 

51992 describes a procedure that may be 

performed using synthetic material or 

fascia. As such, we cannot know 

whether the more costly synthetic 

material is used in any specific 

procedure and do not believe it is 

appropriate to fully incorporate the 

synthetic supply costs into the payment 

for all of the procedures performed. We 

continue to believe that ASC payment 

group 5 is an appropriate assignment for 

the procedure, and we are not proposing 

to change that assignment. 

One commenter requested that we 

make separate payment for the 

microinserts that are used in performing 

CPT code 58565 (Hysteroscopy, 

surgical; with bilateral fallopian tube 

cannulation to induce occlusion by 

placement of permanent implants) even 

though there is no specific HCPCS code 

to describe the microinserts for billing, 

making separate payment impossible. 

We added CPT code 58565 to the ASC 

list in the last update in response to 

public comment. We assigned the 

procedure to ASC payment group 4 with 

other procedures with similar clinical 

indications. After further review, we are 

convinced that the procedure described 

by CPT code 58565 is significantly more 

resource-intensive than the other 

procedures in ASC payment group 4 

and, therefore, we are proposing to 

reassign it to ASC payment group 9 for 

CY 2007. 

Several comments requested that CMS 

issue instructions to permit separate 

payment for the catheters that are 

inserted during the procedures 

described by CPT codes 19296 

(Placement of radiotherapy afterloading 

balloon catheter into the breast for 

interstitial radioelement application 

following partial mastectomy, includes 

imaging guidance; on date separate from 

partial mastectomy) and 19298 

(Placement of radiotherapy afterloading 

brachytherapy catheters into the breast 

for interstitial radioelement application 

following partial mastectomy, includes 

imaging guidance). 

One commenter supported adding 

CPT code 19296 to the ASC list and 

assigning it to ASC payment group 9, 

but asserted that separate payment 

should also be provided for the balloon 

catheter inserted during the procedure. 

With regard to CPT code 19298, other 

commenters also stated that the 

payment level is inadequate and that 

separate payment should be allowed for 

the catheters inserted during the 

procedure. One of the commenters 

explained that the catheters used to 

perform the procedure described by CPT 

code 19298 are not high cost items 

(about $18.50 each) but these 

procedures typically use 30 catheters 

which makes the catheters a significant 

cost factor in performing the procedure. 

The catheters used in these 

procedures are classified as surgical 

supplies and as such, are not included 

on the DMEPOS fee schedule and are, 

therefore, not eligible for separate 

payment in the ASC. Payments for the 

costs of the catheters are packaged into 

the payments for performing the 

procedures. Currently CPT code 19298 

is assigned to ASC payment group 1. 

Based on the information provided by 

the commenters we are persuaded that 

reassignment to a higher ASC payment 

group is warranted. Therefore, we are 

proposing to reassign CPT code 19298 to 

ASC payment group 9 for CY 2007. 

C. Proposed Regulatory Changes for CY 

2007 

As stated earlier, we are proposing a 

revised payment system for ASCs to be 

implemented effective January 1, 2008, 

including revisions to the ASC list for 

CY 2008, the ratesetting method, and 

the applicable ASC regulations to 

incorporate the requirements and 

payments for ASC facility services 

under the proposed revised ASC system. 

We expect that a final rule 

implementing the revised ASC payment 

system will be published separately in 

the spring of 2007. The revised ASC 

payment system will not take effect 

until January 1, 2008. However, we need 

to revise our current regulations at part 

416, subparts D and E to ensure that the 

rules governing our current system are 

clearly distinguishable from those that 

would apply to the revised system 

beginning January 1, 2008. Therefore, 

we are proposing to revise subparts D 

and E to part 416 to reflect that these are 

the rules governing the APC payment 

system prior to January 1, 2008, and to 

redesignate the existing subpart F as 

subpart G under part 416 to codify the 

rules governing the ASC payment 

adjustment for NTIOLs. In addition, we 

are proposing to revise existing—

• § 416.1 (Basis and scope) to remove 

the obsolete reference to ‘‘a hospital 

outpatient department,’’ to add 

provisions of section 5103 of Pub. L. 

109–171, and applicable provisions of 

Pub. L. 108–173. 

• § 416.65 (Covered surgical 

procedures) to modify the introductory 

text to clearly denote the section’s 

application to covered surgical 

procedures furnished before January 1, 

2008. In addition, we are proposing to 

remove the obsolete cross-reference in 

paragraph (a)(4) to § 405.310 and replace 

it with the correct cross-reference to 

§ 411.15. 

• § 416.125 (ASC facility services 

payment rate) to incorporate the 

limitation on payment imposed by 

section 5103 of Pub. L. 109–171. 

• § 488.1 (Definitions) to correct a 

longstanding error by adding 

ambulatory surgical centers to the 

definition of a supplier in conformance 

with section 1861(d) of the Act. 

We also are proposing to add a new 

§ 416.76 and § 416.121 to subparts D 

and E, respectively, to clearly state that 

the provisions of subparts D and E apply 

to services furnished before January 1, 

2008. 

D. Implementation of Section 5103 of 

Pub. L. 109–171 (DRA) 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Section 5103’’ at the beginning 

of your comments.) 

As noted in section XVII.A.1. of this 

preamble, section 5103 of Pub. L. 109–

171 requires us to substitute the OPPS 

payment amount for the ASC standard 

overhead amount for surgical 

procedures performed at an ASC on or 

after January 1, 2007, but prior to the 

revised payment system when the ASC 

standard overhead amount exceeds the 

OPPS payment amount for the 

procedure. In Addendum AA of this 

proposed rule, we identify the HCPCS 

codes that we believe would be subject 

to section 5103 based on a comparison 

of the CY 2007 proposed OPPS payment 

rates and the ASC standard overhead 

amounts that are effective in CY 2007. 

We are proposing to add paragraph (c) 

to § 416.125 to reflect this change. 

E. Proposal To Modify the Current ASC 

Process for Adjusting Payment for New 

Technology Intraocular Lenses (NTIOLs) 

1. Background 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘NTIOL’’ at the beginning of 

your comments.) 

At the inception of the ASC benefit on 

September 7, 1982, Medicare paid 80 

percent of the reasonable charge for 

IOLs supplied for insertion concurrent 

with or following cataract surgery 

performed in an ASC (see 47 FR 34082, 

August 5, 1982). Section 4063(b) of 

OBRA 1987, Pub. L. 100–203, amended 

the Act to mandate that we include 

payment for an IOL furnished by an 

ASC for insertion during or following 

cataract surgery as part of the ASC 

facility fee for insertion of the IOL, and 

that the facility fee include payment 

that is reasonable and related to the cost 

of acquiring the class of lens involved 

in the procedure. 

Section 4151(c)(3) of the Omnibus 

Budget Reconciliation Act of 1990 


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(OBRA 1990), Pub. L. 101–508, froze the 

IOL payment amount at $200 for IOLs 

furnished by ASCs in conjunction with 

surgery performed during the period 

beginning November 5, 1990, and 

ending December 31, 1992. We 

continued paying an IOL allowance of 

$200 from January 1, 1993, through 

December 31, 1993. 

Section 13533 of the Omnibus Budget 

Reconciliation Act of 1993 (OBRA 

1993), Pub. L. 103–66, mandated that 

payment for an IOL furnished by an 

ASC be equal to $150 beginning January 

1, 1994, through December 31, 1998. 

Section 141(b)(1) of the Social 

Security Act Amendments of 1994 

(SSAA 1994), Pub. L. 103–432, required 

us to develop and implement a process 

under which interested parties may 

request a review of the appropriateness 

of the payment amount for insertion of 

an IOL, to ensure that the facility fee for 

the procedure includes payment that is 

reasonable and related to the cost of 

acquiring a lens that belongs to a class 

of NTIOLs. 

In the February 8, 1990 Federal 

Register (55 FR 4526), we published a 

final notice entitled ‘‘Revision of 

Ambulatory Surgery Center Payment 

Rate Methodology,’’ which 

implemented Medicare payment for an 

IOL furnished at an ASC as part of the 

ASC facility fee for insertion of the IOL. 

In the June 16, 1999 Federal Register 

(64 FR 32198), we published a final rule 

entitled ‘‘Adjustment in Payment 

Amounts for New Technology 

Intraocular Lenses Furnished by 

Ambulatory Surgical Centers’’ to add a 

subpart F (§§ 416.180 through 416.200) 

to 42 CFR Part 416, which established 

a process for adjusting payment 

amounts for insertion of a class of 

NTIOLs furnished by ASCs. 

Our current regulations §§ 416.180 

through 416.200 define the terms 

relevant to the process, establish the 

payment review process, and establish 

$50 as the payment adjustment amount 

that is added to the ASC facility fee for 

insertion of a lens that CMS determines 

is an NTIOL. Section 416.200 provides 

that the payment adjustment applies for 

a 5-year period that begins when we 

recognize the first lens that establishes 

a class of NTIOLs. In accordance with 

§ 416.200(b), insertion of a lens that we 

subsequently recognize as belonging to 

an existing NTIOL class would receive 

the payment adjustment for the 

remainder of the 5-year period 

established for the class. Section 

416.185(f)(2) provides that after July 16, 

2002, we have the option of changing 

the $50 adjustment amount through 

proposed and final rulemaking in 

connection with ASC services. 

Since June 16, 1999, we have issued 

a series of Federal Register notices to 

list lenses for which we received 

requests for a NTIOL payment 

adjustment and to solicit comments on 

those requests, or to announce the 

lenses that we have determined meet 

the criteria and definition of NTIOLs. 

We last published a Federal Register 

notice pertaining to NTIOLs on April 

28, 2006 (71 FR 25176). 

a. Current ASC Payment for Insertion of 

IOLs 

The current ASC payment groups, 

payment rates and procedural HCPCS 

codes for cataract extraction with IOL 

insertion are as follows: 

Payment Group 6—$826 ($676 + $150 

IOL Allowance) 

• CPT code 66985, Insertion of 

intraocular lens prosthesis (secondary 

implant), not associated with concurrent 

cataract removal 

• CPT code 66986, Exchange of 

intraocular lens 

Payment Group 8—$973 ($823 + $150 

IOL allowance) 

• CPT code 66982 Extracapsular 

cataract removal with insertion of 

intraocular lens prosthesis (one stage 

procedure), manual or mechanical 

technique (for example, irrigation and 

aspiration or phacoemulsification), 

complex, requiring devices or 

techniques not generally used in routine 

cataract surgery (for example, iris 

expansion device, suture support for 

intraocular lens, or primary posterior 

capsulorrhexis) or performed on 

patients in the amblyogenic 

developmental stage 

• CPT code 66983 Intracapsular 

cataract extraction with insertion of 

intraocular lens prosthesis (one stage 

procedure) 

• CPT code 66984 Extracapsular 

cataract removal with insertion of 

intraocular lens prosthesis (one stage 

procedure), manual or mechanical 

technique (for example, irrigation and 

aspiration or phacoemulsification) 

b. Classes of NTIOLs Approved for 

Payment Adjustment 

Since implementation of the process 

for adjustment of payment amounts for 

NTIOLs, that was established in the 

June 16, 1999 Federal Register, we have 

approved three classes of NTIOLs, as 

shown in the following table: 

NTIOL category HCPCS 

code 

$50 approved for services 

furnished on or after 

NTIOL 

characteristic IOLs eligible for adjustment 

1 ........................ Q1001 .... May 18, 2000, through 

May 18, 2005.

Multifocal ........................... Allergan AMO Array Multifocal lens, model SA40N. 

2 ........................ Q1002 .... May 18, 2000, through 

May 18, 2005.

Reduction in Preexisting 

Astigmatism.

STAAR Surgical Elastic Ultraviolet-Absorbing Silicone 

Posterior Chamber IOL with Toric Optic, models 

AA4203T, AA4203TF, and AA4203TL. 

3 ........................ Q1003 .... February 27, 2006, 

through February 26, 

2011.

Reduced Spherical Aberration.Advanced Medical Optics (AMO) Tecnis() IOL models Z9000, Z9001, and ZA9003; Alcon Acrysof IQ 

Model SN60WF. 

2. Proposed Changes 

a. Process for Recognizing IOLs as 

Belonging to an Active NTIOL Class 

Currently, we accept and review 

applications for inclusion in an active 

NTIOL class on a continuous basis 

throughout the year in accordance with 

§§ 416.180 through 416.200 of the 

regulations. We are proposing to 

continue this established process and to 

update and streamline it, as discussed 

below, to specify the request and 

comment review process, the 

information that a request must include 

to be accepted for review, the specific 

factors to be considered in evaluating 

requests, and the process to provide 

notification of determinations. As stated 

in section XVII.D. of this preamble, we 

are proposing to redesignate existing 

subpart F of part 416 as subpart G, 

which would include the regulations 

pertaining to the ASC payment 

adjustment for NTIOLs. In addition, we 

are proposing to revise redesignated 

subpart G to add new § 416.180, 

§ 416.185, § 416.190, § 416.195, and 

§ 416.200 to the regulations to reflect the 

changes that we are proposing to this 

process. 

One of the regulatory changes that we 

are proposing is to revise existing 

§ 416.180 to establish the basis and 


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scope for this ASC payment adjustment. 

This proposal would eliminate the 

definitions currently included in that 

section for ‘‘Class of new technology 

intraocular lenses (IOLs),’’ ‘‘Interested 

party,’’ ‘‘New technology IOL,’’ and 

‘‘New technology subset.’’ We do not 

believe that we need to retain these 

definitions because additional revisions 

that we are proposing to the regulations 

at part 416 would eliminate the term 

‘‘interested party’’ from §§ 416.185(c) 

and 416.190 and the term ‘‘new 

technology subset’’ from §§ 416.185(g), 

416.200(a), (b), and (c) and further 

clarify the terms ‘‘new technology IOL’’

and ‘‘class of new technology 

intraocular lenses (IOLs).’’

The other changes that we are 

proposing to part 416, pertaining to the 

ASC payment adjustment for NTIOLs, 

are discussed in this section. 

b. Public Notice and Comment 

Regarding Adjustments of NTIOL 

Payment Amounts 

We are proposing to update and 

streamline the process for determining 

whether an IOL that is to be inserted 

during or subsequent to cataract 

extraction qualifies for payment 

adjustment as a NTIOL, as set forth in 

existing § 416.185 of our regulations. 

The basis for the current NTIOL 

payment review process was enacted in 

1994 and has been implemented 

through a series of separate Federal 

Register notices specific to NTIOLs. We 

are proposing to modify the current 

process of using separate Federal 

Register notices to notify the public of 

requests to review lenses for 

membership in new NTIOL classes, to 

solicit public comment on requests, and 

to notify the public of CMS 

determinations concerning new classes 

of NTIOLs for which an ASC payment 

adjustment would be made. We are 

proposing that these NTIOL-related 

notifications would be fully integrated 

into the annual notice and comment 

rulemaking for updating the ASC 

payment rates, the specific payment 

system in which NTIOL payment 

adjustments are made. Given that the 

NTIOL payment adjustments are 

applicable to ASC services and that the 

proposal for updating the new ASC 

payment system to be implemented in 

January 2008 anticipates an annual 

update process in coordination with 

notice and comment rulemaking on the 

OPPS, aligning the NTIOL process with 

this annual update would promote 

coordination and efficiency, thereby 

streamlining and expediting the NTIOL 

notification, comment, and review 

process. 

Specifically, we are proposing the 

following process: 

• We would announce annually in 

the Federal Register document that 

proposes the update of ASC payment 

rates for the following calendar year, a 

list of all requests to establish new 

NTIOL classes accepted for review 

during the calendar year in which the 

proposal is published and the deadline 

for submission of public comments 

regarding those requests. The deadline 

would be 30 days following publication 

of the list of requests. 

• In the Federal Register document 

that finalizes the update of ASC 

payment rates for the following calendar 

year we would—

+ Provide a list of determinations 

made as a result of our review of all 

requests and public comments; and 

+ Publish the deadline for submitting 

requests for review in the following 

calendar year. 

We believe that the coordination of 

public notice and comment regarding 

requests to establish new NTIOL classes 

with the update of ASC payment rates 

would facilitate judicious and 

comprehensive review and comment by 

interested parties, thereby resulting in 

more timely access to improved health 

technologies for Medicare beneficiaries. 

Accordingly, we are proposing to revise 

§ 416.185 to reflect these proposed 

changes to the current process for 

publishing separate Federal Register 

notices specific to NTIOLs. 

We note that we did not receive any 

review requests in response to the 

specific NTIOL April 28, 2006 notice 

(71 FR 25176) soliciting CY 2006 

requests for review of the 

appropriateness of the payment amount 

for particular NTIOLs furnished in 

ASCs. 

c. Factors CMS Considers in 

Determining Whether an Adjustment of 

Payment for Insertion of a New Class of 

NTIOL Is Appropriate 

In determining whether a lens belongs 

to a new class of NTIOLs for which the 

ASC payment amount for insertion in 

conjunction with cataract surgery is 

appropriate, we expect that the insertion 

of the candidate IOL would result in 

significantly improved clinical 

outcomes compared to currently 

available IOLs. In addition, to establish 

a new NTIOL class, the candidate lens 

must be distinguishable from lenses 

already approved as members of active 

or expired classes of NTIOLs that share 

a predominant characteristic associated 

with improved clinical outcomes that 

was identified for each class. We are 

proposing to base our determinations on 

consideration of the following factors: 

• The IOL must have been approved 

by the FDA and claims of specific 

clinical benefits and/or lens 

characteristics with established clinical 

relevance in comparison with currently 

available IOLs must have been approved 

by the FDA for use in labeling and 

advertising. 

• The IOL is not described by an 

active or expired NTIOL class; that is, it 

does not share the predominant, classdefining characteristic associated with 

improved clinical outcomes with 

designated members of an active or 

expired NTIOL class. 

• Evidence demonstrating that use of 

the IOL results in measurable, clinically 

meaningful, improved outcomes in 

comparison with use of currently 

available IOLs. According to the statute, 

and consistent with previous examples 

provided by CMS, superior outcomes 

that would be considered include the 

following: 

+ Reduced risk of intraoperative or 

postoperative complication or trauma; 

+ Accelerated postoperative recovery; 

+ Reduced induced astigmatism; 

+ Improved postoperative visual 

acuity; 

+ More stable postoperative vision; 

+ Other comparable clinical 

advantages, such as—

++ Reduced dependence on other 

eyewear (for example, spectacles, 

contact lenses, and reading glasses) 

++ Decreased rate of subsequent 

diagnostic or therapeutic interventions, 

such as the need for YAG laser 

treatment. 

++ Decreased incidence of subsequent 

IOL exchange. 

++ Decreased blurred vision, glare, 

other quantifiable symptom or vision 

deficiency. 

In order to assess the clinical 

performance of a candidate IOL to 

establish a new NTIOL class, outcomes 

from use of the candidate lens would be 

compared with outcomes of use of 

currently available IOLs. Due to the 

rapid evolution of medical technology, 

we expect that the baseline of currently 

available IOLs for comparison would 

change from year to year. It is our 

expectation that the current ASC 

payment adjustment for active NTIOL 

classes should support the development 

and dissemination of new IOL 

technologies that would continue to 

improve the clinical outcomes of 

Medicare beneficiaries furnished IOLs 

after cataract extraction. 

Accordingly, we are proposing to 

revise our process for determining 

whether a lens belongs to a new class 

of NTIOLs for which an ASC payment 

adjustment is appropriate by setting 

forth the factors that we propose to 


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consider in making this determination. 

In addition, we are proposing to revise 

§ 416.195 of the regulations to 

incorporate these proposed factors. 

Further, we are seeking public 

comments on the desirability of further 

interpreting the phrase ‘‘currently 

available lenses’’ for purposes of 

comparison and specific approaches to 

providing such clarifications. We 

believe that further interpretation could 

be helpful to requestors seeking to 

provide the most relevant, authoritative 

evidence concerning the clinical 

benefits of their lenses in comparison 

with those currently available lenses 

and to us as we review the information 

provided in requests to establish new 

NTIOL classes. However, we also 

believe that any clarifications should 

incorporate our expectations for 

technological progression of the 

baseline comparison lenses over time as 

we make future annual determinations 

regarding the establishment of new 

NTIOL classes. Therefore, we believe 

that the public’s comments regarding 

practical and meaningful approaches to 

elaborating on the phrase ‘‘currently 

available lenses’’ would facilitate both 

requestors’ submission of complete 

requests for review and appropriate 

determinations by CMS regarding new 

NTIOL classes to receive the ASC 

payment adjustment. 

d. Proposal To Revise Content of a 

Request To Review 

To enable us to make a determination 

that the criteria for a payment 

adjustment for a new NTIOL class are 

met, we are proposing to require that a 

request include the information listed 

below. We are proposing to revise the 

content of a request (as currently set 

forth in § 416.195(a)) based on our 

experience in evaluating applications 

for OPPS pass-through status for new 

device categories over the past 6 years. 

We have found that the additional 

information allows our medical advisors 

to complete a more comprehensive 

evaluation, which would ensure that a 

payment adjustment is appropriate. We 

also have found that such information 

must be updated in a timely manner to 

ensure its relevancy to advancing 

technologies. Therefore, we also are 

proposing to post the information listed 

below on the CMS Web site at: http:// 

www.cms.hhs.gov/center/asc/asp to 

provide easy access for updating rather 

than incorporating it in § 416.195(a) of 

the regulations. 

In addition, we are proposing to 

continue to require that a separate 

request would be required for each 

NTIOL for which a payment review as 

member of a new class is sought. We are 

proposing that a request that does not 

include all of the following information 

would be considered incomplete and 

could not be accepted for review until 

all information is furnished: 

• Proposed name or description of a 

new class of NTIOLs. 

• Trade/brand name, manufacturer, 

and model number of the IOL for which 

the request to establish a new NTIOL 

class is being made. (Applications must 

include the name and description of at 

least one marketed IOL that would be 

placed in the proposed new NTIOL 

class.) 

• A list of all active or expired NTIOL 

classes that describe similar IOLs. For 

each active or expired class, provide a 

detailed explanation as to why that class 

would not describe the candidate IOL. 

• Detailed description of the FDA 

approved clinical indications for the 

candidate IOL. 

• Description of the IOL—

+ What is it? Provide a complete 

physical description of the IOL, 

including its components, for example, 

its composition; coating or covering; 

haptics; material; and construction. 

+ What does it do? 

+ How is it used? 

+ What makes it different from other 

currently available IOLs? 

+ What makes it superior to other 

currently available IOLs used for similar 

indications? 

+ What are its clinical characteristics, 

for example, is it used for treatment of 

specific pathology; what is its life span; 

what are the complications associated 

with its use; and for what patient 

populations is it intended? 

+ Submit relevant booklets, 

pamphlets, brochures, product 

catalogues, price lists, and/or package 

inserts that further describe and 

illuminate the nature of the IOL. 

• If the candidate IOL replaces or 

improves upon an existing IOL, identify 

the trade/brand name and model of the 

existing IOL(s). 

• Full discussion of the clinically 

meaningful, improved outcomes that 

result from use of the candidate IOL 

compared to use of other currently 

available IOLs. This discussion must 

include evidence to demonstrate that 

use of the IOL results in measurable, 

clinically significant improvement over 

currently available IOLs in one or more 

of the following areas: 

+ Reduced risk of intraoperative or 

postoperative complication or trauma. 

+ Accelerated postoperative recovery. 

+ Reduced induced astigmatism. 

+ Improved postoperative visual 

acuity; 

+ More stable postoperative vision. 

+ Other comparable clinical 

advantages, such as—

++ Reduced dependence on other 

eyewear (for example, spectacles, 

contact lenses, and reading glasses); 

• Decreased rate of subsequent 

diagnostic or therapeutic interventions, 

such as the need for YAG laser 

treatment; 

++ Decreased incidence of 

subsequent IOL exchange; and 

++ Decreased blurred vision, glare or 

other quantifiable symptom or vision 

deficiency. 

• Provide the following information 

for the IOL(s) for which a new class is 

proposed: 

+ Dates the candidate IOL was first 

marketed, reporting inside the United 

States and outside the United States 

separately. 

+ Dates of sale of the first unit of the 

IOL, reporting inside the United States 

and outside the United States 

separately. 

+ Number of IOLs that have been sold 

up to the date of the application. 

+ A copy of the FDA’s original 

approval notification. 

• A copy of the labeling claims 

approved by the FDA for the IOL, 

indicating its clinical advantages and/or 

the lens characteristics with clinical 

relevance. 

• A copy of the FDA’s summary of 

the IOL’s safety and effectiveness. 

• Reports of modifications made after 

the original FDA approval. 

We strongly encourage and may give 

greater consideration for the submission 

of published, peer-reviewed literature 

and other materials that demonstrate 

substantial clinical improvement with 

use of the candidate IOL over use of 

currently available IOLs. 

Proposed § 416.190(d) provides that, 

in order for CMS to invoke the 

protection allowed under Exemption 4 

of the Freedom of Information Act (5 

U.S.C. 552(b)(4)) and, with respect to 

trade secrets, the Trade Secrets Act (18 

U.S.C. 1905), the requestor must clearly 

identify all information that is to be 

characterized as confidential. 

For the stated reasons, we are 

proposing to revise § 416.190 to reflect 

these proposed changes to the content of 

a request for payment review of an IOL, 

to clarify when a request can be 

submitted and who may submit, and to 

also clarify the process for maintaining 

confidentiality of information included 

in a request. As stated earlier, we are not 

proposing to incorporate the list of 

proposed information required with 

each request in the regulations, but are 

proposing to post it on the CMS Web 

site to ensure that such information is 

updated in a timely manner and 

relevant to advancing IOL technologies. 

We are proposing to revise § 416.190 to 


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require that the content of each request 

for an IOL review must include all 

information as specified on the CMS 

Web for the request to be considered 

complete. 

e. Notice of CMS Determination 

We are proposing three possible 

outcomes from review of a request for 

determination of a new NTIOL class. As 

appropriate, for each completed request 

for a candidate IOL that is received by 

the established deadline, one of the 

following determinations would be 

announced annually in the final rule 

updating the ASC payment rates for the 

next calendar year: 

• The request for a payment 

adjustment is approved for the IOL for 

5 full years as a member of a new 

NTIOL class described by a new code. 

• The request for a payment 

adjustment is approved for the IOL for 

the balance of time remaining as a 

member of an active NTIOL class. 

• The request for a payment 

adjustment is not approved. 

We also are proposing to summarize 

briefly in the ASC final rule the 

evidence that was reviewed, the public 

comments, and the basis for our 

determination. When a new NTIOL 

class is established, we are proposing to 

identify the predominant characteristic 

of NTIOLs in that class that sets them 

apart from other IOLs (including those 

previously approved as members of 

other expired or active NTIOL classes) 

and is associated with improved clinical 

outcomes. The date of implementation 

of a payment adjustment in the case of 

approval of an IOL as a member of a 

new NTIOL class would be set 

prospectively as of 30 days after 

publication of the ASC payment update 

final rule, consistent with the statutory 

requirement. The date of 

implementation of a payment 

adjustment in the case of approval of a 

lens as a member of an active NTIOL 

class would be set prospectively as of 

the publication date of the ASC 

payment update final rule. 

f. Proposed Payment Adjustment 

The current payment adjustment for a 

5-year period from the implementation 

date of a new NTIOL class is $50. We 

are not proposing to revise this payment 

adjustment for CY 2007. 

For CY 2007, we are proposing to 

revise § 416.200(a) through (c) to clarify 

how the IOL payment adjustment would 

be made and how an NTIOL would be 

paid after expiration of the payment 

adjustment. We also are proposing 

minor editorial changes to § 416.200(d). 

XVIII. Proposed Revised Ambulatory 

Surgical Center (ASC) Payment System 

for Implementation January 1, 2008 

A. Background 

Generally, there are two primary 

elements in the total cost of performing 

a surgical procedure: the cost of the 

physician’s professional services for 

performing the procedure and the cost 

of services furnished by the facility 

where the procedure is performed (for 

example, surgical supplies, equipment, 

nursing services, and overhead). The 

former is covered by the Medicare 

physician fee schedule. In 1980, a new 

Medicare benefit was enacted, 

authorizing payment of a fee to ASCs for 

facility services furnished in connection 

with performing certain surgical 

procedures. 

The statute requires us to specify 

surgical procedures that are 

appropriately and safely performed on 

an ambulatory basis in an ASC. 

Moreover, we are to review and update 

the list of these procedures not less 

often than every 2 years, in consultation 

with appropriate trade and professional 

associations. The ASC list was limited 

in 1982 to approximately 100 

procedures. Currently, the list consists 

of more than 2,500 CPT codes 

encompassing a cross-section of surgical 

services, although 150 of these codes 

account for more than 90 percent of the 

approximately 4.5 million procedures 

paid for each year under the ASC Part 

B benefit. Eye, pain management, and 

gastrointestinal endoscopic procedures 

are the highest volume ASC surgeries 

under the present payment system. 

Medicare only allows payment to 

ASCs for procedures on the ASC list. 

Medicare pays 80 percent of the 

prospectively determined fee; the 

coinsurance rate is 20 percent for all 

procedures on the ASC list. In Pub. L. 

108–173, the Congress mandated 

implementation of a revised payment 

system for ASC surgical services by no 

later than January 1, 2008. Pub. L. 108–

173 sets forth several requirements for 

the revised payment system, but does 

not amend those provisions of the 

statute pertaining to the ASC list. 

In section XVIII. of this preamble, we 

describe the provisions of the revised 

ASC payment system that we are 

proposing to implement, as required by 

Pub. L.108–173, not later than January 

1, 2008. Our proposal encompasses two 

components: first, our proposal for 

establishing and maintaining the ASC 

list of Medicare approved procedures 

under the revised payment system, and 

second, the method we are proposing to 

use to set payment rates for ASC facility 

services furnished in association with 

procedures on the ASC list. We also 

discuss in this section regulatory 

changes that we are proposing to 42 CFR 

parts 416 and 488 to incorporate the 

rules governing ASC facility payments 

under the revised payment system that 

would be applicable beginning in CY 

2008. 

1. Provisions of Pub. L. 108–173 

Section 626(a) of Pub. L. 108–173 

amended section 1833(i)(2)(C) of the 

Act, which requires the Secretary to 

update ASC payment rates using the 

Consumer Price Index for all urban 

consumers (U.S. City average) (CPI-U) if 

the Secretary has not otherwise updated 

the amounts under the revised ASC 

payment system. As amended by Pub. L. 

108–173, this section requires that if the 

Secretary is required to apply the CPIU increase, the CPI-U percentage 

increase is to be applied on a fiscal year 

basis beginning with FY 1986 through 

FY 2005 and on a calendar year basis 

beginning with 2006. 

Pub. L. 108–173 further amended 

section 1833(i)(2)(C) of the Act to 

require us in FY 2004, beginning April 

1, 2004, to increase the ASC payment 

rates using the CPI-U as estimated for 

the 12-month period ending March 31, 

2003, minus 3.0 percentage points. Pub. 

L. 108–173 also requires that the CPI 

adjustment factor equal zero percent in 

FY 2005, the last quarter of CY 2005, 

and each CY from 2006 through 2009. 

Section 626(b) of Pub. L. 108–173 

repeals the requirement that CMS 

conduct a survey of ASC costs upon 

which to base a standard overhead 

payment amount for surgical services 

performed in ASCs, and adds section 

1833(i)(2)(D)(iii) to the Act, which 

requires us to implement by no earlier 

than January 1, 2006, and not later than 

January 1, 2008, a revised ASC payment 

system. The revised payment system 

under section 1833(i)(2)(D)(i) of the Act 

is to take into account the 

recommendations contained in a Report 

to Congress that the GAO was required 

to submit by January 1, 2005. Section 

1833(i)(2)(D)(ii) of the Act requires that 

the revised ASC payment system be 

designed to result in the same aggregate 

amount of expenditures for surgical 

services furnished in ASCs the year the 

system is implemented as would be 

made if the new system did not apply 

as estimated by the Secretary. This 

requirement is to take into account the 

limitation in ASC expenditures 

resulting from implementation of 

section 5103 of Pub. L. 109–171 

beginning January 1, 2007, as we 

describe in section XVII.A.1 of this 

preamble. 


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Section 1833(i)(2)(D)(iv) of the Act 

exempts the classification system, 

relative weights, payment amounts, and 

geographic adjustment factor (if any) 

under the revised ASC payment system 

from administrative and judicial review. 

Section 626(c) of Pub. L. 108–173 

adds a conforming amendment to 

section 1833(a)(1) of the Act providing 

that the amounts paid under the revised 

ASC payment system shall equal 80 

percent of the lesser of the actual charge 

for the services or the payment amount 

that we determine. 

2. Other Factors Considered 

On August 2, 2005, we convened a 

listening session teleconference on 

revising the Medicare ASC payment 

system. Over 450 callers participated, 

including ASC staff, physicians, and 

representatives of industry trade 

associations. The listening session 

provided an opportunity for participants 

to identify the issues and concerns that 

they wanted us to address as we 

developed the revised ASC payment 

system. 

Callers encouraged us to foster 

beneficiary access to ASCs by creating 

incentives for physicians to use ASCs. 

The issues raised by participants 

included suggestions to expand or 

eliminate altogether the ASC list, 

recommendations to model payment on 

the hospital OPPS, and concerns about 

how we would propose to treat the 

geographic wage index adjustment and 

the annual ASC payment rate update. 

Several callers also raised concerns 

about ensuring adequate payment for 

supplies, ancillary services, and 

implantable devices under the new 

payment system, as well as developing 

a process to allow special payment for 

new technology. 

We have also met with representatives 

of the ASC industry over the past 

several years to discuss options for 

ratesetting other than conducting a 

survey, to discuss timely updates to the 

ASC list, and to listen to industry 

concerns related to the implementation 

of a new payment system. We 

appreciate the thoughtful suggestions 

that have been presented. We have 

carefully considered the concerns and 

issues brought to our attention, and a 

number of the proposals in this section 

for revising the ASC list and the method 

by which we set ASC payment rates take 

these concerns and issues into account. 

We look forward to receiving comments 

on the proposed changes set forth in this 

proposed rule and to continued input 

from representatives of industry 

associations and professional societies 

as we develop the final rule. 

B. Procedures Proposed for Medicare 

Payment in ASCs Effective for Services 

Furnished On or After January 1, 2008 

1. Proposed Payable Procedures 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Payable Procedures’’ at 

the beginning of your comments.) 

In its March 2004 Report to the 

Congress, MedPAC recommended 

replacing the current ‘‘inclusive’’ list of 

procedures, which are the only 

procedures for which Medicare allows 

payment of an ASC facility fee, with an 

‘‘exclusionary’’ list. That is, rather than 

limiting payment of an ASC facility fee 

to a list of procedures that CMS 

specifies, Medicare would allow 

payment to an ASC facility for any 

surgical procedure except those that 

CMS explicitly excludes from payment. 

MedPAC further recommended that 

clinical safety standards and the need 

for an overnight stay be the only criteria 

for excluding a procedure from payment 

of an ASC facility fee. MedPAC 

suggested that some of the criteria, such 

as site-of-service volume and time 

limits, which we have used in the past 

to identify procedures for the ASC list, 

are probably no longer clinically 

relevant. 

We have given careful consideration 

to MedPAC’s recommendations and 

participated in considerable discussion 

and consultation with members of ASC 

trade associations and physicians who 

represent a variety of surgical specialties 

regarding the criteria that we would use 

to identify procedures that we would 

propose for payment under the new 

ASC payment system. We agree that 

adoption of a policy like that 

recommended by MedPAC would serve 

both to protect beneficiary safety and 

increase beneficiary access to 

procedures in appropriate clinical 

settings, recognizing the ASC industry’s 

interest in obtaining Medicare payment 

for a much wider spectrum of services 

than is now allowed. Therefore, we are 

proposing that, under the revised ASC 

payment system for services furnished 

on or after January 1, 2008, Medicare 

would allow payment of an ASC facility 

fee for any surgical procedure 

performed at an ASC, except those 

surgical procedures that we determine 

are not payable under the ASC benefit. 

Further, we are proposing to establish 

beneficiary safety and the need for an 

overnight stay as the principal clinical 

considerations and factors in 

determining whether payment of an 

ASC facility fee would be allowed for a 

particular surgical procedure. As 

discussed in section XVIII.B.2 below, 

we also are proposing to exclude from 

payment under the ASC revised 

payment system those surgical 

procedures that are not eligible for 

separate payment under the OPPS and 

CPT surgical unlisted procedure codes. 

We discuss below the criteria that we 

are proposing as the basis for identifying 

procedures that would pose a significant 

safety risk to a Medicare beneficiary 

when performed in an ASC, or 

procedures following which we would 

expect a Medicare beneficiary to require 

overnight care. 

a. Proposed Definition of Surgical 

Procedure 

In order to delineate the scope of 

procedures that constitute ‘‘outpatient 

surgical procedures,’’ we must first 

clarify what we consider to be a 

‘‘surgical’’ procedure. Under the current 

ASC payment system, we define as a 

surgical procedure any procedure 

described within the range of CPT 

Category I codes that the AMA defines 

as ‘‘surgery’’ (CPT codes 10000–69999) 

for purposes of the ASC payment 

system. Under the revised payment 

system, we are proposing to continue 

that standard. However, we seek 

comment on whether all services 

contained in this range are 

appropriately defined as ‘‘surgery.’’ For 

example, should procedures that are 

primarily office-based (see Addendum 

CC) or procedures that require relatively 

inexpensive resources to perform be 

excluded from the list? Within the CPT 

surgical code range, such procedures 

that either require very limited facility 

resources or are primarily performed in 

procedure rooms in physician offices 

could be considered not to be surgical 

procedures, in that they may not require 

typical surgical resources, such as a 

fully equipped operating room or 

significant postoperative recovery area, 

that are generally associated with 

surgical procedures that are 

predominantly performed in facility 

settings or have significant associated 

resource costs. Procedures that require 

relatively inexpensive resources to 

perform could be defined based on an 

ASC payment threshold, for example 

$100 or $200, such that procedures 

below this threshold would be excluded 

from the ASC list of procedures. We 

seek comment on what an appropriate 

payment threshold would be for 

defining procedures that require 

relatively inexpensive resources. 

In addition, we are proposing to 

include within the scope of surgical 

procedures payable in an ASC certain 

services that are described by HCPCS 

alphanumeric codes (Level II HCPCS 

codes) or by CPT Category III codes 

which directly crosswalk to or are 


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clinically similar to procedures in the 

CPT surgical range. We are proposing to 

include these three types of codes in our 

definition of surgical procedures 

because they all are eligible for payment 

under the OPPS and, to the extent it is 

reasonable to do so, we are proposing 

that the new ASC payment system 

parallel the OPPS in its policies. 

An example of a Level II HCPCS code 

that we believe represents a procedure 

that could be safely and appropriately 

performed in an ASC is HCPCS code 

G0297 (Insertion of single chamber 

pacing cardioverter defibrillator pulse 

generator). We developed this 

alphanumeric code for use in the OPPS 

because CPT code 33240, which 

describes the surgical insertion of 

cardioverter defibrillator pulse 

generators, does not distinguish 

insertion of a single chamber 

cardioverter defibrillator generator from 

insertion of a dual chamber cardioverter 

defibrillator generator. We were 

concerned that different facility 

resources could be required for the 

insertion of these two types of 

cardioverter defibrillator pulse 

generators, so we developed alternate 

codes to permit hospitals to more 

accurately report the resources required 

when these surgical procedures are 

performed for payment under the OPPS. 

In instances such as this, when an 

alphanumeric Level II HCPCS code is 

established as a substitute for a CPT 

surgical procedure code which does not 

adequately describe, from a facility 

perspective, the nature of a surgical 

service, we are proposing to allow 

payment for the alphanumeric code 

under the proposed new ASC payment 

system. We are proposing not to allow 

payment of an ASC facility fee for Level 

II HCPCS codes or Category III CPT 

codes that describe services which fall 

outside the scope of surgical procedures 

described by CPT codes 10000–69999. 

We recognize that continuing to use 

this definition of surgery would exclude 

from payment of an ASC facility fee 

certain invasive, ‘‘surgery-like’’

procedures, such as cardiac 

catheterization or certain radiation 

treatment services which are assigned 

codes outside the CPT surgical range. 

However, we believe that continuing to 

rely on the CPT definition of surgery 

would be administratively 

straightforward, uncontroversial, and 

consistent with our proposal to allow 

ASC payment for all outpatient surgical 

procedures. Since 1987, the ASC list has 

consisted of CPT codes that are defined 

as surgery by CPT. Given the number of 

other changes that we expect to be 

implemented as part of the proposed 

new payment system, along with the 

significant expansion of the ASC list 

that we are proposing, we believe that 

it would be prudent at the outset to 

continue to define surgery as it is 

defined by the CPT code set, which is 

used to report services for payment 

under both the Medicare Physician Fee 

Schedule (MPFS) and the OPPS. 

However, we are interested in 

commenters’ opinions regarding the 

appropriateness of including primarily 

office-based procedures or including 

procedures that require relatively 

inexpensive resources to perform on the 

approved list of ASC procedures and we 

seek comment on this issue. That said, 

we have reviewed thousands of CPT 

codes in the surgical range (CPT codes 

10000 through 69999), and we are 

proposing to not exclude payment for 

more than 750 additional surgical 

procedures, as well as continuing to not 

exclude payment for the more than 

2,500 CPT codes on the current ASC 

list. If we were to consider CPT codes 

in the surgical range that were 

predominantly office-based to not be 

surgical procedures for purposes of the 

ASC payment system, the additions to 

the ASC list for CY 2008 would be 

limited to no more than about 300 other 

procedures. Similarly, if we were to 

define procedures requiring relatively 

inexpensive resources to not be surgical 

procedures, then additions to the ASC 

list for ASC payment would be more 

limited than under our current proposal. 

However, we are cognizant of the 

dynamic nature of ambulatory surgery, 

which has resulted in a dramatic shift 

of services from inpatient to outpatient 

settings over the past two decades. 

Therefore, we are soliciting comments 

regarding other services which are 

invasive and ‘‘surgery-like,’’ which 

could safely and appropriately be 

performed at an ASC, and which require 

the resources typical of an ASC, even 

though the procedures are described by 

codes that fall outside the range of CPT 

surgical codes. In particular, we would 

be interested in considering 

commenters’ views of what constitutes 

a ‘‘surgical’’ procedure. 

b. Procedures Proposed for Exclusion 

From Payment Under the Revised ASC 

System 

As stated above, we are proposing to 

allow payment of an ASC facility fee for 

all procedures within the surgical range 

of CPT codes that do not pose a safety 

risk to Medicare beneficiaries or require 

an overnight stay. Having established 

what we would propose as constituting 

a ‘‘surgical procedure,’’ we next 

considered criteria that would enable us 

to identify procedures that could pose a 

significant safety risk when performed 

in an ASC or that would require an 

overnight stay within the bounds of 

prevailing medical practice. We discuss 

in this section how we propose to 

identify procedures that could pose a 

significant safety risk. 

(1) Significant Safety Risk 

First, we are proposing to exclude 

from payment of an ASC facility fee any 

procedure that is included on the 

current OPPS inpatient list. (See 

Addendum E to this proposed rule and 

section XII. of this preamble for a 

discussion of the OPPS inpatient list.) 

The procedures included on that list are 

typically performed in the inpatient 

hospital setting due to the nature of the 

procedure, the need for at least 24 hours 

of postoperative recovery time or 

monitoring before the patient can be 

safely discharged, or the underlying 

physical condition of the patient. We 

believe that any procedure for which we 

do not allow payment in the hospital 

outpatient setting due to safety concerns 

would not be safe to perform in an ASC. 

Second, we are proposing to exclude 

from payment of an ASC facility fee 

procedures that the CY 2005 Part B 

Extract Summary System (BESS) data 

indicate are performed 80 percent or 

more of the time in the hospital 

inpatient setting, even if those 

procedures are not included on the 

OPPS inpatient list. (See Table 4.) We 

selected an 80 percent threshold 

because we believe that an 80 percent 

level of inpatient performance is a fair 

indicator that a procedure is most 

appropriately performed on an inpatient 

basis and as such, would pose 

significant safety risks for Medicare 

beneficiaries if performed in an ASC. 

We find that procedures with inpatient 

utilization frequencies above this 

proposed threshold are complex and are 

likely to require a longer and more 

intensive level of care postoperatively 

than what is provided in a typical ASC. 

We believe that performing these 

procedures in an ASC, where immediate 

access to the full resources of an acute 

care hospital is not the norm, would 

pose a significant safety risk for 

beneficiaries. 

Third, we are proposing to retain the 

specific criteria for evaluating safety 

risks that are listed in § 416.65(b)(3). 

Procedures that involve major blood 

vessels; prolonged or extensive invasion 

of body cavities; extensive blood loss; or 

are emergent or life-threatening in 

nature could, by definition, pose a 

significant safety risk. Therefore, we are 

proposing to exclude from payment of 

an ASC facility fee, procedures that may 

be expected to involve any of these 

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our medical advisors. We note that most 

of the procedures that our medical 

advisors identified as involving any of 

the characteristics listed currently in 

§ 416.65(b)(3), also require overnight or 

inpatient stays, reinforcing their 

exclusion from being paid when 

performed in an ASC. 

Finally, we are proposing not to 

continue applying under our proposed 

revised system the current time-based 

prescriptive criteria at § 416.65(b)(1) and 

(2), which exclude from the ASC list 

procedures that exceed 90 minutes of 

operating time or 4 hours of recovery 

time or 90 minutes of anesthesia. We 

believe these criteria are no longer 

clinically appropriate for purposes of 

defining a significant safety risk for 

surgical procedures. 

In light of these proposed changes for 

evaluating procedures that pose a 

significant safety risk for beneficiaries 

under our proposed revised system, we 

believe that it would not be appropriate 

to apply the existing standard at 

§ 416.65(a)(1), which states that covered 

surgical procedures are those that are 

commonly performed on an inpatient 

basis but may be safely performed in an 

ASC, because this standard is no longer 

relevant to prevailing medical practice 

in the realm of ambulatory or outpatient 

surgery. Similarly, we believe that it 

would not be appropriate to continue 

applying the existing standard at 

§ 416.65(a)(2), which states that 

procedures performed in an ASC are not 

of a type that are commonly performed, 

or that may be performed in a 

physician’s office. This standard is no 

longer relevant within the context of our 

proposal only to exclude from payment 

of an ASC facility fee under the revised 

payment system those surgical 

procedures that pose a safety risk or 

require an overnight stay. We would 

expect the types of procedures that are 

commonly performed or that may be 

performed in a physician’s office to pose 

no significant safety risk and to require 

no overnight care. 

Therefore, we are proposing to add 

new subpart F to reflect coverage, scope 

and payment for ASC services under the 

revised payment system. Included in 

these changes will be new § 416.166 that 

will reflect these changes that we are 

proposing to our current policy for 

evaluating and identifying those 

procedures that would pose a significant 

safety risk for beneficiaries and would 

be excluded from our list of ASC 

covered procedures beginning January 

1, 2008. To set apart the provisions that 

are applicable to our current ASC 

payment system from those that would 

apply to our proposed revised system, 

we are proposing to revise the section 

headings of subparts D and E to clearly 

denote the provisions that would govern 

covered surgical procedures furnished 

before January 1, 2008. We also will add 

new §§ 416.76 and 416.121 to clearly 

denote the effective dates of subparts D 

and E. 

(2) Overnight Stay 

A longstanding criterion for 

determining which procedures are 

appropriate for inclusion on the ASC 

list has been that the procedures on the 

list do not require an extended recovery 

time. Section 416.65(a)(3) of the 

regulations provides that ASC 

procedures ‘‘[a]re limited to those 

requiring a dedicated operating room (or 

suite), and generally requiring a postoperative recovery room or short-term 

(not overnight) convalescent room.’’

Under § 416.65(b)(1)(ii), we have 

considered procedures that require more 

than 4 hours recovery or convalescent 

time to be inappropriately performed in 

the ASC. 

We have heard many differing 

opinions as to what constitutes an 

‘‘overnight’’ stay, ranging from ‘‘more 

than 24 hours’’ to time spent in recovery 

after sunset. After careful deliberation 

and consideration of several options, we 

are proposing to exclude from payment 

of an ASC facility fee any procedure for 

which prevailing medical practice 

dictates that the beneficiary will 

typically be expected to require active 

medical monitoring and care at 

midnight following the procedure. Our 

clinical staff evaluated each procedure 

using available claims and physician 

pricing data, as well as clinical 

judgment, to determine which 

procedures would be expected to 

require monitoring at midnight of the 

day on which the surgical procedure 

was performed. 

We are proposing to use midnight as 

the defining measure of an overnight 

stay for several reasons. First, a patient’s 

location at midnight is a generally 

accepted standard for determining his or 

her status as a hospital inpatient or 

skilled nursing facility patient and as 

such, it seems reasonable to apply the 

same standard in the ASC setting. 

Second, overnight care is not within the 

scope of ASC facility services for which 

Medicare makes payment. The 

expectation is that procedures 

performed at an ASC are ambulatory in 

nature; that is, patients undergoing a 

procedure in an ASC will recover from 

anesthesia and return home on the same 

day that they report to the ASC for a 

scheduled procedure. Finally, the 

expected need for monitoring at 

midnight is a straightforward and easily 

understood definition of ‘‘overnight 

stay.’’ We are proposing to add the 

requirement that procedures not require 

an overnight stay to proposed new 

§ 416.166. 

2. Proposed Treatment of Unlisted 

Procedure Codes and Procedures That 

Are Not Paid Separately under the OPPS 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Unlisted Procedures’’ at 

the beginning of your comment.) 

Unlisted procedure CPT codes are 

used to report services and procedures 

that are not accurately described by any 

other, more specific CPT codes. An 

example of an unlisted CPT code is 

33999 (Unlisted procedure, cardiac 

surgery). Within the surgical range of 

CPT codes, there are 91 such codes. 

None of the unlisted CPT codes in the 

surgical range is on the current ASC list 

of approved procedures. Under the 

OPPS, we assign unlisted CPT codes to 

the lowest weighted APC in the relevant 

clinical group regardless of the median 

cost for the unlisted procedure code, 

and we do not include the highly 

variable claims-based cost information 

for unlisted services in calculating APC 

median costs for purposes of 

establishing APC relative payment 

weights. Payment for unlisted CPT 

codes is made only at the discretion of 

the carrier under the MPFS. 

Because of concerns about the 

potential for safety risks when 

procedures that may only be reported 

with CPT unlisted procedure codes are 

performed, we are proposing to 

continue excluding unlisted procedure 

codes from payment of an ASC facility 

fee. For example, when CPT code 33999 

is reported on a claim, we know only 

that some kind of cardiac surgery was 

performed. We have no other 

information about the procedure, and 

we have no way of knowing whether the 

procedure involved major blood vessels, 

prolonged or extensive invasion of body 

cavities, extensive blood loss, or was 

emergent or life-threatening in nature. 

Therefore, because of potential safety 

concerns, we are proposing to continue 

to exclude the unlisted surgical codes 

from payment of an ASC facility fee 

under the revised payment system. 

Prior to our evaluation of surgical 

procedure codes for their safety risk, we 

decided to propose that we would not 

make separate payment under the 

revised ASC payment system for CPT 

codes in the surgical range that are 

‘‘packaged’’ under the OPPS. Packaged 

CPT codes under the OPPS are 

identified by status indicator ‘N’ in 

Addendum B of this proposed rule. We 

are making this proposal for three 

reasons. First, we would not be able to 


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establish an ASC payment rate for 

packaged surgical procedures using the 

same method we are proposing for all 

other ASC procedures because packaged 

surgical codes have no relative payment 

weights under the OPPS upon which to 

base an ASC payment rate. Second, 

because we want an ASC system that is 

as similar to the OPPS as possible, we 

believe that surgical procedures whose 

costs we package under the OPPS 

should also be packaged in the ASC 

system. Finally, ASCs, just like 

hospitals, would receive payment for 

these surgical procedures because their 

costs are already packaged into the APC 

relative payment weights for associated 

separately payable procedures, for 

which we are proposing to pay a 

derivative ASC facility fee. 

3. Proposed Treatment of Office-Based 

Procedures 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Office-Based Procedures’’

at the beginning of your comment.) 

According to the general standard in 

§ 416.65(a)(2) of the regulations, 

procedures that ‘‘are commonly 

performed, or that may be safely 

performed, in physicians’ offices’’ are 

excluded from the ASC list. We are not 

proposing to continue to apply this 

provision under our revised system. 

Rather we are proposing to allow 

payment of an ASC facility fee for 

surgical procedures that are commonly 

and safely performed in the office 

setting. We reason that the types of 

procedures performed in physician 

offices would neither pose a significant 

safety risk nor require an overnight stay 

when performed in an ASC. However, 

we have concerns that allowing 

payment for office-based procedures 

under the ASC benefit may create an 

incentive for physicians inappropriately 

to convert their offices into ASCs or to 

move all their office surgery to an ASC. 

In section XVIII.C.5 below, to address 

this concern, we propose to limit 

payment for office-based procedures to 

help neutralize any such incentive. We 

also propose in new § 416.171(e) to set 

forth rules governing office-based 

procedures. We specifically invite 

comment regarding the effect on the 

Medicare program and on practice 

patterns for ambulatory surgery 

generally of our proposal to allow 

payment of an ASC facility fee for 

office-based procedures that historically 

have been excluded from the ASC list. 

As discussed elsewhere in this 

proposed rule, we are proposing to limit 

payment for office-based procedures in 

an attempt to mitigate potentially 

inappropriate migration of services from 

the physician office setting to the ASC. 

Alternatively, we could entirely exclude 

office-based procedures or procedures 

that require relatively inexpensive 

resources to perform from the approved 

ASC list of procedures. 

4. Listing of Surgical Procedures 

Proposed for Exclusion From Payment 

of an ASC Facility Fee Under the 

Revised Payment System 

Tables 44 and 45 below, list the codes 

and short descriptors for surgical 

procedures that, in addition to the codes 

that comprise the inpatient list in 

Addendum E of this proposed rule, we 

are proposing to exclude from payment 

of an ASC facility fee for services 

furnished on or after January 1, 2008 

because they pose a significant safety 

risk or require an overnight stay. We 

discuss in section XVIII.B.1.b.(1) above, 

our rationale for excluding the 

procedures in Table 44 from payment of 

an ASC facility fee. 

For many of the procedures listed in 

Table 45, several disqualifying criteria 

could be applicable, such as ‘‘requires 

inpatient stay’’ or ‘‘could potentially 

cause extensive blood loss’’ or ‘‘is 

emergent in nature.’’ Rather than list 

multiple disqualifying criteria for 

individual codes in Table 45, we have 

defaulted to the one characteristic that 

is common to all the codes listed. That 

is, we believe that, at a minimum, 

prevailing medical practice would 

dictate the provision of overnight care 

following each of the procedures listed 

in Table 45. We acknowledge that we 

had to exercise a degree of clinical 

judgment in identifying procedures for 

which we are proposing to exclude 

payment of an ASC facility fee. 

Therefore, we are soliciting comments 

on the appropriateness of excluding 

these procedures from payment of an 

ASC facility fee under the revised 

payment system. We request that 

commenters who disagree with a 

proposed exclusion from payment of an 

ASC facility fee submit clinical 

evidence that demonstrates that the 

criteria we are proposing in proposed 

new § 416.166 of the regulations are not 

factors when the procedure is performed 

in the majority of cases, including data 

to support that the preponderance of 

Medicare beneficiaries upon whom the 

procedure is performed do not require 

overnight care or monitoring following 

the surgery. Simply asserting that the 

procedure can be safely performed in an 

ASC without providing corroborative 

evidence and data does not furnish us 

with sufficient information upon which 

to make an informed decision. 

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BILLING CODE 4120–01–C 

C. Proposed Ratesetting Method 

1. Overview of Current ASC Payment 

System 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Ratesetting’’ at the 

beginning of your comment.) 

The current ASC payment system 

consists of 9 standard overhead amounts 

ranging from $333 to $1339, based on 

data collected in a 1986 survey of ASC 

costs. An ASC payment ‘‘group’’

currently consists of all the procedures 

assigned to a particular standard 

overhead amount. ASC payment groups 

are heterogeneous in terms of clinical 

characteristics, cutting across all body 

systems and types of surgery. Medicare 

pays a $150 allowance for IOLs that are 

inserted during or subsequent to 

cataract surgery and an additional $50 

for IOLs that we approved as NTIOLs. 

Medicare also makes separate payment 

for implantable prosthetic devices and 

implantable durable medical equipment 

surgically inserted at an ASC. Payment 

for all other facility services that are 

directly related to performing a surgical 

procedure is packaged into the 

prospectively determined ASC facility 

fee. 

The statute requires that ASC facility 

services amount be increased by the 

CPI–U in years when the amounts are 

not updated. However, since 1990, the 

Congress has frozen or reduced the 

update adjustment for periods of 

varying duration. ASC payment rates are 

currently frozen at their FY 2003 level. 

Carriers account for geographic wage 

variations when calculating individual 

ASC payments by applying the hospital 

IPPS wage index value established for 

the county in which the ASC is located 

to 34.45 percent of the national ASC 

standard overhead amount. The 1986 

survey data are the basis for attributing 

34.45 percent of ASC overhead costs to 

labor-related expenses. Medicare pays 

80 percent of the standard overhead 

amount; the beneficiary coinsurance 

rate is 20 percent for all procedures on 

the list of Medicare approved ASC 

procedures. 

The standard overhead amounts for 

procedures on the ASC list were last 

rebased in 1990 using data collected in 

a 1986 survey of ASC costs. The process 

and methodology that we used to 

establish the current payment system 

are explained in the February 8, 1990 

Federal Register (55 FR 4526). In the 

June 12, 1998 Federal Register, we 

issued a proposed rule to revise the ASC 

payment rates and ratesetting 

methodology based on data collected in 

a 1994 survey of ASC costs (63 FR 

32290). In that proposed rule, we also 

proposed to expand the ASC list and 

establish payment groups similar to 

those being considered for the hospital 

OPPS, which was under development at 

the time, but which was not 

implemented until August 2000. 

Although we never implemented the 

revised ASC payment rates and 

ratesetting methodology proposed in 

1998, we did make final some of the 

1998 proposed additions to the ASC list 

in the March 28, 2003 final rule with 

comment period (68 FR 15268). In that 

rule, we explained in detail why we did 

not implement the ratesetting 

methodology and payment amounts 

proposed in the June 12, 1998 proposed 

rule. 

The ASC payment system that we are 

proposing in this proposed rule would 

implement requirements set forth in 

section 626 of Pub. L. 108–173. The 

revised payment system mandated by 

section 626(d) of Pub. L. 108–173 

requires us to take into account 

recommendations in a report to 

Congress prepared by the GAO. The 

GAO recommendations are to be based 

on its study of the comparative relative 

costs of procedures furnished in ASCs 

and procedures furnished in hospital 

outpatient departments paid under the 

OPPS, and the extent to which the APCs 

reflect procedures performed in ASCs. 

Although the statutory due date for this 

report is January 1, 2005, CMS has not 

yet received the report or 

recommendations from the GAO. We are 

moving forward with our proposal for a 

revised ASC payment system without 

the benefit of GAO’s recommendations 

because we are concerned that further 

delay would not give the public 

sufficient opportunity to review and 

comment on our proposed methodology, 

and the ASC industry and CMS would 

not have adequate time to prepare for 

changes scheduled for implementation 

January 1, 2008. 


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2. Proposal to Base ASC Relative 

Payment Weights on APC Groups and 

Relative Payment Weights Established 

Under the OPPS 

We considered several strategies and 

methodologies for setting ASC payment 

rates under a revised payment system. 

We could require ASCs to submit 

modified cost reports as a basis for 

establishing ASC costs. We could 

simply expand the number and payment 

range of the current ASC payment 

groups. We could base payments to 

ASCs on the relative weights for surgical 

services established under the MPFS. 

We could base payments to ASCs on the 

relative weights for surgical services 

established under the Medicare OPPS, 

as suggested in Pub. L. 108–173. We 

could base payments to ASCs on a flat 

percentage of the payment for the same 

services established under the OPPS, as 

advocated by representatives of several 

ASC associations. 

After carefully reviewing the 

advantages and disadvantages of each of 

these approaches, we are proposing, 

within the parameters of section 626 of 

Pub. L. 108–173, to use the APC groups 

and the relative payment weights for 

surgical procedures established under 

the OPPS as the basis of the payment 

groups and the relative payment weights 

for surgical procedures performed at 

ASCs. These payment weights would be 

multiplied by an ASC conversion factor 

in order to calculate the ASC payment 

rates. Several factors persuaded us to 

advance this proposal over the other 

approaches that we considered. 

First, in section 626(d) of Pub. L. 108–

173, the Congress explicitly targets the 

OPPS for consideration by the GAO in 

its study of ASC payments. We believe 

it is reasonable to assume that Congress, 

by so doing, was highlighting the 

relative payment weights under the 

OPPS as a theoretical model for ASC 

relative payment weights under the 

revised payment system. Second, the 

ASC benefit provides payment for 

facility services associated with 

performing surgical procedures. The 

OPPS has equipped us with nearly a 

decade of experience in developing and 

refining a relative payment system for 

facility services furnished in connection 

with outpatient surgical procedures. 

Third, Pub. L. 108–173 applies for the 

first time a budget neutrality 

requirement to the ASC benefit. That is, 

in the year the revised system is 

implemented, the system is to be 

designed to result in the same aggregate 

amount of expenditures that would be 

made if the revised payment system 

were not implemented. Because the 

OPPS is also a prospective payment 

system for facility services that is 

subject to budget neutrality 

requirements, it provides useful 

parallels for a ratesetting methodology 

based on relative facility payment 

weights for surgical services under the 

revised ASC payment system. 

Fourth, in our analysis of the APC 

groups to which surgical procedures are 

assigned for payment under the OPPS, 

we found a significant overlap between 

surgical procedures furnished in the 

hospital outpatient setting and those 

performed in ASCs. Currently, of the 

150 highest volume surgical procedures 

furnished in hospital outpatient 

departments, more than half (80) are 

also among the 150 highest volume 

procedures performed in ASCs. 

Finally, the ASC industry in 

numerous meetings with us over the 

past several years has frequently voiced 

its preference for a payment system that 

parallels the OPPS for the sake of 

promoting transparency across sites of 

service in the arena of outpatient 

surgery and to streamline and 

modernize how Medicare sets payments 

and determines what is payable under 

the ASC benefit. 

As we explain in sections I through 

XVI of this proposed rule, the OPPS 

payment rates are based on relative 

payment weights which are updated 

annually. APCs to which surgical 

procedures are assigned are generally 

homogeneous both in terms of clinical 

characteristics and resource 

requirements. The APCs have been 

continually refined over the past 6 years 

through the work of the APC Panel and 

as a result of comments received during 

the OPPS annual rulemaking cycles. 

Moreover, we believe that the APC 

groups and the relativity in resource 

utilization among APCs containing 

surgical procedures have matured so 

that they are reasonable and appropriate 

models for grouping outpatient surgical 

procedures and determining the 

relativity in the ASC payment weights 

in terms of clinical and resource 

homogeneity. For example, whether 

performed in a hospital outpatient 

department or in an ASC, we believe the 

time and facility resources required to 

perform a routine laparoscopic hernia 

repair (CY 2006 OPPS relative payment 

weight of 43.0498) are approximately 4 

times higher than those required to 

perform a diagnostic colonoscopy (CY 

2006 OPPS relative payment weight of 

8.5588). Thus, we believe that the 

relative payment weights established 

under the OPPS for procedures 

performed in the outpatient hospital 

setting reasonably reflect the relative 

resources required for such procedures 

and do so with sufficient coherence to 

be applicable to other ambulatory sites 

of service. Taking all these factors into 

account, we are proposing to use the 

APCs as a ‘‘grouper’’ and the APC 

relative payment weights as the basis for 

ASC relative payment weights and for 

calculating ASC payment rates under 

the revised payment system. 

Accordingly, we are proposing to 

establish provisions in proposed new 

subpart F §§ 416.167, 416.169, and 

416.171 to reflect these proposed 

changes for calculating the ASC 

payment rates beginning January 1, 

2008. 

In the following sections, we focus on 

several additional basic assumptions 

that affect how we are proposing to 

calculate the ASC payment rates for 

implementation in January 2008. 

3. Proposed Packaging Policy 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Packaging’’ at the 

beginning of your comment.) 

Payment for a surgical procedure 

under both the current OPPS and ASC 

payment systems represents payment 

for a package of various items and 

services, all of which are directly related 

and required in order to perform the 

procedure. In both systems, we package 

into a single facility fee the payment for 

a bundle of direct and indirect costs 

incurred by the facility to perform the 

procedure. These costs include, but are 

not limited to, use of the facility, 

including an operating suite or 

procedure room and recovery room; 

nursing, technician, and related 

services; administrative, recordkeeping 

and housekeeping items and services; 

medical and surgical supplies and 

equipment; surgical dressings; and 

materials for anesthesia. 

Medicare currently applies different 

rules under the ASC payment system 

and the OPPS system for determining 

whether payment for other items and 

services directly related to a surgical 

procedure is packaged into the facility 

payment for the associated surgical 

procedure or paid for separately. These 

other items and services include drugs, 

biologicals, contrast agents, implantable 

devices, and diagnostic services such as 

imaging. Currently, Medicare packages 

payment for the costs for all drugs, 

biologicals, and diagnostic services, 

including imaging, into the ASC 

standard overhead amount for the 

surgical procedure with which these 

items and services are associated. Under 

the OPPS, Medicare pays separately for 

some of these items and services, in 

addition to paying for the surgical 

procedure. 


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ASCs currently receive separate 

payment for prosthetic implants and 

implantable durable medical equipment 

(DME). Conversely, under the OPPS, 

payment for prosthetic implants and 

implantable DME is packaged into the 

facility fee for the surgical procedure 

performed to insert the implants. 

Payment for IOLs and implantable 

surgical supplies, such as stents, mesh, 

guide wires, pins, and catheters is 

packaged into the associated surgical 

facility fee under both the OPPS and the 

ASC payment systems. We considered 

several packaging options for the 

revised ASC payment system. First, we 

considered making no change to the 

current policy regarding items and 

services for which payment is packaged 

into the ASC facility fee. That is, we 

would continue under the revised ASC 

payment system to package into the 

facility fee payment for overhead, 

payment for all drugs, biologicals, 

surgical dressings, supplies, splints, 

casts, and appliances and equipment 

directly related to the provision of 

surgical procedures; diagnostic or 

therapeutic services or items directly 

related to the provision of a surgical 

procedure; materials for anesthesia; and 

IOLs. In addition, we would continue to 

pay separately under other fee 

schedules for items and services such as 

NTIOLs, prosthetic implants and 

implantable DME surgically inserted at 

an ASC (DMEPOS fee schedule); 

laboratory services (clinical lab fee 

schedule); physician services (MPFS); 

and X-ray or diagnostic procedures 

other than those directly related to 

performance of the surgical procedure 

(MPFS). Section 416.164(a) addresses 

the services for which payment is 

included in the ASC facility fee, and 

§ 416.164(b) addresses those services 

that are not included in the ASC facility 

fee. 

We also considered proposing to 

apply the OPPS packaging rules to the 

ASC payment system and to pay under 

the new ASC system the same way we 

pay under the OPPS for items and 

services directly related to a surgical 

procedure. If we adopted this option, 

payment for certain imaging procedures, 

drugs, biologicals, and contrast agents 

directly related to performing a surgical 

procedure would not be packaged into 

the facility fee for the procedure but 

would, instead, be paid separately. 

Conversely, payment for most surgically 

implanted devices and implantable 

DME would be packaged. 

Each of the preceding two options 

have characteristics that are inconsistent 

with a fundamental principle of a 

prospective payment system, which is 

to base payment on large bundles of 

items and services so as to promote the 

efficient provision of services. To 

preserve as much as possible the 

elements of a prospective payment 

system within the revised ASC payment 

system, we are proposing a third option. 

That is, we are proposing to continue 

the current policy of packaging into the 

ASC facility fee payment all direct and 

indirect costs incurred by the facility to 

perform a surgical procedure. This 

would include payment for all drugs, 

biologicals, contrast agents, anesthesia 

materials, and imaging services, as well 

as the other items and services that are 

currently packaged into the ASC facility 

fee as listed in § 416.164(a). 

In addition, we are proposing to cease 

making separate payment for 

implantable prosthetic devices and 

implantable DME inserted surgically at 

an ASC. Instead, under the revised 

payment system, we are proposing to 

package into the ASC facility fee 

payment for implantable prosthetic 

devices and implantable DME when 

they are surgically inserted, as we do 

under the OPPS. 

However, we are proposing to 

continue excluding from payment as 

part of the ASC facility fee the other 

services addressed in § 416.164(b). That 

is, payment for items and services for 

which payment is made under other 

Part B fee schedules, with the exception 

of implantable prosthetic devices and 

implantable DME, would not be 

included in the ASC facility fee. 

Payment for items and services, such as 

physicians’ professional services, for 

laboratory, X-ray or diagnostic 

procedures (other than those directly 

related to performance of the surgical 

procedure), nonimplantable prosthetic 

devices, ambulance services, leg, arm, 

back and neck braces, artificial limbs, 

and durable medical equipment for use 

in the patients’ home would not be 

included in the ASC facility fee. 

We are proposing this option for a 

number of reasons. First, this approach 

to packaging is most consistent with the 

principles of a prospective payment 

system. Second, we believe that ASCs 

generally treat a less complex and 

severely ill patient case mix and, as a 

result, we believe that ASCs are less 

likely to provide on a regular basis 

many of the separately paid items and 

services that patients might receive 

more consistently in a hospital 

outpatient setting. Thus, we do not 

believe there is a need to pay for these 

services separately in ASCs, because 

that would unbundle some items and 

services that are currently packaged into 

the ASC facility fee, reduce incentives 

for cost-efficient delivery of services at 

ASCs, and increase the complexity of 

the revised ASC payment system. In 

addition, we believe it is critical to 

continue to focus the ASC payment 

system on appropriate payment for 

surgical services provided in ASCs. 

Moreover, after careful analysis of 

OPPS claims for surgical procedures, we 

were unable to identify ancillary items 

and services that are repeatedly and 

consistently reported separately in 

association with specific ambulatory 

surgical procedures. Rather, the OPPS 

claims for surgical procedures were of 

two types: one group showed a broad 

range of items and services that were 

provided on the same day that a surgical 

procedure was performed in the 

hospital outpatient department, only 

some of which were likely to be directly 

related to the surgical procedure; the 

second group of claims revealed that 

many surgical procedures are only 

infrequently associated with ancillary 

items and services paid separately 

under the OPPS. Therefore, we are 

proposing to reflect this proposed 

packaging policy in proposed new 

§ 416.164. 

We are seeking comments from ASC 

clinical and administrative staff and 

from physicians who perform surgery at 

ASCs regarding nonsurgical ancillary 

services or items that are directly related 

to a surgical procedure that would be 

paid separately under the OPPS but that 

would be packaged under our proposal 

for the revised ASC payment system. 

We are specifically requesting that 

commenters provide data to indicate the 

frequency with which specific items 

and services are typically furnished in 

association with given procedures, the 

reasons why one patient might require 

the additional items and services 

whereas another patient would not, and 

the costs of those items and services 

relative to the other costs incurred to 

perform the associated surgery. 

4. Payment for Corneal Tissue Under the 

Revised ASC Payment System 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Payment for Corneal 

Tissue’’ at the beginning of your 

comment.) 

In a memorandum dated May 21, 

1992, CMS (known at the time as the 

Health Care Financing Administration 

or ‘‘HCFA’’) notified Regional 

Administrators that carriers could pay 

corneal tissue acquisition costs when 

HCPCS code V2785 (Processing, 

preserving and transporting corneal 

tissue), is reported with corneal 

transplant procedures performed in an 

ASC. The memorandum indicated that 

payment for corneal tissue acquisition 

costs is subject to the usual copayment 


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and deductible requirements, and could 

be paid as an add-on to either the ASC 

facility fee or the physician’s fee for 

corneal transplant surgery performed at 

an ASC. In the June 12, 1998 proposed 

rule to revise the ASC ratesetting 

methodology and payment rates, we 

proposed to package the costs incurred 

by an ASC to procure corneal tissue into 

the payment for the associated cornea 

transplant procedure rather than 

continue making separate payment for 

those costs (63 FR 32312 and 32313). 

We also proposed to package corneal 

tissue acquisition costs into the APC 

payment for corneal transplant 

procedures in the September 8, 1998 

proposed rule to implement the OPPS 

(63 FR 47760). 

We received numerous comments 

from physicians, eye banks, and health 

care associations opposing both 

proposals. In the April 7, 2000 final rule 

with comment period, which 

implemented the OPPS, we summarize 

the comments that we received in 

response to the September 8, 1998 

proposal, and we determined that we 

would not implement our proposal to 

package payment under the OPPS for 

corneal tissue costs but would, instead, 

make separate payment based on 

hospitals’ reasonable costs to procure 

corneal tissue (65 FR 18448 and 18449). 

Because we never made final the 

changes in the ASC payment rates and 

ratesetting methodology that we 

proposed in the June 12, 1998 Federal 

Register, the policy issued in the June 

1992 memorandum remains in effect, 

which allows carriers to make separate 

payment for the costs incurred to 

procure corneal tissue for transplant at 

an ASC. 

We are proposing under the revised 

ASC payment system to continue to pay 

ASCs separately, based on their 

invoiced costs, for the procurement of 

corneal tissue. We have no evidence to 

suggest that costs incurred to procure 

corneal tissue are any less variable now 

than they were in 1992, in 1998 or in 

2000. If we were to package payment for 

the procurement of corneal tissue into 

the APC for corneal transplant 

procedures, we believe the resulting 

payment rate would continue to overpay 

those facilities that are able to acquire 

corneal tissue at little or no cost through 

philanthropic organizations and 

underpay those facilities that must pay 

for corneal tissue processing, testing, 

preservation, and transportation costs. 

Therefore, we are proposing to include 

in proposed new § 416.164, our 

proposal to exclude payment for corneal 

tissue furnished in an ASC on or after 

January 1, 2008, from the ASC facility 

payment rate. 

We invite comment and data that 

support or challenge this proposal to 

continue paying ASCs for corneal tissue 

on an acquisition cost basis. 

5. Proposed Payment for Office-Based 

Procedures 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Payment for Office-Based 

Procedures’’ at the beginning of your 

comment.) 

Since the inception of the ASC 

benefit, procedures that are commonly 

performed or that can be safely 

performed in a physician’s office have 

generally been excluded from the ASC 

list. For the sake of convenience, we 

refer to these procedures as ‘‘officebased’’ in this preamble discussion. 

Over the past 15 years, physicians and 

ASC associations have urged CMS to 

add office-based procedures to the ASC 

list or to retain on the ASC list 

procedures that were originally 

performed most commonly in an 

institutional setting, but that have 

subsequently moved to an office setting 

as surgical techniques and technology 

have advanced. Representatives of the 

ASC industry argue that although, for 

most patients, the office is an 

appropriate setting for most high 

volume office procedures, there are 

some patients for whom an ASC or 

another more resource-intensive setting 

is required. The physician may decide 

that a facility setting is necessary for 

individual patients for various clinical 

reasons, such as the need for more 

nursing staff, a sterile operating room, or 

a piece of equipment not typically 

available in the office setting. CPT code 

52000 (Cystourethroscopy (separate 

procedure)) is a prime example of a high 

volume procedure that is performed 

more than 80 percent of the time in an 

office setting, but for which a small 

number of patients require resources 

usually available only at an ASC or 

hospital. Unless we make an exception 

to the criteria that currently govern 

which procedures comprise the ASC list 

and allow an office-based procedure to 

remain on the ASC list, as we have done 

with CPT code 52000, the hospital 

would be the only facility setting 

available as an alternative to the office 

setting. ASC industry commenters assert 

that this limitation is burdensome both 

to physicians and to beneficiaries and 

could, in some cases, limit beneficiary 

access to needed surgery. 

We generally interpret ‘‘office-based’’

or ‘‘commonly performed in a 

physician’s office’’ to mean a surgical 

procedure that the most recent BESS 

data available indicate is performed 

more than 50 percent of the time in the 

physician’s office setting. In section 

XVIII.B.1 of this preamble, we are 

proposing to expand the ASC list to 

allow payment for all surgical 

procedures, except those procedures 

that pose a significant safety risk or 

require an overnight stay. Because 

office-based surgical procedures 

typically do not pose a significant safety 

risk and do not require an overnight 

stay, we are proposing not to exclude 

them from payment of an ASC facility 

fee under the revised ASC payment 

system. However, we are seeking 

comment on the appropriateness of 

excluding office-based procedures or 

procedures that require relatively 

inexpensive resources to perform from 

the approved ASC list of procedures. 

We recognize that paying an ASC 

facility fee for office-based procedures 

based on OPPS relative payment 

weights could have a significant impact 

on Medicare program costs. 

Approximately two-thirds of the 

additional procedures for which we 

propose to not exclude for payment 

beginning in CY 2008 are office-based, 

that is, they are performed in the 

physician office more than 50 percent of 

the time. The Medicare payment for 

many of these procedures under the 

MPFS would be lower than the payment 

for the same procedures when they are 

performed in an ASC where the facility 

fee is based on OPPS relative weights. 

The separate physician payment and 

facility payment when the procedures 

are performed in an ASC would exceed 

the combined payment when they are 

performed in the physician office. 

Therefore, ASC payment rates based on 

the OPPS relative payment weights 

could result in a significant program 

cost were these high volume procedures 

to shift from the office to the ASC 

setting. 

One reason why we are concerned if 

there were to be a sizable shift of officebased procedures to ASCs is the impact 

that would have on ASC payments in 

light of the statutory requirements that 

the revised ASC payment system be 

designed to result in the same aggregate 

amount of expenditures as would be 

made if the revised payment system 

were not implemented. (See section 

XVIII.A.1. of this preamble for a 

discussion of this requirement). An 

influx of high-volume, relatively low 

cost office-based procedures into the 

ASC setting under the revised payment 

system could lower the payment 

amounts for other procedures paid for in 

the ASC due to the constraints of budget 

neutrality. In other words, we would 

have to scale the ASC conversion factor 

downward in order for estimated 


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aggregate expenditures under the 

revised system to not exceed what they 

would have been if the new payment 

system were not implemented. Payment 

for procedures with relatively high 

payments would have to be reduced in 

order to offset increased aggregate costs 

resulting from an influx of relatively 

low cost, high volume office procedures 

shifting to ASCs. (See section 

XVIII.C.10. of this preamble for a 

detailed discussion of our proposal for 

calculating an ASC conversion factor.) 

We are committed to refining 

Medicare payment systems wherever 

possible to prevent payment incentives 

from inappropriately driving decisions 

about where to perform a surgical 

procedure when those decisions should 

be based on clinical considerations. We 

strive to promote value-based 

purchasing in all Medicare payment 

systems that leads to significant positive 

effects on the health of Medicare 

beneficiaries by improving quality and 

efficiency in the delivery of health 

services. We are also committed to 

ensuring Medicare payments that are 

efficient and reasonable. To mitigate the 

impact of office-based procedures 

migrating to the more expensive ASC 

setting if we were to implement our 

proposal not to exclude them from 

payment of an ASC facility fee under 

the revised ASC payment system, we are 

proposing to cap payment for officebased surgical procedures for which 

payment of an ASC facility fee would be 

allowed under the revised payment 

system as of January 1, 2008, at the 

lesser of the MPFS nonfacility practice 

expense payment or the ASC rate under 

the revised ASC payment system. We 

also are proposing to exempt procedures 

that are on the ASC list as of January 1, 

2007, that meet our criterion for 

designation as office-based, from the 

payment limitation proposed for officebased procedures for which payment of 

an ASC facility fee would be allowed for 

the first time beginning January 1, 2008. 

Accordingly, we are proposing to 

incorporate in proposed new 

§ 416.171(e) the limitation on payment 

for these procedures beginning January 

1, 2008. 

As discussed elsewhere in this 

proposed rule, we are proposing to limit 

payment for office-based procedures in 

an attempt to mitigate potentially 

inappropriate migration of services from 

the physician office setting to the ASC. 

Alternatively, we could entirely exclude 

office-based procedures or procedures 

that require relatively inexpensive 

resources to perform from the approved 

ASC list of procedures, although this is 

not the approach we are advancing. In 

considering value-based purchasing, we 

seek comment concerning whether 

procedures that are currently primarily 

office-based or that require relatively 

inexpensive resources are most 

efficiently and effectively provided in 

the ASC facility setting, which typically 

possesses greater surgical capacity than 

such procedures would generally 

require. 

When we started to identify the codes 

that we would propose to classify as 

office-based beginning in CY 2008, we 

encountered some anomalous cases that 

required further refinement of our 

office-based criterion beyond strict 

application of a 50-percent utilization 

threshold. For example, we identified 

some CPT codes that meet the 50- 

percent office utilization threshold for 

which a nonfacility practice expense 

amount has not been developed under 

the MPFS. We are proposing to classify 

as office-based any surgical codes that 

our physician claims data indicate are 

performed more than 50 percent in an 

office setting, even if the codes lack a 

nonfacility practice expense RVU under 

the MPFS. We further propose to cap 

payment for these procedures, as 

appropriate, once a nonfacility practice 

expense RVU is established. Until that 

time, we are proposing to calculate 

payment for these office-based surgical 

CPT codes using the methodology we 

propose in sections XVIII.C.11.c. and d. 

below, for other surgical procedures. 

Similarly, until a national nonfacility 

practice expense RVU is established for 

office-based surgical CPT codes that are 

‘‘carrier priced’’ under the MPFS, we are 

proposing to calculate the ASC facility 

payment using the same methodology 

that we are proposing for surgical 

procedures that are not office-based. 

Application of the cap to codes 

designated as office-based would be 

updated through rulemaking as part of 

the annual ASC payment update. 

In applying the data-based 50-percent 

threshold, we discovered some 

contradictions in the data that required 

us to further refine our definition of 

office-based. For example, we noted 

instances in which seemingly very 

similar procedures had inconsistent site 

of service utilization. The BESS data 

showed high levels of office utilization 

for some complex procedures which we 

expected to be performed infrequently 

in an office setting whereas simpler but 

related procedures showed lower levels 

of office utilization. 

We therefore undertook another, more 

detailed level of review and identified 

groups of CPT surgical codes related to 

procedures that are performed 50 

percent or more of the time in the office 

setting to determine if there was a 

logical correlation between procedure 

complexity within a group of related 

procedures and the frequency with 

which those procedures were performed 

in the office setting. For example, 

according to CPT coding, the following 

three codes are related: 

13120, Repair, complex, scalp arms and/ 

or legs; 1.1cm to 2.5 cm 

13121, Repair, complex, scalp arms and/ 

or legs; 2.6 cm to 7.5 cm 

13122, Repair, complex, scalp arms and/ 

or legs; each additional 5 cm or less 

As is often the case for groups of 

related codes in the CPT coding system, 

the first of these codes is the least 

complex clinically and, in this example, 

the complexity of the procedure 

increases in proportion to the increase 

in the size of the area to be repaired. If 

utilization data indicated that CPT code 

13122 was performed in the office 67 

percent of the time in CY 2005, we 

would expect to find that both CPT 

codes 13120 and 13121 were also 

performed in the physician office more 

than 50 percent of the time during that 

year. Because the most complex 

procedure was provided in the office 

most of the time, logically, the less 

complex procedures would also have 

been performed in that site of service. 

However, the BESS data showed that 

this was not always the case. 

So, although our expectation was that, 

the less complex procedures within a 

group of related procedure codes would 

typically be performed most often in the 

office and the more complex procedures 

less often in the office, there are 

instances in which the less complex 

procedures with the code group were 

billed more often in an ASC or hospital 

outpatient department and the more 

complex procedures within the code 

billed in the office setting. 

In our analysis of the BESS site of 

service data, we also took into 

consideration the volume of cases 

represented in the data. There were a 

few instances in which we initially 

identified a procedure as office-based 

because the data indicated that 100 

percent of the cases were performed in 

the physician office. However, closer 

inspection revealed that there was only 

one case reported for the procedure with 

physician’s office as the site of service. 

We were concerned about using such 

low volume as the basis for identifying 

a procedure as office-based. Because of 

the unevenness of the data associated 

with some of the codes we initially 

classified as office-based, we conducted 

a code-by-code analysis to buttress 

inconclusive data with the clinical 

judgment of our medical advisors. As a 

result, on the basis of clinical judgement 

overriding inadequate or insufficient 


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claims data, there are some procedures 

that we deem meet the 50-percent 

threshold when taken in isolation from 

other closely related codes that we have 

designated as office-based. 

We are proposing to assess each year 

based on the most recent available BESS 

and other data available to us whether 

there are additional procedures that we 

would propose to classify as officebased. We would solicit comment on 

proposed classification of additional 

codes as office-based as part of the 

annual OPPS/ASC rulemaking cycle. In 

addition, we are proposing that once we 

identify a procedure as office-based, that 

classification would not change in 

future updates of the ASC payment 

system. We reason that once a 

procedure becomes safe enough to be 

performed in more than 50 percent of 

cases in the office setting, it would be 

improbable for it to revert to an 

institutional setting. 

To summarize, the list of codes that 

we propose as office-based in this rule 

takes into account the most recent 

available volume and utilization data for 

each individual procedure code and, if 

appropriate, the utilization and volume 

of related codes. While we are 

proposing to apply the office-based 

designation only to procedures that 

would no longer be excluded from 

payment of an ASC facility fee 

beginning in CY 2008, were we to 

exclude office-based services from ASC 

payments, we expect that the same 

approach to developing and updating 

the set of procedures in the CPT surgical 

code range that we consider to be officebased would be applicable. Finally, we 

are concerned that our proposal to allow 

payment of an ASC facility fee for 

office-based procedures, even if the ASC 

payment amount were capped at the 

lesser of the MPFS nonfacility practice 

expense payment or the revised ASC 

rate, would result in a downward 

adjustment to ASC payments overall, 

and would increase Medicare spending. 

We propose to exempt all procedures 

on the CY 2007 ASC list from 

application of the office-based 

classification. The procedures that we 

are proposing to designate as subject to 

the office-based payment limit are 

identified in new Addendum CC of this 

proposed rule. Those procedures for 

which the proposed CY 2008 payment 

would be based on the MPFS nonfacility 

practice expense RVU are flagged in 

Addendum BB. The ASC relative 

payment weight shown for procedures 

in Addendum BB that would be capped 

by the MPFS nonfacility practice 

expense RVU has been adjusted to 

reflect the capped payment amount. We 

remind readers that the ASC payment 

rates in Addendum BB of this proposed 

rule are based on proposed CY 2007 

OPPS relative payment weights and 

proposed MPFS nonfacility practice 

expense RVUs. The final ASC relative 

weights and payment amounts for CY 

2008 would be different from the rates 

published in this proposed rule because 

they would take into account the CY 

2008 updates of both the OPPS and the 

MPFS. The proposed and final ASC 

relative weights and payment amounts 

for CY 2008 would be published in the 

Federal Register during the proposed 

and final rulemaking cycles for the CY 

2008 OPPS. 

6. Payment Policy for Multiple 

Procedure Discounting 

We are proposing to mirror the OPPS 

policy for discounting when a 

beneficiary has more than one surgical 

procedure performed on the same day at 

an ASC. The current policy for multiple 

procedure discounting in the ASC, as 

specified in § 416.120(c)(2)(ii), is based 

on a simple count of procedures 

performed on the same day. The most 

costly procedure is paid the full amount 

and all other procedures are discounted 

by half. 

Under the OPPS, certain surgical 

procedures are not subject to the 

discounting policy. Generally, the 

procedures that are exempted are those 

performed to implant costly devices. 

They are not discounted even when 

performed in association with other 

surgical procedures because the cost of 

the implantable device does not change, 

so resource savings due to efficiencies 

would be minimal. 

Until now, there has been no reason 

to exempt any procedure from the 

multiple procedure discounting policy 

in ASCs because separate payments 

have been made for implantable 

devices. Thus, although the facility 

payment for the procedure may have 

been discounted, the cost of the device 

was paid outside of that rate and was 

unaffected by the multiple procedure 

discount. 

Under the revised ASC payment 

system, we are proposing to package 

into the payment for the procedure 

payment for implantable devices in the 

ASC, as in the OPPS. Because we are 

trying wherever possible to implement 

parallel payment policy across both 

systems, we are proposing to adopt the 

OPPS discounting policy that is applied 

more specifically to surgical procedures 

so that the costs of performing multiple 

procedures that require implantation of 

costly devices are taken into account. 

Thus, payment for the same set of 

multiple procedures in the OPPS and 

the ASC would be made using similar 

packaging and payment rules. 

Table 46 below lists the procedures 

that would be exempt from multiple 

procedure discounting. These exempt 

procedures are those surgical 

procedures proposed for payment of an 

ASC facility fee that are assigned a 

status indicator other than ‘‘T’’ under 

the OPPS, to indicate that a multiple 

surgical procedure reduction does not 

apply. We are proposing to update this 

list annually in the OPPS/ASC proposed 

rule, soliciting comment on the list. 

We are proposing to incorporate our 

proposed policy on multiple procedure 

discounts in proposed new § 416.172(e). 

BILLING CODE 4120–01–P 


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7. Proposed Geographic Adjustment 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Wage Index’’ at the 

beginning of your comment.) 

Currently, Medicare adjusts 34.45 

percent of the national ASC payment 

rates using wage index values and 

localities that were established under 

the IPPS prior to implementation of the 

new Core Based Statistical Areas 

(CBSAs) issued by OMB in June 2003. 

Medicare currently adjusts 60 percent of 

national OPPS payment rates by the 

IPPS wage index value assigned to 

hospitals using the June 2003 OMB 

definitions for geographical statistical 

areas and wage adjustments required 

under Pub. L. 108–173. 

Since 1990, ASC payments have been 

adjusted for regional wage variations 

using the hospital IPPS wage index 

values. We believe that standardization 

continues to be appropriate in 

recognition of widely varying labor 

market costs tied to geographic 

localities. We also believe that it is 

advisable to maintain the consistency in 

locality designations between ASCs and 

hospitals and acknowledge parity of 

labor costs between ASCs and HOPDs 

that are competing for staff in the same 

locality. Therefore, we are proposing to 

apply to ASCs the IPPS prereclassification wage index values 

associated with the June 2003 OMB 

geographic localities, as recognized 

under the IPPS and OPPS, to adjust 

national ASC payment rates for 

geographic wage differences under the 

revised payment system. 

Although we have not collected new 

data to identify whether the current 

labor-related share is correct, the results 

of a 1994 survey of ASC costs supported 

the current 34.45 percent labor 

adjustment factor, and we have received 

no complaints from the ASC community 

about our continued use of the 34.45/ 

65.55 ratio of labor to nonlabor costs for 

purposes of adjusting payments for 

regional wage differences. Moreover, we 

believe it is reasonable to expect ASCs 

to have a lower labor adjustment factor 

than that of a hospital. For example, 

most OPPS hospital outpatient 

departments are staffed 24 hours per 

day to provide emergency department 

services and observation care. 

Therefore, we are proposing to continue 

using 34.45 percent as the labor 

adjustment factor for regional wage 

differences under the ASC revised 

payment system, beginning in CY 2008. 

We are proposing to establish rules 

governing this proposed new 

§ 416.172(c). 

8. Proposed Adjustment for Inflation 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Inflation’’ at the 

beginning of your comment.) 

As noted above, section 

1833(i)(2)(C)(iv) of the Act, as amended 

by section 626(a) of Pub. L. 108–173, 

requires the adjustment of ASC facility 

services amounts for inflation for FY 

2005, the last quarter of CY 2005, and 

each of CYs 2006 through 2009, to equal 

zero percent. Otherwise, section 

1833(i)(2)(C)(i) of the Act provides that 

ASC facility services amounts are to be 

adjusted by the percentage increase in 

the CPI–U during years when the ASC 

amounts are not updated. 

As explained in section II.C. of the 

preamble of this proposed rule, the 

OPPS conversion factor is updated 

annually using the hospital inpatient 

market basket percentage increase. 

Although section 626(d) of Pub. L. 108–

173 suggests that the Congress found 

merit in linking the ASC payment 

system to the OPPS relative payment 

weights and APC groups, it did not 

require that the new ASC payment 

system be updated using the hospital 

market basket that is the basis for 

annual OPPS updates. However, we 

believe that an update of the ASC 

amount is performed through the annual 

relative ASC payment weight 

adjustments that we propose in section 

XVIII.C.11.d.(1) below, which obviates 

the requirement for the statutory CPI 

adjustment. Nonetheless, although we 

are not compelled to do so by the 

statute, we are proposing under the 

revised ASC payment system, beginning 

in CY 2008, to apply a CPI–U 

adjustment to update the ASC 

conversion factor for inflation on an 

annual basis, in accordance with the 

statutory formula. The CPI–U 

adjustment in CY 2008 and CY 2009 

would equal zero. Beginning in CY 

2010, we would update the ASC 

conversion factor by the percentage 

increase in the CPI–U (U.S. city average) 

as estimated for the 12-month period 

ending with the midpoint of the year 

involved. As we explain in section 

XVIII.C.11.d.(2) below, we are proposing 

to adjust the conversion factor for 

inflation annually to ensure that ASC 

payments keep up with cost increases 

attributable to inflation. Accordingly, 

we are proposing to establish rules in 

proposed new §§ 416.171 and 416.172 

to reflect our proposed policies for 

standardizing labor-related costs, 

applying an inflationary adjustment, 

and calculating a conversion factor, 

respectively under the proposed new 

payment system beginning January 1, 

2008. 

9. Proposed Beneficiary Coinsurance 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Coinsurance’’ at the 

beginning of your comment.) 

Payment for ASC facility services is 

subject to the Medicare Part B 

deductible and coinsurance 

requirements. Currently, Medicare pays 

participating ASCs 80 percent of a 

prospectively determined rate, adjusted 

for regional wage variations. The 

beneficiary deductible and coinsurance 

make up the other 20 percent. 

Section 626(c) of Pub. L. 108–173 

amended section 1833(a)(1) of the Act to 

provide that, beginning with the 

implementation date of the revised 

payment system, the Medicare program 

payment to ASCs shall equal 80 percent 

of the lesser of the actual charge for the 

services or the payment amount that we 

determine under the revised payment 

system for the services. We are 

proposing to make this change and to 

continue to maintain the beneficiary 

deductible and coinsurance at 20 

percent. We are proposing to reflect this 

statutory requirement in proposed new 

§ 416.172(b) and (d). 

10. Proposal To Phase In 

Implementation of Payment Rates 

Calculated Under the CY 2008 Revised 

ASC Payment System 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Phase In’’ at the 

beginning of your comment.) 

We discuss in section XXVII.D. of this 

preamble our analysis of the impact the 

revised ASC payment system and 

estimated payment rates proposed for 

implementation in CY 2008 could have 

on certain ASCs that specialize in or 

perform high volumes of procedures for 

which payment under the new system 

would decrease. We want to ensure that 

the revised payment system does not 

cause a sudden, unwarranted migration 

of services from ASCs to other 

ambulatory settings, or the reverse; that 

ASCs would have an opportunity to 

balance their Medicare case mix 

between procedures whose rates 

decrease and procedures whose rates 

increase; and, that beneficiaries and 

their physicians would continue to have 

a robust choice of sites where important 

preventive and other surgical services 

are paid for by Medicare. Therefore, we 

propose to implement the revised ASC 

payment system in CY 2008 using 

transitional payment rates that would be 

based upon a 50/50 blend of the 

payment rate for procedures on the CY 


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2007 list of approved ASC procedures 

and the payment rate for that procedure 

calculated under the revised payment 

methodology described in the next 

section and reflected in proposed new 

§ 416.171(c). (Procedures added for 

payment of an ASC facility fee 

beginning in CY 2008 would be paid the 

full amount calculated under the 

revised payment methodology for CY 

2008 rather than a blended amount.) We 

further propose that, in CY 2009, we 

would fully implement the ASC 

payment rates calculated under the 

payment methodology proposed in the 

next section, discontinuing the blended 

transitional payment rate for services 

furnished beginning January 1, 2009. 

This is proposed in new § 416.171(d). 

11. Proposed Calculation of ASC 

Conversion Factor and Payment Rates 

for CY 2008 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Conversion Factor’’ at the 

beginning of your comment.) 

a. Overview 

In section XVIII.C.2 of this preamble, 

we are proposing to base ASC relative 

payment weights and rates under the 

revised system on APC groups and 

relative payment weights established 

under the OPPS. In section XVIII.C.4 of 

this preamble, we are proposing to set 

the ASC relative payment weight for 

certain office-based surgical procedures 

so that the national ASC payment rate 

does not exceed the MPFS nonfacility 

practice expense payment. The 

proposed ASC payment weights are 

multiplied by an ASC conversion factor 

to calculate the proposed ASC payment 

rates. For CY 2008, our current estimate 

of the budget neutral ASC conversion 

factor is $39.688. The final ASC 

conversion factor may be higher or 

lower than this figure for a number of 

reasons, including (1) The final OPPS 

relative payment weights for CY 2008, 

(2) the final physician fee schedule 

practice expense payments for CY 2008 

and (3) updated utilization data. 

b. Budget Neutrality Requirement 

Section 626(b) of the MMA amended 

section 1833(i)(2) of the Act by adding 

subparagraph (D) to require that in the 

year the new system is implemented: 

‘‘* * * [S]uch system shall be 

designed to result in the same aggregate 

amount of expenditures for such 

services as would be made if this 

subparagraph did not apply, as 

estimated by the Secretary * * *’’. 

The ASC conversion factor is 

calculated so that aggregate 

expenditures under the new system are 

estimated to be the same as the 

aggregate expenditures for ASC facility 

services in CY 2008 that would have 

been paid had the ASC payment system 

not been revised, taking into 

consideration the cap on payments in 

CY 2007 as required under section 5103 

of Pub. L. 109–171, which we discuss in 

section XVII.D., that is, the conversion 

factor is calculated so the new system is 

budget neutral. 

Note that we consider expenditures in 

the context of section 626(b) of the Pub. 

L. 108–173 budget neutrality 

requirement to mean expenditures from 

the Medicare Part B Trust Fund. We do 

not consider expenditures to include 

beneficiary coinsurance and 

copayments. We note, however, that the 

exclusion of beneficiary coinsurance 

payments does not impact the 

calculation of the ASC conversion factor 

under our proposed methodology. (See 

section XXVI.D. of this preamble for 

impacts of the revised ASC system on 

beneficiary coinsurance.) 

c. Proposed Calculation of the ASC 

Payment Rates for CY 2008 

We are proposing to calculate the ASC 

payment rates for CY 2008 as follows: 

Estimated payments under the current 

ASC system 

Step 1: To estimate the aggregate 

amount of expenditures that would be 

made in CY 2008 under the current ASC 

payment system, we first multiplied the 

estimated CY 2008 ASC volume for each 

CPT code on the current ASC list by the 

estimated CY 2008 ASC payment rate 

for the CPT code under the current ASC 

system. The estimated CY 2008 ASC 

payment rates are based on the 

proposed CY 2007 ASC payment rates, 

which are found in Addendum BB to 

take into account the OPPS cap on ASC 

services as required by section 5103 of 

Pub. L. 109–171 and to reflect the zero 

percent CY 2008 update for ASC 

services mandated by section 

1833(i)(2)(C) of the Act. We then 

summed the results over all services on 

the current ASC list. 

Estimated payments under the new ASC 

system 

Step 2: To estimate the aggregate 

amount of expenditures that would be 

made in CY 2008, we used estimated CY 

2008 OPPS payment amounts instead of 

estimated CY 2008 ASC payment 

amounts under the current system, and 

we multiplied the estimated CY 2008 

ASC volume for each CPT code on the 

current ASC list by the estimated CY 

2008 OPPS payment rate for the CPT 

code. We summed the results over all 

services on the current ASC list. 

Calculate the CY 2008 budget neutrality 

adjustment 

Step 3: To calculate the CY 2008 ASC 

budget neutrality adjustment, we 

divided the total expenditures 

calculated in Step 1 by the total 

expenditures calculated in Step 2. The 

result is 0.62. 

Apply the CY 2008 budget neutrality 

adjustment to determine the CY 2008 

ASC conversion factor 

Step 4: To determine the CY 2008 

ASC conversion factor, we multiplied 

the estimated CY 2008 OPPS CF by the 

results in Step 3. Our current estimate 

of the CY 2008 OPPS CF is $64.013. 

Multiplying the estimated CY 2008 

OPPS conversion factor by the 0.62 

budget neutrality adjustment yields our 

current estimate of the CY 2008 ASC 

conversion factor: $39.688. 

Calculate the CY 2008 ASC payment 

rate under the new ASC system 

Step 5: To determine the national 

ASC payment rate under the new 

system (including the beneficiary 20 

percent coinsurance), we multiplied the 

ASC conversion factor from Step 4 by 

the ASC relative payment rate. 

The ASC relative payment weights are 

primarily based on the APC groups and 

relative payment weights established 

under the OPPS as described in section 

XVIII.C.2 of this preamble. However, as 

described in section XVIII.C.4 of this 

preamble, the ASC relative payment 

weights for certain office-based surgical 

procedures are set so that the national 

ASC payment rate does not exceed the 

MPFS nonfacility practice expense 

payment. 

As discussed elsewhere in this 

proposed rule, we are proposing to limit 

payment for office-based procedures in 

an attempt to mitigate potentially 

inappropriate migration of services from 

the physician office setting to the ASC. 

Alternatively, we could entirely exclude 

office-based procedures or procedures 

that require relatively inexpensive 

resources to perform from the approved 

ASC list of procedures, although this is 

not the approach we are advancing. 

The ASC relative payment weights are 

listed in Addendum BB of this proposed 

rule. 

Calculate the CY 2008 ASC payment 

rate under the transition 

Step 6: As described in section 

XVIII.C.10. of this preamble, we are 

proposing under the revised payment 

system a 2-year transition to 100 percent 

implementation of the new ASC 

payment rates for procedures on the CY 

2007 list of approved ASC procedures. 

In the first year of this transition, the 

payment rate would be based on 50 


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percent of the final CY 2007 ASC 

standard overhead amount and 50 

percent of the final payment rate 

calculated under the revised payment 

methodology proposed in this section of 

the preamble. 

d. Proposed Calculation of the ASC 

Payment Rates for CY 2009 and Future 

Years 

(1) Updating the ASC Relative Payment 

Weights 

We are proposing to update the ASC 

relative payment weights each year 

using the national OPPS relative 

payment weights for that calendar year 

and, for the office-based procedures, the 

practice expense payments under the 

physician fee schedule for that calendar 

year. We further propose to uniformly 

scale the ASC relative payment weights 

each year so that estimated aggregate 

expenditures using updated ASC 

relative payment weights are the same 

as estimated aggregate expenditures 

using the current year ASC relative 

payment weights. That is, we propose to 

make the relative payment weights 

budget neutral to ensure that changes in 

the relative payment weights from year 

to year do not cause the estimated 

amount of expenditures to ASCs to 

increase or decrease as a function of 

those changes. For example, we propose 

to uniformly scale the ASC relative 

payment weights for CY 2009 so that 

estimated expenditures for CY 2009 

using the updated CY 2009 ASC relative 

payment weights are the same as they 

would be using the CY 2008 ASC 

relative payment weights. We propose 

to uniformly scale the ASC relative 

payment weights for CY 2010 so that 

estimated expenditures for CY 2010 

using the updated CY 2010 ASC relative 

payment weights are the same as they 

would be using the CY 2009 ASC 

relative payment weights. 

We are proposing to scale the relative 

payment weights annually because we 

believe that the purpose of using 

relative payment weights as part of the 

rate setting methodology under the 

revised ASC system is to establish 

appropriate relativity among surgical 

procedures paid for in an ASC. Scaling 

the relative payment weights each year 

would also serve as a buffer to protect 

ASCs from sudden changes that could 

occur under the OPPS. For example, by 

making the relative payment weights 

budget neutral under the revised ASC 

payment system, the ASC relative 

weights would not drop were there to be 

a sudden upsurge in costs associated 

with hospital outpatient emergency or 

clinic visits relative to outpatient 

surgical costs. Moreover, making the 

ASC relative weights budget neutral 

would shield the ASC payment system 

against the inadvertent impact of 

unrelated aggregate changes in OPPS 

expenditures. We propose to continue 

this methodology to update the ASC 

payment system in future years. 

(2) Updating the ASC Conversion Factor 

In section XVIII.11.d.1, above, we 

propose to scale the relativity among 

surgical procedures each year so that 

aggregate expenditures under the ASC 

are budget neutral notwithstanding 

changes in the relative payment 

weights. In section XVIII.11.c, above, we 

propose to calculate the ASC payment 

rates each year as the product of the 

ASC relative payment weight and the 

ASC conversion factor which have been 

adjusted for budget neutrality. Section 

1833(i)(2)(C) of the Act requires that if 

the Secretary has not updated the ASC 

facility services amounts in a calendar 

year after CY 2009, the payment 

amounts shall be increased by the 

percentage increase in the CPI-U as 

estimated by the Secretary for the 12- 

month period ending with the midpoint 

of the year involved. 

Although we are only required to 

increase ASC payment rates by the 

percentage increase in the CPI–U in 

years when we do not update the ASC 

payment amounts, beginning with the 

CY 2008 revised ASC payment system, 

we propose to update the ASC 

conversion factor annually using the 

CPI–U. For example, for CY 2009, the 

statute requires a zero percent CPI–U 

increase for ASC services. Therefore, the 

CY 2009 conversion factor would be 

equal to the CY 2008 conversion factor. 

For CY 2010, we would increase the CY 

2009 conversion factor by the estimated 

percent increase in the CPI–U for the 12- 

month period ending June 30, 2010; in 

CY 2011, we would increase the CY 

2010 conversion factor by the estimated 

percent increase in the CPI–U for the 12- 

month period ending June 30, 2011, and 

so forth, each year thereafter. We 

propose to apply this adjustment 

annually to ensure that ASC payments 

keep up with cost increases attributable 

to inflation. Moreover, we propose to 

use the CPI–U to adjust the conversion 

factor for inflation because we have 

used the CPI–U to adjust payments to 

ASCs for inflation since July 1987, when 

we first updated the ASC payment rates 

in effect at the time by the projected 

increase in the CPI–U (52 FR 20467). 

This proposal is reflected in § 416.167 

and § 416.171. 

e. Alternative Option for Calculating the 

Budget Neutrality Adjustment 

Considered 

We considered an alternative 

approach to calculating the budget 

neutrality adjustment under the new 

payment system, which would take into 

account the effects of the migration of 

procedures between ASCs, physicians’

offices, and hospital outpatient 

departments that might be attributable 

to the new ASC payment system. In the 

following discussion the phrase ‘‘new 

ASC procedure’’ refers to a procedure 

not currently on the ASC list of 

approved procedures that we are 

proposing for inclusion on the ASC list 

of approved procedures beginning in CY 

2008. 

Under this alternative, we assumed 

that 25 percent of the hospital 

outpatient department utilization for 

new ASC procedures would migrate to 

the ASC and we assumed that 15 

percent of the physician office 

utilization for new ASC procedures 

would migrate to the ASC. We believe 

that our assumptions of a 25 percent 

and 15 percent migration from hospital 

outpatient departments and physician 

offices to ASCs, respectively, are 

reasonable given the general utilization 

relationships between these settings for 

services currently on the ASC list. For 

services on the current ASC list that are 

predominately performed in ASC and 

outpatient hospital department settings, 

they are on average performed 30 

percent of the time in the ASC setting. 

For services on the current ASC list that 

are predominately performed in the 

ASC and physician office settings, they 

are on average performed 17 percent of 

the time in the physician office setting. 

We assumed that new ASC services 

would migrate at slightly lower rates in 

the first year of the revised ASC system, 

yielding our migration assumptions of 

25 percent for the hospital outpatient 

department setting and 15 percent for 

the physician office setting. 

We also assumed that the net impact 

of migration on services currently on the 

ASC list is negligible. We note that 

payment rates for the current highest 

volume ASC procedures would 

generally decrease under the proposed 

new ASC system, and the lower volume 

ASC procedures would experience 

significant payment increases. We 

believe it is reasonable to assume that 

some of the higher volume services will 

migrate from ASCs to other settings, and 

some of the current lower volume 

procedures will migrate to the ASC 

setting as a result of the payment 

changes. 


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In order to calculate the budget 

neutrality adjustment, first, we 

estimated expenditures that would 

occur if we did not revise the ASC 

payment system. We estimated CY 2008 

expenditures if the ASC payment 

weights were not revised and the ASC 

list of approved procedures was not 

expanded. As described below (see Step 

1). 

Estimated payments under the current 

system 

Step 1: Hospital outpatient 

department migration valued using 

estimated CY 2008 OPPS payment rates 

(a) Assuming 25 percent of the 

outpatient hospital department 

utilization for new ASC procedures will 

migrate to the ASC, multiple 0.25 times 

the hospital outpatient department 

utilization for each new ASC procedure. 

(b) For each new ASC procedure, 

multiple the results of Step 1(a) by the 

estimated CY 2008 OPPS payment rate 

for the procedure. 

(c) Sum the results of Step 1(b) across 

all new ASC procedures. 

Step 2: Physician office migration 

valued using estimated CY 2008 

physician payment rates 

(a) Assuming 15 percent of the 

physician office utilization for new ASC 

procedures will migrate to the ASC, 

multiple 0.15 times the physician office 

utilization for each new ASC procedure. 

(b) For each new ASC procedure, 

multiple the results of Step 2(a) by the 

estimated CY 2008 physician office 

payment rate for the procedure. 

(c) Sum the results of Step 2(b) across 

all new ASC procedures. 

Step 3: Current ASC services valued 

using the estimated CY 2008 ASC 

payment rates under the current ASC 

system 

(a) This is described under Step 1 in 

the Proposed Calculation of the ASC 

Conversion Factor section above. 

Step 4: Sum the results of Steps 1–3. 

Estimated payments under the new 

system 

Step 5: Hospital outpatient 

department migration valued using 

estimated CY 2008 OPPS payment rates 

(a) Same as Step 1 in this section. 

Step 6: Identify new ASC procedures 

currently considered to be office-based 

(for example, insert examples and see 

Addendum BB) 

Step 7: Physician office migration for 

new ASC procedures currently 

considered to be office based valued 

using the estimated CY 2008 OPPS 

payment rates capped at the estimated 

CY 2008 physician office payment rates 

(a) For each new ASC procedure 

considered to be office based, multiply 

the results of Step 2(a) by the lesser of: 

(1) The estimated CY 2008 OPPS rate 

for the procedure; and 

(2) The estimated CY 2008 physician 

fee schedule office rate for the 

procedure. 

(b) Sum the results of Step 7(a) across 

all new ASC procedures considered to 

be office-based. 

Step 8: Physician office migration for 

new ASC procedures not currently 

considered office based valued using the 

estimated CY 2008 OPPS rates 

(a) For each new ASC procedure not 

considered to be office based, multiply 

the results of Step 2(a) by the estimated 

CY 2008 OPPS rate for the procedure. 

(b) Sum the results of Step 8(a) across 

all new ASC procedures not considered 

to be office based. 

Step 9: Physician office migration 

valued using the estimated CY 2008 

physician fee schedule out-of-office 

payment rate. 

(a) For each new ASC procedure, 

multiple the results of Step 2(a) by the 

estimated CY 2008 out of office 

physician rate for the procedure. 

(b) Sum the results of Step 9(a) across 

all new ASC procedures. 

Step 10: Current ASC services valued 

using the estimated CY 2008 OPPS 

payment rates 

(a) This is described under Step 2 in 

this section. 

Step 11: Sum the results of Steps 5, 

7–10. 

Calculate the budget neutrality 

adjustment 

Step 12: Divide the result of Step 4 by 

the result of Step 11. 

Step 13: The application of the cap at 

the estimated CY 2008 physician office 

payment rates that occurs in Step 7 is 

dependent on the ASC conversion 

factor. The ASC budget neutrality 

adjustment resulting from Step 12 is 

calibrated to take into account the 

interactive nature of the ASC conversion 

factor and the physician office payment 

cap. 

The resulting budget neutrality 

adjustment is 0.62, indicating that under 

the migration assumptions described 

above the difference between our 

proposed budget neutrality adjustment 

without migration (0.62) and this 

alternative budget neutrality adjustment 

with migration (0.62) is equal rounded 

to the nearest hundredth. 

Discussion of the alternative 

calculation of the budget neutrality 

adjustment: 

We have chosen to propose 

calculation of the budget neutrality 

adjustment based on the CY 2007 final 

ASC list of approved services and 

current ASC utilization because we 

believe this is the most appropriate 

approach to estimating expenditures so 

as to result in a budget neutral payment 

system in CY 2008. We have no data 

which would enable us to precisely 

estimate the net potential migration of 

services between the ASC setting, the 

outpatient hospital setting, and the 

physician office setting that might result 

from implementation of the new ASC 

payment system. Moreover, basing our 

estimate of expenditures on current ASC 

utilization without including migration 

from other sites of service is consistent 

with how we estimate expenditures for 

purposes of maintaining budget 

neutrality in other Medicare payment 

systems. 

We expect that some commenters may 

believe it is more appropriate to 

estimate the ASC budget neutrality 

adjustment taking into account the 

potential migration of services between 

the ASC setting, the outpatient hospital 

setting, and the physician office setting. 

We welcome data supporting the use of 

specific migration assumptions in the 

calculation of the ASC budget neutrality 

adjustment. We describe above the 

budget neutrality calculation under the 

alternative approach based on our 

current best estimate of the potential 

migration of services between the 

different settings so as to facilitate and 

stimulate comment and to encourage the 

submission of pertinent quantitative 

evidence of surgical migration resulting 

from changes in payment rates. We 

welcome data on all of the migration 

assumptions under this alternative 

approach. We note again that under the 

reasonable migration assumptions 

described above, our proposed budget 

neutrality calculation without migration 

(0.62) and the alternative budget 

neutrality adjustment with migration 

(0.62) is equal rounded to the nearest 

hundredth. However, if we exclude 

office-based procedures from the 

approved list of procedures, under the 

alternative budget neutrality adjustment 

that takes into account migration across 

different practice settings, payment rates 

for the ASC services remaining on the 

list (those procedures that are not officebased) would be slightly higher due to 

the statutory budget neutrality 

requirement. 

12. Proposed Annual Updates 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Updates’’ at the beginning 

of your comment.) 

Currently, we update the ASC list 

every 2 years through the notice and 

comment regulation process. We make 

additions to and deletions from the ASC 

list based on clinical judgment and data 

that are available regarding utilization of 


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care settings. The last update was 

published in the May 4, 2005 Federal 

Register (70 FR 23690) and the update 

for CY 2007 is proposed in section XVII 

of this preamble. The process we follow 

currently to update the ASC list is 

explained in section XVII of this 

preamble. 

Under the revised ASC payment 

system, which would be implemented 

effective January 1, 2008, we are 

proposing to update on an annual 

calendar year basis the ASC conversion 

factor, the relative payment weights and 

APC assignments, the ASC payment 

rates, and the list of procedures for 

which Medicare would not make 

payment of an ASC facility fee. To the 

extent possible under the rules and 

policies of the revised ASC payment 

system, we are proposing to maintain 

consistency between the OPPS and the 

ASC payment systems in the way we 

treat new and revised HCPCS and CPT 

codes for payment under the ASC 

payment system. We also are proposing 

to invite comment as part of the annual 

update cycle to determine if there are 

procedures that we exclude from 

payment in the ASC setting that merit 

reconsideration as a result of changes in 

clinical practice or innovations in 

technology. 

We are proposing to update the ASC 

list and payment system as part of the 

annual proposed and final rulemaking 

cycle updating the hospital OPPS. We 

believe that including the ASC update 

as part of the OPPS rulemaking cycle 

would ensure that updates of the ASC 

payment rates and the list of surgical 

procedures for which Medicare pays an 

ASC facility fee would be issued in a 

regular, predictable, and timely manner. 

Moreover, the ASC payment system 

would be updated concurrent with 

changes in the APC groups and the 

OPPS inpatient list, making it easier to 

predict changes in payment for 

particular services from year to year. 

In the first part of CY 2007, we are 

proposing to issue a final rule in which 

we would respond to comments 

submitted timely regarding the 

proposals set forth in this proposed rule 

and make final the policy and 

regulations for the revised ASC payment 

system for implementation effective 

January 1, 2008. We are proposing to 

include the CY 2008 ASC payment rates 

as part of the proposed and final rules 

for the CY 2008 OPPS update. 

We are proposing to evaluate each 

year all new CPT and alphanumeric 

HCPCS codes that describe surgical 

procedures to make preliminary 

determinations regarding whether or not 

they should be payable in the ASC 

setting and, if so, whether they are 

office-based procedures. In the absence 

of claims data that would indicate 

where procedures described by new 

codes are being performed, and 

resources required to perform them, we 

are proposing to use other available 

information, including our clinical 

advisors’ judgment, predecessor CPT 

and HCPCS codes, information 

submitted by representatives of 

specialty societies and professional 

associations, and information submitted 

by commenters during the public 

comment period following publication 

of the final rule with comment period in 

the Federal Register. We would publish 

in the annual OPPS/ASC payment 

update final rule those interim 

determinations for the new codes to be 

active January 1 of the update year. 

Those procedures would be open to 

comment on that final rule, and we 

would respond to comments about our 

determinations in the final rule for the 

following year, just as we currently 

respond to comments about our APC 

assignments for new codes in the OPPS 

final rule for the following year. After 

our review of public comments and in 

the absence of physicians’ claims data, 

if our determination regarding the new 

codes is that they should reside on the 

ASC list as office-based procedures 

subject to the payment limitation, this 

determination would remain 

preliminary until there are adequate 

physicians’ claims data available for 

these procedures to assess their 

predominant sites of service. Using 

those data, if we confirm our 

determination that the new codes are 

office-based because they were 

performed in the physician office setting 

more than 50 percent of the time, the 

codes would then be permanently 

assigned to the list of office-based 

procedures subject to the payment 

limitation. 

Accordingly, we are proposing to 

reflect this annual rulemaking and 

publication of revised payment 

methodologies and payment rates in 

new § 416.173 in proposed new subpart 

F. 

D. Information in Addenda Related to 

the Revised CY 2008 ASC Payment 

System 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘ASC Addenda’’ at the 

beginning of your comment.) 

The ASC payment rates, copayment 

amounts, and relative payment weights 

displayed in Addendum BB of this 

proposed rule are presented to model 

the ratesetting methodology that we are 

proposing for the revised ASC payment 

system required by Pub. L. 108–173. 

Actual payment rates proposed and 

made final for CY 2008 are dependent 

upon the final policies and regulations 

affecting the revised payment system 

that we would publish in a final rule in 

CY 2007; the proposed and final APC 

groups, APC relative payment weights, 

and MPFS nonfacility practice expense 

RVUs for CY 2008; and, the ASC 

conversion factor updated to reflect CY 

2006 utilization data and CY 2007 ASC 

standard overhead payment amounts. 

E. Technical Changes to 42 CFR Parts 

414 and 416 

We are proposing to make the 

following technical change to 42 CFR 

414: 

• § 414.22 (Non-facility practice 

expense RVUs) is revised to conform to 

changes occurring under the ASC 

revised payment system. The change 

will be effective January 1, 2008. 

We are proposing to make the 

following technical changes to 42 CFR 

416: 

• § 416.65(a)(4) is revised to replace 

the obsolete cross-reference to § 405.310 

with § 411.15. 

• § 416.120 is revised by replacing the 

incorrect cross-reference to ‘‘Part 413’’

with ‘‘Part 419.’’

• § 416.150 (Beneficiary appeals) is 

deleted because it does not conform 

with the appeals process provisions of 

42 CFR Part 405, subparts H and I. 

XIX. Medicare Contracting Reform 

Mandate 

A. Background 

Section 911 of the Medicare 

Prescription Drug, Improvement, and 

Modernization Act of 2003 (MMA), Pub. 

L. 108–173, amended Title XVIII of the 

Act to add section 1874A, Contracts 

with Medicare Administrative 

Contractors (MACs). Section 1874A of 

the Act replaces the prior Medicare 

intermediary and carrier contracting 

authorities formerly found in sections 

1816 and 1842 of the Act, respectively. 

This reform (commonly referred to as 

‘‘Medicare contracting reform’’ for 

Medicare fee-for-service) is intended to 

improve Medicare’s administrative 

services to beneficiaries and health care 

providers and to bring standard 

contracting principles to Medicare, such 

as competition and performance 

incentives, which the government has 

long applied to other Federal programs 

under the Federal Acquisition 

Regulation (FAR). For Department of 

Health and Human Services 

acquisitions, the FAR is supplemented 

by the Department of Health and Human 

Services Acquisition Regulation 

(HHSAR) (48 CFR chapter 3). Using 


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competitive procedures, CMS will 

replace its current claims payment 

contractors (intermediaries and carriers) 

with new contract entities, MACs. 

Section 911(d)(1)(C) of Pub. L. 108–173 

requires that CMS compete and 

transition all Medicare claims 

processing workloads to MACs by 

October 1, 2011. 

In accordance with section 911(e) of 

Pub. L. 108–173, on or after October 1, 

2005, any reference to an 

‘‘intermediary’’ or ‘‘carrier’’ in a 

regulation shall be deemed a reference 

to a MAC. The process of transition 

from intermediaries and carriers to 

MACs is not a single point-in-time 

occurrence, but rather necessarily 

happens over a multiyear period due to 

the size and nature of the claims 

workloads involved. Therefore, for the 

purposes of clarity, the term 

‘‘intermediary’’ is used throughout this 

proposed rule to describe a Medicare 

contractor, pursuant to the authority of 

section 1816 of the Act, that has not yet 

transitioned to a MAC. In addition, for 

the purpose of clarity, the term ‘‘carrier’’

is used throughout this proposed rule to 

describe a Medicare contractor, 

pursuant to the authority of section 

1842 of the Act, that has not yet 

transitioned to a MAC. 

B. CMS’ Vision for Medicare Fee-forService and MACs 

CMS’ vision for the Medicare fee-forservice (FFS) program is that of a 

premier health plan that allows for 

comprehensive, quality care and worldclass beneficiary and provider service. 

Achieving this vision requires 

substantial improvement of CMS’

current FFS administrative structure. 

Further information on CMS’ plans to 

improve Medicare FFS may be obtained 

through the Medicare Contracting 

Reform Web site: http:// 

www.cms.hhs.gov/medicarereform/ 

contractingreform/. 

In 2006, there are 24 intermediaries 

and 17 carriers that process FFS claims. 

Intermediaries process claims for 

Medicare Parts A and B relating to 

services furnished by health care 

facilities, including hospitals and SNFs. 

Carriers process claims for Medicare 

Part B, in particular, for physician, 

laboratory, and other nonfacility 

services. In addition, 4 intermediaries 

serve as regional home health 

intermediaries (RHHIs) and process 

Medicare claims for home health 

services and hospice services. (Section 

1816 of the Act was amended in 1977 

to allow the Secretary to designate 

regional or national intermediaries, 

which we refer to as RHHIs, to process 

claims for home health services. We 

have designated these RHHIs to serve 

both the home health agency (HHA) and 

the hospice provider communities.) For 

a complete listing of the current 

Medicare intermediaries and carriers, 

refer to the CMS Web site: http:// 

www.cms.hhs.gov/contacts/incardir.asp. 

Although health care delivery in the 

United States has evolved with 

advances in modern technology, the 

contracting authorities relating to the 

Medicare FFS administrative structure 

did not substantially evolve between the 

enactment of the Medicare statute in 

1965 and the enactment of Pub. L. 108–

173. 

Prior to passage of Pub. L. 108–173, 

intermediary and carrier acquisition 

authorities did not permit full and open 

competition or unified processing of 

Medicare Part A and Part B claims. 

Medicare contracting was significantly 

hampered by the absence of 

performance-based incentives and 

cumbersome termination procedures. 

In an effort to achieve Congress’ goal 

of a more efficient and effective 

Medicare operation, CMS developed a 

plan for most current Medicare Part A 

and Part B intermediary and carrier 

responsibilities to be integrated into a 

single contract entity to be administered 

by a single contractor in each area of the 

country. These new MACs will handle 

claims processing and related activities 

traditionally performed by 

intermediaries and carriers. 

Under Medicare contracting reform, 

the MACs will perform all the core 

claims processing operations for both 

Medicare Part A and Part B. CMS will 

ensure that MACs focus on providing a 

high level of customer service to 

providers and beneficiaries. MACs will 

be the providers’ primary contact with 

Medicare, and CMS will hold the MACs 

accountable for overall provider and 

beneficiary satisfaction and correct 

claims payment. 

With respect to financial 

management, as was required of 

intermediaries and carriers, MACs will 

promote the fiscal integrity of the 

program and be accountable stewards of 

the Medicare Trust Fund dollars. The 

MACs will be required to pay claims 

timely, accurately, and in a reliable 

manner while promoting cost efficiency 

and the delivery of maximum value to 

the program. 

We recognize the potential for 

improving the efficiency and 

effectiveness of services to Medicare 

beneficiaries and providers through the 

Medicare contracting reform provisions 

contained in section 1874A of the Act. 

Through our implementation of these 

provisions, we expect to realize 

significant performance improvements. 

The future environment is designed to 

generate substantial savings both from 

an administrative and programmatic 

standpoint and will safeguard CMS’

mission. 

C. Provider Nomination and the Former 

Medicare Acquisition Authorities 

As originally enacted in 1965 and 

until the enactment of Pub. L. 108–173, 

section 1816 of the Act afforded groups 

or associations and individual providers 

of services (as defined at section 1861(a) 

of the Act) the right to nominate 

(appoint) their intermediary. The 

intermediary agreements were governed 

by Medicare laws that diverge from the 

FAR in a number of important respects. 

Prior to Public Law 108–173, section 

1816 of the Act precluded the Medicare 

program from competing intermediary 

functions on a full and open basis. 

Rather, institutional providers of 

services, such as hospitals and nursing 

facilities, nominated a particular 

intermediary to process and pay their 

Medicare Part A claims. 

In a significant historical 

development that took place shortly 

after Medicare’s enactment in 1965, the 

American Hospital Association and 

other provider trade associations 

nominated the Blue Cross Association 

(BCA) to serve as the intermediary for 

their membership. The BCA merged 

with the Blue Shield Association in the 

1970s to form today’s Blue Cross and 

Blue Shield Association (BCBSA.) CMS 

and the BCBSA then entered into a 

prime contract, which continues to 

currently exist through the annual 

renewal process. In turn, the BCBSA 

subcontracted most operational 

intermediary functions to its member 

plans. The BCBSA assigned the majority 

of the nation’s hospitals to its local Blue 

Cross plans. Some providers of services 

nominated commercial insurers to serve 

as their intermediaries. 

Most recently, section 911(b) of Pub. 

L. 108–173 amended section 1816 of the 

Act to remove the provider nomination 

authority. The section has been 

renamed: ‘‘Provisions Relating to the 

Administration of Part A.’’ Section 

1816(a) of the Act, which authorized 

providers to select a contractor to 

perform claims payment and audit 

functions, has been amended. It now 

contains one sentence mandating the 

use of contracts with MACs to 

administer section 1816 of the Act. 

Sections 1816(e), (f), and (g), which 

authorized the Secretary to develop 

standards, criteria, and procedures for 

the assignment of providers to 

intermediaries and to reassign providers 

periodically, have been repealed. 


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Section 911(d) of Pub. L. 108–173 

permits the Secretary to transition the 

current intermediary and carrier 

functions to the MACs. More 

information about CMS’ plans to 

implement Medicare contracting reform, 

including the Report to the Congress on 

this subject, can be obtained at the CMS 

Web site: http://www.cms.hhs.gov/ 

medicarereform/contractingreform/. 

MACs will perform all core claims 

processing operations for both Medicare 

Part A and Part B. The Part A and Part 

B MACs will operate in distinct, 

nonoverlapping geographic 

jurisdictions, which will form the basis 

of the Medicare claims processing 

operations. A transitional period runs 

between October 1, 2005, and October 1, 

2011. During this period, any existing 

intermediary and carrier contracts could 

be maintained until replaced by a MAC 

contract. The statute requires that all 

intermediary and carrier contract 

functions are to be competed and 

awarded as MAC contracts by October 1, 

2011. 

D. Summary of Changes Made to 

Section 1816 of the Act 

Substantial changes to section 1816 of 

the Act that were required by sections 

911(b) and 911(c) of Pub. L. 108–173 

took effect on October 1, 2005. The 

changes that we are proposing in this 

proposed rule to the regulations under 

42 CFR part 421, subpart B (discussed 

under section XIX.E. of this preamble) 

are intended to conform the regulations 

to these statutory changes. 

Prior to the statutory developments 

directed by Pub. L. 108–173, section 

1816 of the Act provided the foundation 

acquisition authority for agreements 

between CMS, acting for the Secretary, 

and intermediaries, for the purpose of 

administering benefits under Medicare 

Part A and making payments to 

providers of services. 

In particular, section 1816(a) of the 

Act formerly gave groups and 

associations of providers of services 

(which, under section 1861(u) of the 

Act, includes hospitals, critical access 

hospitals (CAHs), skilled nursing 

facilities (SNFs), comprehensive 

outpatient rehabilitation facilities 

(CORFs), HHAs, hospices, and, for the 

purposes of sections 1814(g) and 1835(e) 

of the Act, funds) the power to nominate 

their servicing intermediary to 

determine and make Medicare payments 

to their members. Under this provision, 

an intermediary could be a ‘‘national, 

state, or other public or private agency 

or organization.’’ As previously stated, 

under this provision, the American 

Hospital Association nominated the 

national Blue Cross Association to serve 

as the prime Medicare intermediary for 

its membership in 1965, an arrangement 

that continues to exist. 

Moreover, prior to the enactment of 

Pub. L. 108–173, section 1816(d) of the 

Act allowed individual providers and 

groups of providers to—

• Part with their group or association 

and nominate another entity to serve as 

their intermediary; and 

• Withdraw its/their nomination from 

an intermediary, and obtain services 

from another intermediary that had an 

agreement with the Secretary. 

Finally, section 1816(e) of the Act, as 

it formerly read, specified the 

substantial procedural requirements to 

be followed by the Secretary in the 

event that the Secretary desired to 

assign or reassign individual providers 

of services to any intermediary other 

than the nominated entity. This 

provision also gave limited authority to 

the Secretary to designate a regional or 

national intermediary for a particular 

‘‘class’’ of providers of services. 

However, this authority was subject to 

substantial procedural requirements. 

Among these procedural requirements 

were: 

• The Secretary had to promulgate 

standards, criteria and procedures for 

evaluating the performance of 

intermediaries under section 1816(f) of 

the Act; 

• The Secretary had to make a 

finding, after applying such standards, 

criteria, and procedures, that the 

reassignment of the individual provider 

and/or the designation of the regional or 

national intermediary would result in 

more efficient and effective 

administration of the Medicare program; 

• The Secretary had to provide a full 

explanation of his reasons for 

determining that the intermediary 

change would result in more efficient 

and effective administration; and 

• Affected agencies and organizations 

were given the right to a hearing, and 

any determinations of the Secretary on 

nominations and provider assignments 

were subject to judicial review. 

In the former sections 1816(e)(4) and 

1816(e)(5) of the Act, the Secretary was 

given authority to establish regional 

intermediaries with respect to HHAs 

and hospice providers, although certain 

procedural requirements still had to be 

met. 

In summary, while under section 

1816 of the Act, the Secretary was not 

required to accept all Medicare 

intermediary nominations, the Secretary 

had no independent authority to 

contract with any entity for Medicare 

intermediary services outside the 

nomination process. Moreover, while 

providers of services were given the 

opportunity to seek a reassignment to a 

new intermediary, the Secretary could 

not assign or reassign individual 

providers or classes of providers unless 

substantial procedural requirements 

were followed. 

The existing Medicare regulations 

under 42 CFR Part 421, particularly 

those within Subparts A and B, were 

substantially shaped by this statutory 

framework relating to provider 

nominations and the assignment or 

reassignment of providers of services to 

intermediaries. In particular, the 

following regulatory provisions have 

their basis in the statutory provisions of 

sections 1816(a), (d), and (e) of the Act 

(all are located within 42 CFR Part 421): 

• § 421.1(c), which discusses criteria 

to be used in assigning and reassigning 

providers; 

• § 421.3, which provides exceptions 

to definitions to accommodate the 

designation of regional intermediaries 

for HHAs and intermediaries for 

hospices; 

• § 421.103, which identifies options 

available to providers for receiving 

Medicare payments; 

• § 421.104, which provides the 

procedural framework governing the 

administration of provider nominations 

for intermediaries; 

• § 421.105, which obligates CMS to 

provide notice as to its action on 

nominations; 

• § 421.106, which specifies the 

process to be used by a provider 

desiring a change of intermediary; 

• § 421.112, which provides the 

considerations to be taken into account 

by CMS when, among other things, it 

desires to assign or reassign a provider 

to an intermediary or designate a 

regional or national intermediary for a 

class of providers; 

• § 421.114, which governs the 

assignment or reassignment of 

individual providers; 

• § 421.116, which specifies the 

requirements for designating national or 

regional intermediaries consistent with 

sections 1816(e)(1) through (e)(3) of the 

Act; and 

• § 421.117, which specifies the 

parameters for assigning HHAs and 

hospice providers to regional 

intermediaries consistent with sections 

1816(e)(4) and (e)(5) of the Act. 

In addition to the provisions 

discussed above that relate to provider 

nominations, prior to the enactment of 

Pub. L. 108–173, section 1816 of the Act 

also contained other provisions 

governing agreements with Medicare 

intermediaries that were not consistent 

with the mainstream of Federal 

acquisition and procurement 


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authorities, as this mainstream is 

reflected in the FAR. For instance—

• Section 1816(b) of the Act contains 

provisions that limited payment under 

all intermediary agreements to a costreimbursement basis only; 

• Section 1816(f) of the Act required 

the Secretary to publish his performance 

criteria and standards for intermediary 

agreements in the Federal Register, and 

specified requirements relating to the 

application of such criteria and 

standards; and 

• Section 1816(g) afforded 

intermediaries the right to terminate 

their agreements with CMS, but limited 

the right of the Secretary to terminate 

the agreement; in particular, no 

provision was made for the normal right 

of the government to terminate for 

convenience. 

In section 911(b) of Pub. L. 108–173, 

Congress reiterated the requirement that 

CMS begin to move beyond the legacy 

nomination-based intermediary 

agreements during FY 2006. This was 

done by repealing outright or 

substantially modifying many of the 

provisions of section 1816 of the Act, 

effective October 1, 2005. In particular, 

section 911(b) of Pub. L. 108–173—

• Repealed the prior language of 

section 1816(a) of the Act, including the 

basic provider nomination provision, 

and replaced it with a statement 

indicating that Medicare Part A 

administrative functions would be 

contracted through section 1874A of the 

Act; 

• Repealed section 1816(b) of the Act 

in full, including its provisions limiting 

payment to cost reimbursement; 

• Repealed the contract-related 

provisions of section 1816(c) of the Act; 

• Repealed sections 1816(d), (e), (f), 

(g), (h), (i), and (l) of the Act; and 

• Made conforming changes to 

sections 1816(c), (j), and (k) of the Act. 

With these changes, section 1816 of 

the Act is no longer an acquisition 

authority, and there is no vestige of the 

former provider nomination provisions 

or the partial exceptions to those 

provisions relating to home health and 

hospice providers. 

While section 911(d)(1)(B) of Pub. L. 

108–173 allows the Secretary to 

continue intermediary and carrier 

contracts in effect prior to October 1, 

2005, under their terms and conditions 

until October 1, 2011, there was no 

similar extension for existing 

nomination arrangements. Section 

911(d)(2)(A) of Pub. L. 108–173 

provides the Secretary with authority to 

enter into intermediary agreements 

outside of the provider nomination 

process starting with the date of 

enactment of Pub. L. 108–173 

(December 8, 2003). Therefore, while 

Congress specified that the Secretary 

should submit his plan for 

implementing section 911 at the start of 

FY 2005, the Secretary was authorized 

to contract outside of the section 1816 

nomination provisions immediately and 

in advance of delivery of his report. 

This analysis requires that similar, 

conforming changes be made in our 

regulations as set forth in this proposed 

rule. 

E. Provisions of the Proposed 

Regulations 

As discussed under section XIX.A. of 

this preamble, based on the authority 

provided in sections 1874A(a) through 

(d) of the Act, as established by section 

911(a)(1) of Pub. L. 108–173, we are 

proposing to establish regulations 

pertaining to MACs in a new Subpart E 

of 42 CFR Part 421. Moreover, based on 

the substantial changes to section 1816 

of the Act, including the repeal of all of 

the section 1816 provisions relating to 

the ability of providers to nominate 

their servicing intermediary, as enacted 

by section 911(b) of Pub. L. 108–173, we 

also are proposing a number of changes 

to Subparts A and B of 42 CFR Part 421. 

In addition, we are proposing to change 

the title of Part 421 from 

‘‘Intermediaries and Carriers’’ to 

‘‘Medicare Contracting’’ and make 

conforming revisions to Subpart B of 

Part 421. 

As discussed earlier, section 911(b) of 

Pub. L. 108–173 either repealed outright 

or substantially modified sections 

1816(a), (b), (c), (d), (e), (f), (g), (h), (i), 

and (l) of the Act, and made clear that 

the acquisition authority for Part A 

claims processing would, after October 

1, 2005, be found in section 1874A of 

the Act. Among all these changes, each 

of the former ‘‘provider nomination’’

provisions within section 1816 of the 

Act was repealed. In addition, section 

911(d)(2)(A) of Pub. L. 108–173 gave the 

Secretary authority to disregard the 

provider nomination provisions in his 

contracting, even prior to October 1, 

2005. In accordance with these statutory 

changes, we are proposing to 

substantially modify or delete 

§§ 421.1(c), 421.3, 421.103, 421.104, 

421.105, 421.106, 421.112, 421.114, 

421.116, and 421.117 of the regulations. 

As discussed earlier, the amendment 

to title XVIII of the Act (to allow for the 

new section 1874A: ‘‘Contracts with 

Medicare Administrative Contractors’’) 

requires CMS to contract with eligible 

entities to perform Medicare functions 

using the FAR. We are proposing to add 

regulations pertaining to MAC contracts 

in a new subpart E (Medicare 

Administrative Contractors) under Part 

421 as follows: 

Subpart E—Medicare Administrative 

Contractors 

Sec. 

421.400 Basis and scope. 

421.401 Definitions. 

421.404 Assignment of providers and 

suppliers to MACs. 

1. Definitions 

Under proposed § 421.401, we define 

a ‘‘Medicare administrative contractor 

(MAC)’’ as an agency, organization, or 

other person with a contract to perform 

any or all of the functions set forth 

under section 1874A of the Act. With 

respect to the performance of a 

particular function in relation to an 

individual entitled to benefits under 

Medicare Part A or enrolled under 

Medicare Part B, or both, a specific 

provider of services or supplier (or class 

of such providers of services or 

suppliers), we are proposing to define 

an ‘‘appropriate MAC’’ as a MAC that 

has a contract to perform a Medicare 

administrative function in relation to a 

particular individual, provider of 

services, or supplier or class of 

providers. 

2. Assignment of Providers and 

Suppliers to MACs 

We are proposing to establish a new 

§ 421.404 to incorporate the rules 

governing the processing of claims 

submitted by providers and suppliers 

that enroll with and receive Medicare 

payment and other Medicare services. 

As a general rule, Medicare providers 

and suppliers will be assigned to the 

MAC that is contracted to administer 

the types of services (benefits) billed by 

the provider or supplier within the 

geographic locale in which the provider 

or supplier is physically located or 

furnishes health care services, 

respectively. One significant exception 

to this general rule pertains to suppliers 

of durable medical equipment, 

prosthetics, orthotics, and supplies. 

CMS would continue to allow these 

suppliers to bill to the contractor 

assigned to the locale in which the 

beneficiary receiving the items or 

supplies resides. 

In the past, under the provider 

nomination provisions that were 

repealed by section 911 of Pub. L. 108–

173, CMS had considered (and 

occasionally approved) requests from 

certain classes of institutional providers 

covered by these section 1816 

provisions, primarily, hospitals, SNFs, 

and CAHs, to bill an intermediary other 

than the one servicing providers in the 

geographic locale of the provider. The 


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process and criteria for making these 

determinations are set forth in detail in 

the existing regulations under 42 CFR 

part 421, subpart B (which we are 

proposing to remove in accordance with 

the changes effectuated by section 

911(b) of Pub. L. 108–173. 

In particular, not automatically but on 

a fairly frequent basis, CMS approved 

requests from large multi-State groups of 

such providers under common 

ownership and control, called ‘‘chain 

providers,’’ to bill a single intermediary 

on behalf of all the individual providers 

in the chain through the headquarters 

office, or ‘‘home office,’’ of the chain 

provider. These chain providers were 

granted ‘‘single intermediary’’ status. 

The premise behind granting 

privileges to bill a single intermediary to 

such large multi-State chain providers 

was that this might reduce 

administrative billing expenses for the 

chain and reduce the administrative 

expenses of the Medicare program. In 

particular, assigning a large multi-State 

chain provider to a single intermediary 

facilitated the Medicare cost report 

audit and reimbursement functions, 

because findings with respect to the cost 

report of the chain’s home office could 

affect the individual provider’s cost 

report. Otherwise, these audit and 

reimbursement issues would need to be 

coordinated among multiple 

intermediaries. 

In addition to applying the relevant 

regulatory requirements in 42 CFR part 

421, subpart B in our review of chain 

provider requests for single 

intermediary status, we applied 

additional criteria to focus our analysis 

and to ensure that the exception to our 

normal practice of assigning providers 

to their ‘‘local’’ intermediary was 

warranted. We advised the chain 

provider that it would have to 

demonstrate that having a single 

intermediary would be consistent with 

efficient and effective administration of 

the Medicare program, and that the 

intermediary would need to have 

sufficient capacity to effectively serve 

the chain (these elements were 

restatements of the regulatory criteria). 

In addition, we required the chain to 

meet the following requirements: 

• Size—The provider chain had to be 

comprised of 10 participating facilities 

or 500 certified beds, or 5 facilities or 

300 certified beds spread across 3 or 

more contiguous States. 

• Central Controls—The provider 

chain had to demonstrate that it 

exercised central controls, assuring 

substantial uniformity in operating 

procedures, utilization controls, 

personnel administration, and fiscal 

operations among the individual 

providers. 

The administrative efficiencies gained 

by both the large multi-State chain 

providers and the Medicare program by 

allowing single intermediary 

relationships to exist may not be as 

significant as they were formerly. Prior 

to the implementation of the 

Administration Simplification 

provisions of Part C of Title XI of the 

Act, the various intermediaries required 

providers to use somewhat divergent 

transaction and formatting standards in 

their electronic claims processing 

systems. A provider chain with 

centralized billing processes could make 

a good business case that it should be 

permitted to bill only one intermediary. 

Moreover, prior to the implementation 

of the many prospective payment 

systems required by the Balanced 

Budget Act of 1997 and subsequent 

public laws, a greater percentage of 

Medicare program payments hinged on 

the Medicare cost report audit and 

reimbursement process. In such an 

environment, there was potential benefit 

to both a chain provider and the 

government to minimize coordination 

issues. Finally, the former Medicare 

environment involved many 

intermediaries, so there were naturally 

more geographic boundaries among 

contractors that a multi-State chain 

could cross. 

We understand the provisions of 

section 1874A of the Act and, more 

particularly, the revisions to section 

1816 of the Act made by section 911(b) 

of Pub. L. 108–173 to authorize the 

Secretary to assign all providers and 

suppliers, even the members of multiState entities, to the geographicallybased MACs based on their physical 

location. This action is consistent with 

CMS’ vision, as articulated in the 

Secretary’s Report to Congress on 

Medicare Contracting, of establishing a 

claims processing environment where 

most Medicare Part A and Part B claims 

involving a particular beneficiary are 

administered by the same contractor. 

However, as indicated in that Report 

(page V–4), we recognize that there may 

still be some legitimate business value 

to allowing large multi-State chains of 

providers that formerly were able to 

nominate their intermediary to bill on a 

consolidated basis to one MAC. While 

Congress has clearly mandated that the 

former provider nomination framework 

be abolished, we believe that allowing 

the practice of consolidated billing by 

large chains is within the discretion of 

the Secretary under section 911 of Pub. 

L. 108–173. Accordingly, in this 

proposed rule, we are proposing under 

§ 421.404 that—

• Providers (as defined in 42 CFR 

400.202) will generally be assigned to 

the MAC with claims processing 

jurisdiction over the geographic locale 

in which the provider is physically 

located. 

• Large chain providers comprised of 

individual providers that were formerly 

permitted by CMS to ‘‘nominate’’ an 

intermediary, which we refer to as 

‘‘qualified chain providers,’’ will be 

permitted to request opportunity to 

consolidate their Medicare billing 

activities to the MAC with jurisdiction 

over the geographic locale in which the 

chain’s home office is located. 

• Qualified chain providers that were 

formerly granted single intermediary 

status do not need to re-request such 

privileges on behalf of the entire chain 

at this time. 

• CMS may grant other exceptions to 

the general rule for assigning providers 

to MACs, but only based on a finding 

that such an exception will support the 

implementation of the MACs or if CMS 

deems the exception to be in the 

compelling interest of the Medicare 

program. 

We are proposing to incorporate a 

definition of ‘‘qualified chain provider.’’

The criteria that constitute the proposed 

definition of a ‘‘qualified chain 

provider’’ mirror the elements that were 

historically applied. We believe these 

are appropriate criteria to employ in 

reviewing whether a chain provider 

should even be considered for 

consolidated billing. Less stringent 

criteria would clearly cut against the 

statutory mandate to establish MACs 

and end the provider nomination 

process. More stringent criteria might 

disrupt the operations of many entities 

that formerly were approved for single 

intermediary handling under the old 

criteria. 

Smaller chains of otherwise eligible 

providers (for example, hospitals, SNFs, 

and CAHs) might also desire 

consolidated billing, as well as other 

types of providers (for example, HHAs 

and hospices). In the latter case, the 

other types of providers (termed 

‘‘ineligible providers’’ in this proposed 

rule) did not have the opportunity to 

request assignment to (nominate) a 

particular intermediary prior to October 

1, 2005. In some cases, these other types 

of providers were assigned to regional 

intermediaries based on a nexus of 

statutory and administrative actions. In 

other cases, assignments were made 

through administrative action. In the 

case of smaller chains of otherwise 

eligible providers, we note that Pub. L. 

108–173 clearly mandates the end of the 

provider nomination process and 


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appears to us to anticipate the use of 

regional contractors. 

We believe that our establishment of 

MACs that, in most cases, will 

administer claims from multiple States 

will largely resolve the concerns these 

other providers may have. Under our 

proposed approach, for instance, we 

believe that few chain providers will 

have to bill more than two MACs even 

if they fail to meet the tests for being a 

‘‘qualified chain provider.’’

Finally, with respect to suppliers (as 

also defined in 42 CFR 400.202 of our 

regulations), we are proposing to assign 

suppliers (including physicians and 

other practitioners) to MACs based on 

the geographic jurisdiction in which 

they operate and furnish services. These 

requirements mirror the various Part B 

claims jurisdiction rules that have been 

in place. CMS may grant an exception 

to this policy only if CMS finds the 

exception will support the 

implementation of MACs or will serve 

some compelling interest of the 

Medicare program.. However, we do 

incorporate the current special billing 

requirements relating to suppliers of 

durable medical equipment, prosthetics, 

orthotics, and supplies under § 421.210 

and § 421.212. 

As we move forward to implement 

MAC contracting in keeping with the 

statutory mandate of section 911 of Pub. 

L. 108–173 and the Secretary’s Report to 

Congress, we invite public comments on 

the above issues, including our 

proposed definitions and criteria. (Once 

the MACs are initially implemented, we 

may propose more stringent criteria for 

consolidated billing status, in keeping 

with the overall thrust of section 911 of 

Pub. L. 108–173.) 

3. Other Proposed Technical and 

Conforming Changes 

a. Definition of ‘‘Intermediary’’ (§ 421.3) 

We are proposing to revise the 

definition of the term ‘‘intermediary’’

under existing § 421.3 to delete 

reference to ‘‘alternative regional 

intermediaries.’’ CMS no longer allows 

HHAs and hospice care providers to 

select an alternative regional 

intermediary. Over the years, as the 

number of intermediaries in the 

program has decreased, the availability 

of alternative intermediaries for HHAs 

and hospices has declined. We have 

implemented the policy that all HHAs 

and hospice care facilities are to be 

assigned to the designated regional 

intermediary that serves their 

geographic jurisdiction. This is required 

for the efficient and effective 

administration of the Medicare program 

as the agency moves forward to 

implement the MACs. 

b. Intermediary Functions (§ 421.100) 

Section 1816(a) of the Act, which 

allowed providers to nominate an 

intermediary, required that only 

nominated intermediaries perform the 

functions of determining payment 

amounts and making payments to 

providers. Section 1874A of the Act, as 

added by section 911 of Pub. L. 108–

173, eliminates the intermediary 

nomination process. All activities 

carried out under intermediary 

agreements will be transitioned to MAC 

contracts by September 30, 2011. 

During the transition period, CMS 

will still require regulations to support 

its intermediary agreements. We are 

proposing to amend § 421.100, 

concerning functions to be included in 

intermediary agreements, to address the 

dual intermediary responsibilities. 

We are proposing to revise existing 

§ 421.100(i), Dual intermediary 

responsibilities, to delete the reference 

to § 421.117 from this section, as the 

statutory provision that made this 

necessary was repealed by Pub. L. 108–

173. 

c. Options Available to Providers and 

CMS (§ 421.103) 

We are proposing to change the title 

of § 421.103 to ‘‘Payment to Providers’’

and to revise the contents of § 421.103 

to clarify that, all providers must receive 

payments for covered services furnished 

to Medicare beneficiaries through an 

intermediary (under § 421.404) and 

eventually through a MAC (under 

§ 421.404). We are proposing that this 

function must remain with the 

intermediaries. We would no longer 

allow providers to receive payments 

directly from CMS, nor would we allow 

providers to receive payments from 

alternative regional intermediaries. We 

believe the inclusion of this function is 

consistent with the effective and 

efficient administration of the Medicare 

program. 

d. Nomination for Intermediary 

(§ 421.104) 

We are proposing to change the title 

of § 421.104 to ‘‘Assignment of 

Providers of Services to Intermediaries 

During Transition to Medicare 

Administrative Contractors (MACs)’’

and to revise the contents of the section 

to provide that new providers that enter 

the Medicare program during the 

transition period will be assigned to the 

local designated intermediary that 

serves the jurisdiction in which the 

provider is located. We believe this 

change is necessary as we prepare to 

transition from intermediary agreements 

and carrier contracts to contracts with 

the MACs. In the MAC environment, 

providers will be assigned based on 

their geographic location to the MAC 

that has jurisdiction for their provider 

type. 

e. Notification of Actions on 

Nominations, Changes to Another 

Intermediary or to Direct Payment, and 

Requirements for Approval of an 

Agreement (§ 421.105 and § 421.106) 

We are proposing to remove § 421.105 

and § 421.106 from the regulations, as 

the sections would no longer be 

applicable with implementation of the 

new Subpart E. 

f. Considerations Relating to the 

Effective and Efficient Administration of 

the Medicare Program (§ 421.112) 

We are proposing to revise 

§ 421.112(a). As stated previously in this 

proposed rule, provider requests to be 

assigned or reassigned to a particular 

intermediary will no longer be 

considered. However, we may deem it 

necessary to reassign providers if we 

find it is necessary for the efficient and 

effective administration of the program. 

In addition, there will no longer be a 

national intermediary to serve a class of 

providers. 

g. Assignment and Reassignment of 

Providers by CMS (§ 421.114) 

We are proposing to revise § 421.114 

to specify that we may consider it 

necessary to assign and reassign 

providers if the assignment or 

reassignment is in the best interest of 

the program. Before making these 

determinations, we will no longer 

review provider requests to be 

reassigned to another intermediary. This 

is consistent with the proposed policy 

to eliminate a provider request to 

change to another intermediary or to 

direct payment. Under Medicare 

contracting reform, we require increased 

flexibility to realign providers to 

geographical jurisdictions for effective 

implementation of the MACs. We 

reserve the right to reassign providers to 

other jurisdictions if we deem it to be 

in the best interest of the program. 

h. Designation of National or Regional 

Intermediaries (§ 421.116) and 

Designation of Regional and Alternative 

Designated Regional Intermediaries for 

Home Health Agencies and Hospices 

(§ 421.117) 

We are proposing to delete § 421.116, 

Designation of national or regional 

intermediaries, and § 421.117, 

Designation of regional and alternative 

designated regional intermediaries for 


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HHAs and hospices. The statutory 

provisions that made these regulations 

necessary were repealed by Pub. L. 108–

173. Therefore, we no longer need these 

regulations. All providers will receive 

payment for covered services as 

described in § 421.103. 

i. Awarding of Experimental Contracts 

(§ 421.118) 

We are proposing to delete § 421.118, 

which specifies the provisions under 

which CMS may award a fixed price or 

performance incentive contract under 

the experimental authority contained in 

42 U.S.C. 1395b–1 for performance of 

intermediary functions under § 421.100. 

The provisions of this section became 

obsolete with the enactment of section 

911 of Pub. L. 108–173. 

XX. Reporting Quality Data for 

Improved Quality and Costs Under the 

OPPS 

(If you choose to comment of issues 

in this section, please include the 

caption ‘‘Hospital Quality Data’’ at the 

beginning of your comment.) 

As noted previously, CMS’ Office of 

the Actuary currently projects that 

Medicare Part B expenditures will 

continue to grow at a significant rate, as 

a result of rapid growth in the use of 

both physician-related services and 

hospital outpatient services in the 

original Medicare fee-for-service 

program. Specifically, the actuaries 

project that the expenditures under the 

OPPS in CY 2007 will be approximately 

$32.540 billion. This represents 

approximately a 9.2 percent increase 

over our estimated expenditure of 

$29.809 billion for the OPPS in CY 

2006, and reflects even more rapid 

spending growth in recent years. As the 

following table shows, implementation 

of the OPPS has not slowed outpatient 

spending growth; in fact, double-digit 

spending growth has been occurring. 

TABLE 47.—GROWTH IN EXPENDITURES UNDER OPPS FROM CY 2001 THROUGH CY 2007 (PROJECTED EXPENDITURES

FOR CY 2006 AND CY 2007) 

[in millions] 

OPPS growth CY 2001 CY 2002 CY 2003 CY 2004 CY 2005 CY 2006 CY 2007 

Incurred Cost ........................................................... 19,172 19,561 21,146 23,912 26,643 29,809 32,540 

Percent Increase ...................................................... ................ 2 .0 8 .1 13 .1 11 .4 11 .9 9 .2 

Source: FY 2007 Mid-Session Review, Budget of the U.S. Government. 

The current rate of growth in 

expenditures for hospital outpatient 

services is of great concern to us. As 

with the other Medicare fee-for-service 

payment systems that are experiencing 

rapid spending growth, brisk growth in 

the intensity and utilization of services 

is the primary reason for the current rate 

of growth in the OPPS, rather than 

general price or enrollment changes. 

The table below illustrates the increases 

in the volume and intensity of 

outpatient hospital services over the last 

several years. 

TABLE 48.—PERCENT INCREASE IN VOLUME/INTENSITY OF HOSPITAL OUTPATIENT SERVICES

CY 2002 CY 2003 CY 2004 CY 2005 

(Est.) 

CY 2006 

(Est.) 

Percent Increase .......................................................................................................... 3.0 2.0 8.0 8.0 10.0 

Source: FY 2007 Mid-Session Review, Budget of the U.S. Government. 

For outpatient hospital services, the 

volume and intensity for CY 2005 are 

estimated to continue to increase 

significantly at a rate of 8 percent, in 

excess of the long-term trend. This 

increase follows the 8 percent increase 

in CY 2004, and the growth is projected 

to be 10 percent in CY 2006. 

As we have stated repeatedly, this 

rapid growth in utilization of services in 

the OPPS shows that Medicare is paying 

mainly for more services each year, 

regardless of their quality or impact on 

beneficiary health. The program should 

promote higher quality services, so that 

Medicare spending is directed in the 

most efficient manner toward higher 

quality services. Medicare payments 

should encourage doctors and other 

providers in their efforts to achieve 

better health outcomes for Medicare 

beneficiaries at a lower cost. Therefore, 

we have been examining the concept of 

‘‘value-based purchasing’’ in a number 

of payment systems. ‘‘Value-based 

purchasing’’ may use a range of 

incentives to achieve identified quality 

and efficiency goals, as a means of 

promoting better quality of care and 

more effective resource use in the 

Medicare payment systems. In 

developing the concept of value-based 

purchasing, we have been working 

closely with stakeholder partners, 

including health professionals and 

providers. 

In this proposed rule, we are seeking 

public comment on value-based 

purchasing as related specifically to 

hospital outpatient departments. As part 

of our overall goal of promoting valuebased purchasing in outpatient 

payment, we also make one specific 

proposal in the OPPS for CY 2007. 

Section 1833(t)(2)(E) of the statute 

permits the Secretary to ‘‘establish, in a 

budget neutral manner, * * * 

adjustments as determined to be 

necessary to ensure equitable 

payments’’ under the OPPS. The 

absence of OPPS measures to promote 

high quality in the provision of services 

to Medicare beneficiaries creates an 

issue of payment equity. In general, 

payments to providers in Medicare’s 

payment systems do not vary on the 

basis of quality or efficiency differences 

among the providers of services. As a 

result, Medicare’s payment systems 

direct additional resources to hospitals 

that deliver care that is not of the 

highest quality. For that reason, each 

Medicare dollar spent does not result in 

the same quality and efficiency of care 

for Medicare beneficiaries. 

We believe that the collection and 

submission of performance data and the 

public reporting of comparative 

information about hospital performance 

can provide a strong incentive to 

encourage hospital accountability in 

general and quality improvement in 

particular. Measurement and reporting 

can focus the attention of hospitals and 

consumers on specific goals and on 


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1The Premier Hospital Quality Incentive 

Demonstration was authorized under section 402 of 

Pub. L 90–248, Social Security Amendments of 

1967 (42 U.S.C. 1395b–1). This section authorizes 

certain types of demonstration projects that waive 

compliance with the regular payment methods used 

in the Medicare program. 

2Additional information on the Premier Hospital 

Quality Incentive Demonstration is available on the 

CMS Web site at: http://www.cms.hhs.gov/ 

HospitalQualityInits/35_HospitalPremier.asp. 

3Additional information on CMS’ Hospital 

Quality Initiative is available on the CMS Web site 

at: http://www.cms.hhs.gov/HospitalQualityInits/. 

4 Institute of Medicine, ‘‘Performance 

Measurement: Accelerating Improvement,’’

December 1, 2005, available at http://www.iom.edu/ 

CMS/3809/19805/31310.aspx. 

hospitals’ performance relative to those 

goals. Development and implementation 

of performance measurement and 

reporting by hospitals can thus produce 

quality improvement in actual health 

care delivery. Hospital performance 

measures may also provide a foundation 

for performance-based rather than 

volume-based payments, which are used 

in the OPPS today. 

We have obtained some evidence of 

the potential for improving quality of 

care in hospitals by means of the 

collection and submission of 

performance data from the Premier 

Hospital Quality Incentive 

Demonstration.1 This demonstration 

was designed to test whether the quality 

of inpatient care for Medicare 

beneficiaries can improve when 

financial incentives are provided. Under 

the demonstration, about 270 hospitals 

of Premier, Inc., a nationwide alliance of 

not-for-profit hospitals, have been 

voluntarily providing data on 34 quality 

measures related to 5 clinical 

conditions: Heart attack, heart failure, 

pneumonia, coronary artery bypass 

graft, and hip and knee replacements. 

Using the quality measures, CMS 

identifies hospitals with the highest 

quality performance in each of the five 

clinical areas. Hospitals scoring in the 

top 10 percent in each clinical area 

receive a 2-percent bonus payment in 

addition to the regular Medicare DRG 

payment for the measured condition. 

Hospitals in the second highest 10 

percent receive a 1-percent bonus 

payment. In the third year of the 

demonstration, if some hospitals do not 

achieve absolute improvements above 

the demonstration’s first year composite 

score baseline (the lowest 20 percent) 

for that condition, then they will have 

their DRG payments reduced by one or 

two percent, depending on how far their 

performance is below the baseline. 

Following the first year of the 

demonstration (FY 2004), CMS awarded 

a total of $8.85 million to participating 

hospitals in the top two deciles for each 

clinical area. In the aggregate, quality of 

care improved in all five clinical areas 

that were measured. Preliminary 

information from the second year of the 

demonstration indicates that quality is 

continuing to improve, particularly for 

the hospitals that were initially poorest 

performing.2 We believe that these 

results indicate that reporting of quality 

data may in and of itself lead to 

improved outcomes for Medicare 

beneficiaries. 

Since 2003, we have operated the 

Hospital Quality Initiative,3 which is 

designed to stimulate improvements in 

inpatient hospital care by standardizing 

hospital performance measures and data 

transmission to ensure that all payers, 

hospitals, and oversight and accrediting 

entities use the same measures when 

publicly reporting on hospital 

performance. Section 501(b) of Pub. L. 

108–173 authorized us to link the 

collection of data for an initial starter set 

of 10 quality measures to the hospital 

IPPS annual payment update. In order 

to implement this provision, we created 

the Reporting Hospital Quality Data for 

Annual Payment Update (RHQDAPU) 

program. For FYs 2005 and 2006, 

hospitals that met the RHQDAPU 

program’s requirements received the full 

IPPS annual payment update, while 

hospitals that did not comply received 

an update that was reduced by 0.4 

percentage points. For FY 2005, 

virtually every hospital in the country 

that was eligible to participate 

submitted data (98.3 percent), and 

approximately 96 percent of all 

participating hospitals met the 

requirements to receive the full update. 

The data regarding the starter set of 10 

quality measures, as well as additional, 

voluntarily-reported data on other 

quality measures, are available to the 

public through the Hospital Compare 

Web site at: http:// 

www.hospitalcompare.hhs.gov. 

The starter set of 10 quality measures 

that was established for the IPPS 

RHQDAPU as of November 1, 2003, are: 

Heart Attack (Acute Myocardial 

Infarction/AMI) 

• Was aspirin given to the patient 

upon arrival to the hospital? 

• Was aspirin prescribed when the 

patient was discharged? 

• Was a beta-blocker given to the 

patient upon arrival to the hospital? 

• Was a beta-blocker prescribed when 

the patient was discharged? 

• Was an ACE inhibitor given for the 

patient with heart failure? 

Heart Failure (HF) 

• Did the patient get an assessment of 

his or her heart function? 

• Was an ACE inhibitor given to the 

patient? 

Pneumonia (PNE) 

• Was an antibiotic given to the 

patient in a timely way? 

• Had the patient received a 

pneumococcal vaccination? 

• Was the patient’s oxygen level 

assessed? 

For FY 2007 and each subsequent 

year, section 5001(a) of Pub. L. 109–171 

amended section 1886(b)(3)(B) of the 

Act and made changes to the program 

established under section 501(b) of Pub. 

L. 108–173. These changes require us to 

expand the number of measures for 

which data must be submitted, and to 

change the percentage point reduction 

in the annual payment update from 0.4 

percentage points to 2.0 percentage 

points for IPPS hospitals that do not 

report the required quality measures in 

a form and manner, and at a time, 

specified by the Secretary. 

Effective for payments beginning with 

FY 2007, new section 

1886(b)(3)(B)(viii)(IV) of the Act 

requires the Secretary to begin to adopt 

the expanded set of performance 

measures set forth in the IOM’s 2005 

report entitled, ‘‘Performance 

Measurement: Accelerating 

Improvement.’’ 4 Those measures 

include the HQA measures and the 

HCAHPS patient perspective survey. 

Effective for payments beginning with 

FY 2008, the Secretary must add other 

measures that reflect consensus among 

affected parties and may replace 

existing measures as appropriate. New 

section 1886(b)(3)(B)(viii)(VII) of the Act 

requires the Secretary to post hospital 

quality data on these measures on the 

CMS Web site. A proposed list of 

expanded quality measures to be used 

for the FY 2007 update was included in 

the FY 2007 IPPS proposed rule (71 FR 

24093). The final expanded set of 21 

quality measures for the FY 2007 

update, as listed in the FY 2007 IPPS 

final rule, is outlined below: 

Heart Failure (Acute Myocardial 

Infarction/AMI) 

• Aspirin at arrival 

• Aspirin prescribed at discharge 

• ACE inhibitor (ACE–I) or 

Angiotensin Receptor Blocker (ARBs) 

for left ventricular systolic dysfunction 

• Beta blocker at arrival 

• Beta blocker prescribed at discharge 

• Thrombolytic agent received within 

30 minutes of hospital arrival 

• Percutaneous Coronary Intervention 

(PCI) received within 120 minutes of 

hospital arrival 


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• Adult smoking cessation advice/ 

counseling 

Heart Failure (HF) 

• Left ventricular function assessment 

• ACE inhibitor (ACE–1) or 

Angiotensin Receptor Blocker (ARBs) 

for left ventricular systolic dysfunction 

• Discharge instructions 

• Adult smoking cessation advice/ 

counseling 

Pneumonia (PNE) 

• Initial antibiotic received within 4 

hours of hospital arrival 

• Oxygenation assessment 

• Pneumococcal vaccination status 

• Blood culture performed before first 

antibiotic received in hospital 

• Adult smoking cessation advice/ 

counseling 

• Appropriate initial antibiotic 

selection 

• Influenza vaccination status 

Surgical Care Improvement Project 

(SCIP) 

• Prophylactic antibiotic received 

within 1 hour prior to surgical incision 

• Prophylactic antibiotics 

discontinued within 24 hours after 

surgery end time 

In order to receive the full FY 2007 

IPPS update, hospitals are required to 

continue to collect data for all 10 starter 

set quality measures (or begin collecting 

such data, if newly participating in the 

program) and are required to provide a 

written pledge to submit data on the set 

of 21 expanded quality measures, in 

addition to completing several 

administrative tasks regarding quality 

reporting. All of the measures for the 

IPPS RHQDAPU program are to be 

reported on inpatient hospital 

discharges. 

We are proposing to employ our 

equitable adjustment authority under 

section 1833(t)(2)(E) of the Act to adapt 

the quality improvement mechanism 

provided by the IPPS RHQDAPU 

program for use in the OPPS. As we 

have discussed above, failure to account 

at all for quality in payment systems 

raises a fundamental issue of payment 

equity. In the absence of mechanisms 

that provide incentives for higher 

quality care, Medicare’s payment 

systems can direct more resources to 

hospitals that do not deliver high 

quality care to Medicare beneficiaries. 

In this rule, we are proposing to 

initiate a Reporting Hospital Quality 

Data for Annual Payment Update under 

the OPPS, (OPPS RHQDAPU program) 

effective for payments beginning 

January 1, 2007. We propose to add a 

new § 419.43(h) to our regulations to 

implement this proposal. Under 

proposed new § 419.43(h)(1), we would 

initially implement an OPPS RHQDAPU 

program by reducing the OPPS 

conversion factor update in CY 2007 for 

those hospitals that are required to 

report quality data under the IPPS 

RHQDAPU program in order to receive 

the FY 2007 update, and fail to meet the 

requirements for receiving the full FY 

2007 IPPS payment update. These 

hospitals would receive an update to the 

CY 2007 OPPS conversion factor that is 

reduced by 2.0 percentage points. Under 

proposed § 419.43(h)(2), any reduction 

would not affect a hospital’s OPPS 

update in a subsequent calendar year. 

Hospitals that meet the IPPS RHQDAPU 

program’s requirements for FY 2007 and 

receive the full IPPS annual payment 

update would also receive the full 

update to the conversion factor used to 

determine payments for CY 2007 under 

the OPPS. 

For this initial phase of implementing 

an OPPS RHQDAPU program in CY 

2007, it will be necessary to provide an 

exception for certain hospital outpatient 

departments to the requirement that 

quality data be submitted under the 

IPPS RHQDAPU program in order to 

receive the full OPPS update. The 

quality data submission requirements of 

the IPPS RHQDAPU program apply only 

to ‘‘subsection (d)’’ hospitals. 

‘‘Subsection (d)’’ hospitals are defined 

under section 1886(d)(1)(B) of the Act as 

hospitals that are located in the fifty 

states or the District of Columbia other 

than those categories of hospitals or 

hospital units that are specifically 

excluded from the IPPS, including 

psychiatric, rehabilitation, long-term 

care, children’s, and cancer hospitals or 

hospital units. In other words, the 

provision does not apply to hospitals 

and hospital units excluded from the 

IPPS, or to hospitals located in Puerto 

Rico or the U.S. territories. For the 

initial stage of implementing the OPPS 

RHQDAPU program in CY 2007, 

hospitals that are paid under the OPPS 

but that do not qualify as ‘‘subsection 

(d)’’ hospitals will continue to receive 

the full update to the OPPS conversion 

factor. However, as we discuss below, 

our intention is to expand the OPPS 

RHQDAPU in the future program by 

requiring all hospitals that receive 

payment under the OPPS to participate 

in the program in order to receive a full 

update, by appropriate expansion, 

adaptation, and/or extension of quality 

performance measures and quality 

reporting mechanisms. 

We believe that it is fair and 

appropriate, for purposes of the initial 

phase of implementing an OPPS 

RHQDAPU program, to take timely and 

accurate reporting of IPPS RHQDAPU 

program quality measures into account 

under our equitable adjustment 

authority. We think that the 10 original 

quality measures and the expanded set 

of 21 process measures as reported for 

inpatient discharges for heart attack, 

heart failure, pneumonia, and surgical 

care reflect the quality of care in the 

outpatient department as well as the 

inpatient hospital, so they are 

appropriate for initial use in the OPPS 

as specific measures are being 

developed to reflect the quality of care 

for hospital outpatients. We believe that 

hospitals generally function as 

integrated systems that provide health 

care services to patients in both 

inpatient and outpatient settings for 

many of the same clinical conditions, 

while recognizing the different typical 

levels of acuity in the two settings. 

Hospital quality measures for multiple 

conditions reflect, in part, the systems 

of care established by hospitals in the 

outpatient setting such as the emergency 

department. Therefore, the welldeveloped quality measures reported for 

the FY 2007 IPPS regarding inpatient 

hospital discharges should reasonably 

represent the quality of care provided to 

hospital outpatients, so we are 

proposing their interim use for the CY 

2007 OPPS while quality measures 

specific to hospital outpatients are being 

developed and refined. This use of 

multiple measures for several clinical 

conditions serves as a proxy for the 

quality of the systems of care 

established by hospitals. As we expand 

quality measurement for the hospital 

outpatient setting, we intend to move 

from measures that serve as proxies for 

the quality of care to actual performance 

measures for the outpatient setting. The 

discussion below focuses on the 

expanded list of 21 quality of care 

measures, as the 10 original measures 

continue to be included in the quality 

measurement expansion. 

There are 7 quality measures 

assessing the processes of care for 

patients presenting to the hospital with 

an acute myocardial infarction, focused 

on the care on arrival, the promptness 

of interventions, and discharge care. For 

the common urgent condition of a 

patient presenting to the hospital with 

chest pain that results in a clinical 

suspicion of acute myocardial 

infarction, in their effort to provide 

consistent, high quality care that is 

founded on evidence-based guidelines, 

hospitals often utilize clinical care 

pathways that are standardized for such 

patients presenting to the emergency 

room of the hospital. Such care 

pathways generally apply to patients 

with specific medical conditions who 


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present to the hospital initially as 

outpatients, regardless of their eventual 

discharge home from the outpatient 

department or inpatient admission. 

Thus, we believe that all 7 of these 

measures likely serve as reasonable 

proxies for the quality of care for 

patients presenting to the hospital 

outpatient department with chest pain 

related to a myocardial infarction, who 

commonly receive care along the 

continuum from outpatient to inpatient 

services in a hospital that provides such 

care in an integrated system. 

Similarly, there are 7 process 

measures related to the care of patients 

with pneumonia, who often present 

urgently to the hospital’s emergency 

room with symptoms suggestive of the 

diagnosis of pneumonia. Because of the 

established clinical evidence regarding 

assessment and treatment activities that 

improve the quality of care for patients 

with pneumonia, most of the 

interventions that are measured, 

including oxygenation assessment, 

drawing of blood cultures, assessment of 

the patient’s pneumococcal and 

influenza vaccine status, and selection 

and provision of an initial antibiotic in 

a timely manner, would generally be 

performed in the outpatient department, 

sometimes prior to a clinical decision 

about the patient’s ultimate need for 

inpatient admission. In particular, the 

measures of vaccine status are quality 

measures that may be especially 

appropriate as hospital outpatient 

prevention measures. Their use in the 

hospital setting provides an opportunity 

for quality improvement in the hospital 

by encouraging assessment of 

immunization status and appropriate 

provision of immunizations, so we see 

no reason why their reporting on 

hospital inpatients is not also reflective 

of the quality of hospital outpatient 

care. While we acknowledge that in 

general the clinical picture of patients 

who are admitted to the hospital with 

pneumonia differs from that of patients 

who are not hospitalized, we expect 

there to be many common elements in 

their assessment, treatment, and 

counseling regarding the significance of 

smoking as the hospital provides their 

initial and subsequent care in the 

outpatient and/or inpatient settings. 

Therefore, we believe that all 7 of the 

measures related to the treatment of 

pneumonia are likely appropriately 

reflective of the quality of the care 

systems established by hospitals for 

outpatients with a diagnosis of 

pneumonia. 

There are 4 quality measures related 

to the treatment of patients with heart 

failure, including assessment of their 

cardiac function, use of certain 

medications in their treatment, 

counseling regarding smoking cessation, 

and provision of discharge instructions. 

Patients with heart failure, a common 

chronic medical condition, are seen 

frequently in hospital clinics and 

emergency departments with 

exacerbations of their symptoms. Once 

again, their initial treatment is often 

standardized and provided in the 

outpatient setting without consideration 

of their eventual discharge from the 

outpatient department or inpatient 

admission, a decision which ultimately 

depends on clinical considerations, 

including their response to treatment. 

Thus, we believe that all 4 of the 

inpatient quality measures regarding the 

treatment of patients with heart failure 

are reasonable surrogates for the quality 

of hospital systems of care for 

outpatients with heart failure. 

Likewise, under the expanded list of 

quality measures for the FY 2007 IPPS 

the surgical infection prevention quality 

measures indicating the provision of a 

prophylactic antibiotic within 1 hour 

prior to surgical incision and 

prophylactic antibiotics discontinued 

within 24 hours after surgery end time 

likely serve as a reasonable 

representation of the quality of surgical 

care for hospital outpatients. Many of 

the same surgical procedures are 

commonly performed on both hospital 

outpatients and inpatients, sometimes 

in the same operating room suites with 

attendance by the same clinical staff. 

Hospitals often have standardized 

protocols for providing antibiotics prior 

to surgery and postoperatively based on 

the types of procedures performed, 

rather than on the inpatient or 

outpatient status of the patient, and a 

decision to admit a patient may not 

even be made until after the completion 

of a procedure. Thus, we have no reason 

to believe that the preoperative and 

postoperative antibiotic experiences of a 

patient undergoing outpatient surgery 

would systemically vary from that of a 

hospital inpatient. 

In summary, we believe that quality 

improvement is usually a function of 

the entire institution as an integrated 

system that provides both inpatient and 

outpatient services to patients with an 

overlapping range of medical 

conditions. Quality improvement in a 

hospital inpatient department is likely 

to correlate with, and indeed to 

promote, similar quality improvement 

in the hospital’s outpatient department 

and other sectors of the institution. 

Conversely, hospitals that fail to 

promote quality improvement in key 

sectors such as inpatient care are also 

unlikely to improve quality in the 

hospital outpatient department. We 

believe that the FY 2007 IPPS quality 

measures for multiple clinical 

conditions reflect the quality of 

hospitals’ systems of care that 

customarily include key outpatient 

settings such as the emergency 

department. Therefore, as an interim 

measure while specific quality measures 

are being developed and refined for 

reporting on the quality of care to 

hospital outpatients, we are proposing 

that the initial CY 2007 OPPS 

RHQDAPU incorporate all of the quality 

measures that are applicable to the IPPS 

during FY 2007. 

We welcome public comments on the 

applicability to the OPPS of the various 

FY 2007 IPPS quality measures as 

proxies for the quality of care in 

hospital systems that include outpatient 

departments, with consideration of both 

the 10 starter set measures and the 11 

new measures in the expanded set for 

FY 2007. 

Elsewhere in this proposed rule 

(section XXIII.), proposed additional 

quality measures for hospital reporting 

of quality data for the FY 2008 IPPS are 

discussed in detail. The proposed areas 

of expansion for the FY 2008 IPPS 

include the HCAHPS survey, which 

incorporates questions measuring 

patients’ perspectives on their hospital 

experiences; 3 additional measures 

related to the processes of surgical care 

to supplement the 2 initial Surgical Care 

Improvement Project (SCIP) measures to 

be implemented in FY 2007; and 3 riskadjusted assessments of mortality 

within 30 days of hospital admission for 

acute myocardial infarction, heart 

failure, and pneumonia. For the same 

reasons detailed above for the FY 2007 

IPPS SCIP measures, we believe that the 

additional surgical process of care 

measures are a reasonable interim proxy 

for the quality of surgical care for 

hospital outpatients. 

In addition, the questions on the 

hospital HCAHPS survey assess 

aspects of the patient’s hospital 

experience, including communication 

with doctors and nurses, responsiveness 

of the staff, pain management, and 

discharge information. These areas of 

questioning are all relevant to a 

hospital’s care for its outpatients, who 

may be treated in the hospital outpatient 

department for an extended period of 

time, particularly if they are in 

observation status or recovering from a 

significant surgical procedure. As 

described above, because hospitals 

generally function as integrated systems, 

with both inpatients and outpatients 

with related medical conditions passing 

through the same departments and 

interacting with similar staff, we believe 

that this survey of patients who have 


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been admitted to the hospital may 

reasonably reflect hospital outpatients’

perspectives on their care experiences 

as well. 

Finally, with respect to the 30-day 

mortality measures, these measures are 

linked to the same 3 medical conditions 

for which quality process measures have 

already been implemented in the IPPS 

RHQDAPU program, in order to expand 

the quality data to more fully reflect the 

true outcomes of care. These mortality 

measures are risk-adjusted based on 

historical medical care use, including 

inpatient and outpatient hospital care 

and physician offices visits, and reflect 

outcomes of care specifically for 

Medicare patients. Since we are 

proposing that the full set of FY 2007 

IPPS process of care quality measures 

are acceptable proxies for the quality of 

care to hospital outpatients as 

previously discussed, and we believe 

that some of the value of health care 

process measures is their relative ease of 

measurement and their ultimate 

relationship to health outcomes, we 

believe that the 30-day mortality 

measures for inpatients may also reflect 

the quality of care to hospital 

outpatients with the same medical 

conditions. In addition, in view of the 

common clinical courses of acute 

myocardial infarction, heart failure, and 

pneumonia in Medicare beneficiaries, it 

is highly likely that hospital outpatient 

services may be provided to previously 

hospitalized patients within the 

measures’ timeframe of 30 days after 

hospital discharge, thereby contributing 

to their care and health outcomes. 

Therefore, our intention is to adopt 

the full set of FY 2008 IPPS quality 

measures as proposed for the CY 2008 

OPPS RHQDAPU program, while we 

continue to develop a set of specific 

quality measures for hospital outpatient 

care. 

We welcome public comments on the 

applicability of the FY 2008 IPPS 

additional quality measures that are 

proposed in this rule to the care of 

hospital outpatients. We also welcome 

public comments on alternative 

measures of quality of care, including 

measures of the cost or efficiency of 

care, that are suitable for adoption to 

reduce the incidence of lower-quality 

and high-cost outpatient hospital care 

for Medicare beneficiaries. We will 

formalize our proposal regarding the CY 

2008 OPPS RHQDAPU program in the 

CY 2008 OPPS proposed rule, which 

may include proposing to adopt none, 

some, or all of the FY 2008 IPPS 

RHQDAPU measures, and may also 

reflect quality measures that are 

discussed in comments on this 

proposed rule. 

For purposes of computing the update 

to the conversion factor under the OPPS 

in CY 2007, therefore, we are proposing 

to reduce the update to the OPPS 

conversion factor by 2.0 percentage 

points for any hospital that is eligible to 

participate in the IPPS RHQDAPU 

program, but that has had its IPPS 

payment update reduced because it 

failed to comply with that program’s 

requirements. Under this proposal, 

hospitals that fail to qualify for the full 

CY 2007 OPPS update would receive 

payments based on a conversion factor 

of $60.36, reflecting an update of 1.4 

percent, in place of the conversion 

factor of $61.551 reflecting the full 

update of 3.4 percent. 

Under proposed § 419.43(h)(1), in 

order to avoid reduction to the CY 2007 

OPPS update, hospitals that are eligible 

to participate in the IPPS RHQDAPU 

program must meet the requirements for 

receiving the full IPPS update for FY 

2007. Updated procedures and 

requirements for the IPPS RHQDAPU 

program are included in the FY 2007 

IPPS final rule. In addition to 

publication in the final rule, all revised 

procedures will be added to the 

‘‘Reporting Hospital Quality Data for 

Annual Payment Update Reference 

Checklist’’ section of the QualityNet 

Exchange Web site 

(www.qnetexchange.org). For purposes 

of determining which hospitals have not 

qualified to receive the full update 

under the OPPS for CY 2007, we will 

follow the determination for FY 2007 

full IPPS payment update eligibility 

under the IPPS RHQDAPU program. 

These determinations will be released 

on or about September 1, 2006. 

As we noted above, we are 

undertaking this initiative under the 

authority granted by section 

1833(t)(2)(E) of the Act, which 

authorizes the Secretary to ‘‘establish, in 

a budget neutral manner, * * * 

adjustments as determined to be 

necessary to ensure equitable 

payments’’ under the OPPS. Proposed 

§ 419.43(h)(3) provides that the 

reduction to the CY 2007 update that we 

will implement for hospitals that fail to 

meet the requirements described above 

will be implemented in a budget neutral 

manner. Therefore, if we determine that 

some hospitals will receive a reduced 

update for CY 2007 as a result of failure 

to meet the requirements established 

under this initial phase of the OPPS 

RHQDAPU program, we will also make 

an adjustment to the OPPS conversion 

factor, so that estimated aggregate 

payments under the OPPS for CY 2007, 

taking into account the reduced update 

for some hospitals, equal the aggregate 

payments that we estimate would have 

been made in CY 2007 if all hospitals 

received the full update to the 

conversion factor. As we noted above, 

determinations concerning which 

hospitals fail to meet the requirements 

for receiving the full update to the OPPS 

conversion factor in CY 2007 will be 

available on or about September 1, 2006. 

We are therefore unable at this time to 

determine how many hospitals will 

receive a reduced update in CY 2007, or 

to determine the budget neutrality 

adjustment factor that will be necessary 

to ensure that estimated aggregate 

payments under the OPPS for CY 2007 

do not change as a result of 

implementing the proposed OPPS 

RHQDAPU program. However, very few 

hospitals have failed to qualify for the 

full annual updates under the IPPS 

RHQDAPU program. We therefore 

anticipate that any further adjustment to 

the CY 2007 conversion factor to satisfy 

the budget neutrality requirement under 

section 1833(t)(2)(E) of the Act will be 

negligible. 

It is not our intention to maintain the 

specific requirements described above 

beyond a short initial phase of 

implementing an OPPS RHQDAPU 

program. Rather our intention is to 

develop this program beyond its initial 

stage in at least two ways. As we have 

stated previously, we believe that it is 

appropriate and fair during this initial 

phase of the OPPS RHQDAPU program, 

to take quality data reporting under the 

IPPS RHQDAPU program into 

consideration for purposes of 

determining the update for hospitals 

under the OPPS. However, it will be 

important for a fully developed OPPS 

RHQDAPU program to be based on 

reporting measures that are defined in 

terms of the quality considerations that 

are most appropriate and applicable in 

the hospital outpatient setting. In 

collaboration with health care 

stakeholders, we intend to begin work 

on a set of quality and cost of care 

measures specific to hospital outpatient 

departments for implementation in a 

later phase of the OPPS RHQDAPU 

program. We intend to implement a 

hospital outpatient-specific set of such 

quality and cost of care measures at the 

earliest possible date. Reporting of a 

more fully developed, outpatientspecific set of quality and cost of care 

measures may be effective for purposes 

of determining the update as early as CY 

2009. However, in implementing the 

system we will allow adequate time for 

development of the appropriate 

measures; announcement of the quality 

and cost of care measures we have 

selected; consideration of comments 

from the hospital community, patient 


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49670 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

5RAND News Release: RAND Study Says 

Computerizing Medical Records Could Save $81 

Billion Annually and Improve the Quality of 

Medical Care, September 14, 2005, available at: 

http://rand.org/news/press.05/09.14.html. 

advocates, and other stakeholders; 

establishment of the requisite 

mechanisms for reporting the measure; 

and initiation of actual reporting of the 

measures by hospitals. As we begin to 

develop such a set of hospital 

outpatient-specific quality and cost of 

care measures, we welcome comments 

on this issue. 

Specifically, we invite comments on 

the following (and related) questions: 

Which current quality and cost of care 

measures, such as IPPS quality 

measures (especially the measure set as 

expanded under the DRA), physician 

practice measures, HCAHPS/ 

ACAHPS, etc., are most applicable in 

the hospital outpatient setting? What 

would be the characteristics of an ideal 

measure set of quality and cost of care 

measures for the outpatient setting? 

What quality and cost of care measures 

are currently available for the outpatient 

setting? What privately-led 

organizations or alliances are best suited 

to conduct needed development and 

consensus endorsement of outpatient 

quality measures? 

As we discussed above, for the initial 

stage of implementing the OPPS 

RHQDAPU program in CY 2007, 

hospitals that are paid under the OPPS 

but that do not qualify as ‘‘subsection 

(d)’’ hospitals will receive the full 

update to the OPPS conversion factor. 

However, we believe that it is essential 

to expand the requirements of the OPPS 

RHQDAPU program that we are 

proposing to all hospital outpatient 

departments paid under the OPPS. We 

will therefore also undertake to study, 

for CYs 2008 and beyond, approaches to 

adapting and expanding the current 

quality and cost of care measures under 

the IPPS RHQDAPU program for use in 

reporting on the quality of outpatient 

care in hospitals that are paid under the 

OPPS but that do not qualify as 

‘‘subsection (d)’’ hospitals. We will also 

begin development of mechanisms by 

which these hospitals can report the 

requisite quality data in a timely and 

effective manner. We welcome 

comments on ways in which we can 

expand the proposed OPPS RHQDAPU 

program to all hospital outpatient 

departments that are paid under the 

OPPS, and on quality and cost of care 

measures that are specifically 

appropriate for reporting by hospital 

outpatient departments paid under the 

OPPS but that do not qualify as 

‘‘subsection (d)’’ hospitals. 

Our ultimate goal is implementation 

of an OPPS RHQDAPU program that 

extends to all hospital outpatient 

departments that are paid under the 

OPPS, that is based on a set of quality 

and cost of care reporting measures that 

are specific to the hospital outpatient 

setting, and that is appropriately aligned 

with developments in quality reporting 

and value-based purchasing in other 

payment systems such as the IPPS. We 

will take into consideration issues 

related to the appropriate alignment of 

quality and cost of care reporting and 

value-based purchasing under the IPPS 

and OPPS during the planning process 

mandated by section 5001(b) of the DRA 

for implementation of inpatient valuebased purchasing by FY 2009. We plan 

to include all hospital services, whether 

inpatient or outpatient, in the report on 

implementation of value-based 

purchasing. We have often heard from 

stakeholders that a more 

comprehensive, systematic approach to 

quality should be our focus. Quality 

reporting of inpatient and outpatient 

services is consistent with such 

comments, and will provide more 

comprehensive information about the 

quality of services provided by 

hospitals. We specifically request 

comments on the alignment of scope 

and other issues that should be 

considered during this planning 

process, including quality and cost of 

care reporting measures, data and 

program infrastructure, incentives, and 

public reporting of quality and cost of 

care measures under value-based 

purchasing. 

Finally, we request comments on the 

most effective use of our authority 

under section 1833(t)(2)(E) of the Act, in 

light of the concerning evidence of rapid 

and uneven payment growth in the 

OPPS with limited evidence of patient 

benefit. In particular, commenters who 

believe that the proposed quality 

reporting initiative is not the most 

effective use of this authority should 

consider submitting comments on 

alternative, more effective approaches to 

using this and related authorities 

available to CMS under the Act to 

promote higher quality, more equitable 

care. We do not believe that the status 

quo, with rapid and uneven growth in 

spending and limited evidence of its 

value, is consistent with a sustainable 

hospital outpatient payment program 

and affordable health care for Medicare 

beneficiaries, and we expect to take 

further steps to address this important 

concern. As we have noted elsewhere, 

continuing rapid growth in Medicare 

spending that is not addressed by 

effective payment reforms often results 

in across-the-board reductions in 

payment rates. In addition, we seek 

comment on whether section 

1833(t)(2)(F) of the Act also supports the 

proposed use of quality reporting to 

determine a hospital’s update under the 

OPPS. 

XXI. Promoting Effective Use of Health 

Information Technology 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Health Information 

Technology’’ at the beginning of your 

comment.) 

We recognize the potential for health 

information technology (HIT) to 

facilitate improvements in the quality 

and efficiency of health care services. 

One recent RAND study found that 

broad adoption of electronic health 

records could save more than $81 

billion annually and, at the same time, 

improve quality of care.5 The largest 

potential savings that the study 

identified was in the hospital setting 

because of shorter hospital stays 

promoted by better coordinated care; 

less nursing time spent on 

administrative tasks; better use of 

medications in hospitals; and better 

utilization of drugs, laboratory services, 

and radiology services in hospital 

outpatient settings. The study also 

identified potential quality gains 

through enhanced patient safety, 

decision support tools for evidencebased medicine, and reminder 

mechanisms for screening and 

preventive care. Despite such large 

potential benefits, the study found that 

only about 20 to 25 percent of hospitals 

have adopted HIT systems. 

It is important to note the caveats to 

the RAND study. The projected savings 

are across the health care sector, and 

any Federal savings would be a reduced 

percentage. In addition, there are 

significant assumptions made in the 

RAND study. National savings are 

projected in some cases based on one or 

two small studies. Also, the study 

assumes patient compliance, in the form 

of participation in disease management 

programs and following medical advice. 

For these reasons, extreme caution 

should be used in interpreting these 

results. 

In summary, there are mixed signals 

about the potential of HIT to reduce 

costs. Some studies have indicated that 

HIT adoption does not necessarily lead 

to lower costs and improved quality. In 

addition, some industry experts have 

stated that factors such as an aging 

population, medical advances, and 

increasing provider expenses would 

make any projected savings impossible. 


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6Transforming Health Care: The President’s 

Health Information Technology Plan, available at: 

http://www.whitehouse.gov/infocus/technology/ 

economic_policy200404/chap3.html. 

In his 2004 State of the Union 

Address, President Bush announced a 

plan to ensure that most Americans 

have electronic health records within 10 

years.6 One part of this plan involves 

developing voluntary standards and 

promoting the adoption of interoperable 

HIT systems that use these standards. 

The 2007 Budget states that ‘‘The 

Administration supports the adoption of 

health information technology (IT) as a 

normal cost of doing business to ensure 

patients receive high quality care.’’

Over the past several years, CMS has 

undertaken several activities to promote 

the adoption and effective use of HIT in 

coordination with other Federal 

agencies and with the Office of the 

National Coordinator for Health 

Information Technology. One of those 

activities is promotion of data standards 

for clinical information, as well as for 

claims and administrative data. In 

addition, through our 8th Scope of Work 

contract with the QIOs, we are offering 

assistance to hospitals on how to adopt 

and redesign care processes to 

effectively use HIT to improve the 

quality of care for Medicare 

beneficiaries, including computerized 

physician order entry (CPOE) and bar 

coding systems. Finally, our Premier 

Hospital Quality Incentive 

Demonstration provides additional 

financial payments for hospitals that 

achieve improvements in quality, which 

effective HIT systems can facilitate. 

We are considering the role of 

interoperable HIT systems in increasing 

the quality of hospital services while 

avoiding unnecessary costs. As noted 

above, the Administration supports the 

adoption of HIT as a normal cost of 

doing business. While payments under 

the OPPS do not vary depending on the 

adoption and use of HIT, hospitals that 

leverage HIT to provide better quality 

services may more efficiently reap the 

reward of any resulting cost savings. In 

addition, the adoption and use of HIT 

may contribute to improved processes 

and outcomes of care, including 

shortened hospital stays and the 

avoidance of adverse drug reactions. We 

are seeking comments on our statutory 

authority to encourage the adoption and 

use of HIT. We also are seeking 

comments on the appropriate role of 

HIT in any value-based purchasing 

program, beyond the intrinsic incentives 

of the OPPS, to provide efficient care, 

encourage the avoidance of unnecessary 

costs, and increase quality of care. In 

addition, we are seeking comments on 

promotion of the use of effective HIT 

through hospital conditions of 

participation, perhaps by adding a 

requirement that hospitals use HIT that 

is compliant with and certified in its use 

of the HIT standards adopted by the 

Secretary. We anticipate that the 

American Health Information 

Community will provide advice to the 

Secretary on these issues. 

XXII. Health Care Information 

Transparency Initiative 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Transparency of Health Care 

Information’’ at the beginning of your 

comment.) 

The United States (U.S.) faces a 

dilemma in health care. Although the 

rate of increase in health care spending 

slowed last year, costs are still growing 

at an unsustainable rate. The U.S. 

spends $1.9 trillion on health care, or 16 

percent of the gross domestic product 

(GDP). By 2015, projections are that 

health care will consume 20 percent of 

GDP. The Medicare program alone 

consumes 3.4 percent of the GDP; by 

2040, it will consume 8.1 percent of the 

GDP and by 2070, 14 percent of the 

GDP. 

Part of the reason health care costs are 

rising so quickly is that most consumers 

of health care—the patients—are 

frequently not aware of the actual cost 

of their care. Health insurance shields 

them from the full cost of services, and 

they have only limited information 

about the quality and costs of their care. 

Consequently, consumers do not have 

the incentive or means to carefully shop 

for providers offering the best value. 

Thus, providers of care are not subject 

to the competitive pressures that exist in 

other markets for offering quality 

services at the best possible price. 

Reducing the rate of increase in health 

care prices and avoiding health services 

of little value could help to stem the 

growth in health care spending, and 

potentially reduce the number of 

individuals who are unable to afford 

health insurance. Part of the President’s 

health care agenda is to expand Health 

Savings Accounts (HSAs), which would 

provide consumers with greater 

financial incentives to compare 

providers in terms of price and quality, 

and choose those that offer the best 

value. 

In order to exercise those choices, 

consumers must have accessible and 

useful information on the price and 

quality of health care items and 

services. Typically, health care 

providers do not publicly quote or 

publish their prices. Moreover, list 

prices, or charges, generally differ from 

the actual prices negotiated and paid by 

different health plans. Thus, even if 

consumers were financially motivated 

to shop for the best price, it would be 

very difficult at the current time for 

them to access usable information. 

For these reasons, DHHS is launching 

a major health care information 

transparency initiative in 2006. This 

effort builds on steps taken by CMS to 

make quality and price information 

available. For example, Medicare has 

provided unprecedented information 

about drug prices in the Medicare drug 

benefit, and is now adding to these 

efforts in other areas. We recently 

posted Medicare payment information 

for common elective procedures and 

other common admissions for all 

hospitals by county on our Web site at 

http://www.cms.hhs.gov/ 

HealthCareConInit/ 

01_Overview.asp#TopOfPage. We will 

post geographically-based Medicare 

payment information for common 

elective procedures for ambulatory 

surgery centers this summer and for 

common hospital outpatient and 

physician services this fall. 

In addition, a number of tools 

providing usable health care 

information are already available to 

Medicare beneficiaries. Consumers can 

access ‘‘Compare’’ Web sites through 

http://www.medicare.gov where they 

can evaluate important aspects of their 

health care options for care at a hospital, 

nursing home, home health agency, and 

dialysis facility, as well as compare 

their costs and coverage when choosing 

a prescription drug plan. 

CMS is developing a transparency 

initiative with the goals of providing 

more comprehensive information on 

quality and costs, including more 

complete measures of health outcomes, 

satisfaction, and volume of services that 

matter to consumers, and more 

comprehensive measures of costs for 

entire episodes of care, not just 

payments for particular services and 

admissions. We intend for the project to 

combine public and private health care 

data to provide cost and quality of care 

information at the physician and 

hospital levels. Quality, cost, pricing, 

and patient information will be reported 

to consumers and purchasers of health 

care in a meaningful and transparent 

way. In addition, we anticipate the 

project will provide a national template 

for performance measures and a 

payment structure that aligns payment 

and performance. 


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XXIII. Additional Quality Measures 

and Procedures for Hospital Reporting 

of Quality Data for the FY 2008 IPPS 

Annual Payment Update 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘FY 2008 IPPS RHQDAPU’’ at 

the beginning of your comments.) 

A. Background 

Section 5001(a) of the Deficit 

Reduction Act of 2005 (DRA) (Pub. L. 

109–171) sets out new requirements for 

the IPPS Reporting Hospital Quality 

Data for Annual Payment Update 

(RHQDAPU) program. The IPPS 

RHQDAPU program was established to 

implement section 501(b) of the 

Medicare Prescription Drug, 

Improvement and Modernization Act of 

2003 (MMA) (Pub. L. 108–173). It builds 

on our ongoing voluntary Hospital 

Quality Initiative which is intended to 

empower consumers with quality of 

care information to make more informed 

decisions about their health care while 

also encouraging hospitals and 

clinicians to improve the quality of care. 

Section 5001(a) of Pub. L. 109–171 

revises the mechanism used to update 

the standardized amount for payment 

for hospital inpatient operating costs. 

New sections 1886(b)(3)(B)(viii)(I) and 

(II) of the Act provide that the payment 

update for FY 2007 and each subsequent 

fiscal year will be reduced by 2.0 

percentage points for any ‘‘subsection 

(d) hospital’’ that does not submit 

certain quality data in a form and 

manner, and at a time, specified by the 

Secretary. Under sections 

1886(b)(3)(B)(viii)(III) and (IV) of the 

Act, we must expand the ‘‘starter set’’ of 

quality measures that we have used 

since FY 2005, and to begin to adopt the 

baseline set of performance measures as 

set forth in a 2005 report issued by the 

Institute of Medicine of the National 

Academy of Sciences (IOM) under 

section 238(b) of the MMA, effective for 

payments beginning with FY 2007. The 

2005 IOM report’s ‘‘baseline’’ quality 

measures include Hospital Quality 

Alliance (HQA)-approved clinical 

quality measures, the Hospital 

Consumer Assessment of Healthcare 

Providers and Systems (HCAHPS) 

patient perspective survey, and three 

structural measures. The structural 

measures are: (1) Implementation of 

computerized provider order entry for 

prescriptions, (2) staffing of intensive 

care units with intensivists, and (3) 

evidence-based hospital referrals. These 

measures originate from the Leapfrog 

Group’s original ‘‘three leaps,’’ and are 

part of the NQF’s 30 safe practices. 

In 2002, the Secretary of HHS 

initiated a partnership with several 

collaborators intended to promote 

hospital quality improvement and 

public reporting of hospital quality 

information. This collaboration is 

known as the Hospital Quality Alliance 

(HQA). The collaborators include the 

American Hospital Association, the 

Federation of American Hospitals, the 

Association of American Medical 

Colleges, the Joint Commission on 

Accreditation of Healthcare 

Organizations (JCAHO), the National 

Quality Forum (NQF), the American 

Medical Association, the ConsumerPurchaser Disclosure Project, the 

American Association of Retired 

Persons, the American Federation of 

Labor Congress of Industrial 

Organizations, the Agency for 

Healthcare Research and Quality, as 

well as CMS, Quality Improvement 

Organizations (QIOs), and others. 

In the FY 2007 IPPS proposed rule, 

we proposed to add to our 10-measure 

‘‘starter set’’ of quality measures, 11 

HQA-approved measures for purposes 

of the FY 2007 update (71 FR 24093). 

Under section 1886(b)(3)(B)(viii)(V) of 

the Act, for payments beginning with 

FY 2008, we are required to add other 

measures that reflect consensus among 

affected parties and, to the extent 

feasible and practicable, must include 

measures set forth by one or more 

national consensus building entities. 

Commenters on the FY 2007 IPPS 

proposed rule requested that we notify 

the public as far in advance as possible 

of any proposed expansions of the 

measure set and program procedures to 

encourage broad collaboration and to 

give hospitals time to prepare for any 

anticipated changes. Other commenters 

requested that we adopt additional 

quality measures and that we do as soon 

as feasible. For example, several 

commenters urged that we adopt the 

HCAHPS patient survey as a part of the 

IPPS RHQDAPU program, while others 

suggested that we adopt more of the 

IOM measures as well as more outcome 

measures, including mortality measures 

that were not included in the 2005 IOM 

report’s ‘‘baseline’’ quality measures. In 

response to these comments and as part 

of our continuing efforts to strengthen 

the IPPS RHQDAPU program, we are 

seeking comments on this proposal to 

expand, for FY 2008, the measurement 

set beyond those measures we proposed 

to adopt for purposes of the FY 2007 

update. This proposed expanded set 

would further broaden the scope of the 

IPPS RHQDAPU program by including 

the HCAHPS patients’ perspectives of 

care measures as well as surgical care 

and mortality outcome measures. 

B. Proposed Additional Quality 

Measures for FY 2008 

1. Introduction 

For FY 2008, we propose to add the 

following categories to the measure set: 

• HCAHPS Survey 

HCAHPS is also known as Hospital 

CAHPS or the CAHPS Hospital Survey. 

The HCAHPS survey is composed of 

the following 27 questions: 

+ 18 substantive questions that 

measure critical aspects of the hospital 

experience (communication with 

doctors; communication with nurses; 

responsiveness of hospital staff; 

cleanliness and quietness of hospital 

environment; pain management; 

communication about medicines; and 

discharge information). 

+ 4 questions that direct patients to 

complete only those survey questions 

that apply to them. 

+ 3 questions to be used to adjust the 

mix of patients across hospitals. 

+ 2 questions that support 

Congressionally-mandated reports, the 

‘‘National Healthcare Disparities 

Report,’’ and the ‘‘National Healthcare 

Quality Report.’’

• Surgical Care Improvement Project 

(SCIP) 

+ SCIP–VTE 1: Venous 

thromboembolism prophylaxis ordered 

for surgery patient 

+ SCIP–VTE 2: VTE prophylaxis 

within 24 hours pre/post surgery 

+ SCIP Infection 2: Prophylactic 

antibiotic selection for surgical patients 

• Mortality 

+ AMI 30-day mortality—Medicare 

patients 

+ HF 30-day mortality—Medicare 

patients 

+ Pneumonia 30-day mortality—

Medicare patients 

We discuss these proposed measures 

in detail below. 

2. HCAHPS Survey and the Hospital 

Quality Initiative 

We have partnered with the Agency 

for Healthcare Research and Quality 

(AHRQ), another HHS agency, to 

develop HCAHPS. The intent of the 

HCAHPS initiative is to provide a 

standardized survey instrument and 

data collection methodology for 

measuring patients’ perspectives of 

hospital care. While many hospitals 

currently collect information on 

patients’ satisfaction with care, there is 

currently no national standard for 

collecting or publicly reporting this 

information that would enable valid 

comparisons to be made across 

hospitals. To make the appropriate 

comparisons to support consumer 

choice, we believe it is necessary to 


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introduce a standard measurement 

approach. HCAHPS can be viewed as 

a core set of questions that can be 

combined with a broader, customized 

set of hospital-specific items. HCAHPS

is intended to complement the data 

hospitals currently collect to support 

improvements in internal customer 

services and quality related initiatives 

within the hospital. 

Three broad goals have shaped 

HCAHPS. The survey is designed to 

produce data on the patient’s 

perspective on care that allows objective 

and meaningful comparisons between 

hospitals on issues that are important to 

consumers. In addition, public reporting 

of the survey results is designed to 

create incentives for hospitals to 

improve their quality of care. Also, 

public reporting will serve to enhance 

public accountability in health care by 

increasing the transparency of the 

quality of hospital care provided in 

return for the public investment. With 

these goals in mind, the HCAHPS

initiative has taken substantial steps to 

assure that the survey will be credible, 

useful, and practical. 

Throughout the HCAHPS

development process, AHRQ and CMS 

have solicited and received a great deal 

of public input. AHRQ published a 

Federal Register notice that called for 

measures in July 2002 (67 FR 48477) 

and we solicited input on drafts of the 

HCAHPS instrument and its 

implementation strategy (February 2003, 

June 2003, and December 2003—68 FR 

5889, 68 FR 38346, 68 FR 68087). In 

addition to the public comments 

received, results from a 3-State Pilot 

Study were used to reduce the pool of 

66 survey questions to 25 questions. 

In addition to the development and 

review processes, we submitted the 25- 

item version of the HCAHPS

instrument to the NQF. The NQF is a 

voluntary consensus standard-setting 

organization established to standardize 

health care quality measurement and 

reporting for its review and 

endorsement through its consensus 

development process. NQF endorsement 

represents the consensus of numerous 

health care providers, consumer groups, 

professional associations, purchasers, 

Federal agencies, and research and 

quality organizations. Following a 

thorough, multi-stage review process, 

HCAHPS was endorsed by the NQF 

board in May 2005. In the process, NQF 

recommended a few modifications to 

the instrument. As a result of the 

recommendations of the NQF 

Consensus Development Process, 

questions regarding courtesy and 

respect were added to the survey. The 

NQF review committee believes that 

these questions are important to all 

patients, and may be particularly 

meaningful to patients who are 

members of racial and ethnic minority 

groups. Upon the recommendation of 

the NQF, we further examined the costs 

and benefits of the 27-item HCAHPS

survey. This cost-benefit analysis of 

HCAHPS was conducted by Abt 

Associates, Inc. The report of this 

analysis can be found at http:// 

www.cms.hhs.gov/HospitalQualityInits/ 

downloads/ 

HCAHPSCostsBenefits200512.pdf. 

We published a Federal Register 

notice soliciting comments on the draft 

27-item HCAHPS Survey in November 

2005 (70 FR 67476). The HCAHPSreg; 

survey received approval by the Office 

of Management and Budget (OMB) on 

December 22, 2005. 

Shortly thereafter, we began final 

preparations for the voluntary national 

implementation (as a part of the 

Hospital Quality Initiative) with the 

support of the HQA. The HQA is a 

private/public partnership that includes 

the American Hospital Association, the 

Federation of American Hospitals, the 

Association of American Medical 

Colleges, JCHAO, NQF, American 

Association of Retired Persons (AARP), 

CMS, AHRQ, and other stakeholders 

who share a common interest in 

reporting on hospital quality. The HQA 

has been proactive in making 

performance data on hospitals 

accessible to the public, thereby 

improving patient care. 

We also offered training sessions for 

hospitals self-administering the survey 

and survey vendors acting on behalf of 

hospitals in February and April 2006. 

Since HCAHPS was a new initiative, 

we decided that it was critical to 

hospitals, survey vendors, and CMS to 

acquire first-hand experience with data 

collection, including sampling and data 

submission to the QualityNet Exchange, 

prior to collecting data for public 

reporting. For hospitals participating in 

the national implementation of 

HCAHPS on October 1, 2006, we 

required participation in a short dry run 

period of at least one month. A hospital 

could choose to sample and survey 

discharges in April, May, and/or June 

2006. Data from this ‘‘dry run’’ are not 

publicly reported. 

National implementation begins 

October 2006 for this first set of 

hospitals and survey vendors that will 

be participating in the HCAHPS

voluntary initiative The initial public 

reporting period will cover nine months 

of patient discharges (October 2006 

through June 2007). In late 2007, 

hospital results will be publicly 

reported on the CMS Hospital Compare 

Web site (http:// 

www.hospitalcompare.hhs.gov). After 

the initial implementation, the Web site 

will contain 12 months of HCAHPS

data and will be updated quarterly. 

The HCAHPS survey is currently 

available in English and Spanish. 

During the HCAHPS dry run and 

initial national implementation 

(discussed more fully below), we will be 

soliciting comments from participating 

hospitals and survey vendors regarding 

additional languages for HCAHPS. 

This information can be submitted to 

our HCAHPS mailbox, 

CMSHOSPITALCAHPS@cms.hhs.gov. 

From the information we receive, we 

will establish priorities for HCAHPS 

translation into additional languages. 

In order for the remaining hospitals to 

participate in HCAHPS, future training 

sessions for hospital personnel and 

survey vendors will take place in early 

2007. Hospitals may choose to selfadminister HCAHPS, or may choose to 

hire a vendor who has completed the 

training. A brief dry run of March 2007 

discharges will allow newly 

participating hospitals and vendors to 

get ‘‘first-hand’’ experience with all 

phases of the data collection and 

submission process. Details about the 

HCAHPS requirements, and the 

additional requirements proposed for 

HCAHPS under the IPPS RHQDAPU 

program, are included in section 

XXIII.C. and XXIII.D. of this preamble. 

3. Surgical Care Improvement Project 

(SCIP) Quality Measures 

The Surgical Care Improvement 

Project (SCIP) is a national quality 

partnership of organizations committed 

to improving the safety of surgical care 

through the reduction of post-operative 

complications. The primary goal of the 

partnership is to save lives by reducing 

the incidence of surgical complications 

by 25 percent by the year 2010. Partners 

in SCIP believe that a meaningful 

reduction in complications requires a 

systems approach to our challenges, 

which means that surgeons, 

anesthesiologists, primary care 

physicians and internal medicine 

specialists, perioperative nurses, 

pharmacists, infection control 

professionals, and hospital executives 

must work together to make surgical 

care improvement a priority. SCIP 

partners coordinate their efforts through 

a steering committee that includes 

representatives of the American 

Hospital Association, the American 

College of Surgeons, the American 

Society of Anesthesiologists, the 

Association of Perioperative Registered 

Nurses, the JCAHO, the Institute of 

Healthcare Improvement, the 


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Department of Veterans Affair (VA), the 

Agency for Healthcare Research and 

Quality (AHRQ), CMS and the Centers 

for Disease Control and Prevention 

(CDC). 

SCIP is a comprehensive program, 

integrated into the quality improvement 

agenda of the CMS, JCAHO, the CDC, 

the American College of Surgeons, the 

Veterans Health Administration, as well 

as the other organizations that comprise 

the SCIP Steering Committee. There are 

a number of activities underway from 

these and other partnering 

organizations. 

4. Mortality Outcome Measures 

CMS recognizes that the current set of 

hospital performance measures should 

be expanded to more fully reflect 

outcomes of care. The 30-day mortality 

measures for patients with acute 

myocardial infarction (AMI), heart 

failure (HF) and pneumonia are three 

separate claims-based, risk-adjusted 

assessments of mortality within 30 days 

of admission for each of the three 

conditions. The measures reflect 

outcomes of care for Medicare patients 

only, and rely on Medicare patients’

historical medical care use, including 

inpatient and physician office visits and 

outpatient care 1 year before their 

hospitalizations, for the risk adjustment 

calculation. 

The 30-day mortality rate measures 

for AMI and HF were endorsed by the 

NQF in 2005 (see http:// 

www.qualityforum.org/news/ 

tb3Hospspecsforweb02-10-06.pdf). We 

anticipate that the 30-day mortality rate 

measure for pneumonia will also be 

endorsed by the NQF since it reflects 

the same underlying methodology as the 

other 30-day mortality measures. 

In contrast to the HCAHPS and SCIP 

quality measures added to the measure 

set for FY 2008, no additional data 

collection from hospitals will be 

required to calculate the 30-day 

mortality measures. All three measures 

can be calculated based on Medicare 

inpatient and outpatient claims data 

that are already reported to the 

Medicare program for payment 

purposes. We anticipate that we will 

conduct a national dry run for the AMI 

and HF measures in late 2006 to test 

implementation and educate hospitals 

on the methodology. During this dry 

run, hospitals will be given the 

opportunity to examine their rates and 

other data associated with the measures, 

and to provide feedback to CMS on 

questions related to the calculation of 

the rates. The rates that will be 

developed for the dry run will be used 

for quality improvement purposes and 

will not be publicly reported to the 

Hospital Compare. More information 

about the dry run will be provided to 

hospitals through QualityNet Exchange 

Web site (http:// 

www.qnetexchange.org). 

We expect to calculate and publicly 

report 30-day mortality rates for the 

AMI and HF conditions in the June 2007 

update of the Hospital Compare Web 

site. Rates for the 30-day pneumonia 

mortality measure will be posted as 

soon as possible after we receive NQF 

endorsement. As is currently the case 

for the other measures, hospitals will be 

provided a 30-day period in which they 

will be permitted to preview their rates 

before publication. As is currently the 

case for the ‘‘starter set’’ measures, 

hospitals that have pledged to submit 

data for full annual payment update for 

FY 2008 will not be permitted to 

suppress or withhold publication of the 

rates on the Hospital Compare Web site, 

except under highly limited 

circumstances. 

C. General Procedures and Participation 

Requirements for the FY 2008 IPPS 

RHQDAPU Program 

All revised procedures for FY 2008 

also will be added to the ‘‘Reporting 

Hospital Quality Data for Annual 

Payment Update Reference Checklist’’

section of the QualityNet Exchange Web 

site. This checklist also links to all of 

the forms to be completed by hospitals 

participating in the program. 

To participate in the RHQDAPU 

program, we are proposing that 

hospitals must follow these steps: 

• Complete all registration steps; this 

information can be found on ‘‘Reporting 

Hospital Quality Data for Annual 

Payment Update Reference Checklist’’

located on the QualityNet Exchange 

Web site. 

• Continue to collect data for all 

clinical quality measures that are 

currently part of the RHQDAPU 

program, and submit the data to the QIO 

Clinical Warehouse either using the 

CMS Abstraction & Reporting Tool 

(CART), the JCAHO ORYX Core 

Measures Performance Measurement 

System, or another third-party vendor 

tool that has met specification 

requirements for data transmission to 

QualityNet Exchange. The submission 

must be done through QualityNet 

Exchange. Because the information in 

the QIO Clinical Warehouse is 

considered QIO information, it is 

subject to the stringent QIO 

confidentiality regulations in 42 CFR 

Part 480. 

In addition, for purposes of the 

annual payment update, we will 

continue to require hospitals to pass our 

validation requirements. We originally 

set forth these requirements in the FY 

2006 IPPS final rule (70 FR 47421), and 

we will continue to require that 

hospitals achieve an 80-percent 

reliability. We will also continue to post 

information related to validation 

requirements on the QualityNet 

Exchange Web site. 

In addition to these general 

procedures, the specific procedures 

below apply to these proposed 

additional measures. 

D. HCAHPS Procedures and 

Participation Requirements for the FY 

2008 IPPS RHQDAPU Program 

1. Introduction 

Under sections 1886(b)(3)(B)(viii)(III) 

and (IV) of the Act, CMS must begin to 

adopt the baseline set of performance 

measurements as set forth in a 2005 

report issued by the Institute of 

Medicine (IOM) of the National 

Academy of Sciences under section 

238(b) of Pub. L. 108–173, effective for 

payments beginning with FY 2007. The 

2005 IOM report recommends that we 

expand the ‘‘starter’’ measures by 

including the HCAHPS patient 

perspective survey. We began to adopt 

the IOM measures in the FY 2007 IPPS 

final rule, in which we adopted 11 

additional HQA-approved quality 

measures. In this proposed rule, we are 

proposing to expand the set of IOM 

measures hospitals will be required to 

report to receive the full IPPS market 

basket update for FY 2008. In addition, 

section 1886(b)(3)(B)(viii)(V) of the Act 

states that effective for payments 

beginning with FY 2008, we must add 

‘‘other measures that reflect consensus 

among affected parties and, to the extent 

feasible and practicable,’’ include 

‘‘measures set forth by one or more 

national consensus building entities.’’

Accordingly, we are proposing to add 

additional SCIP quality and measures 

and three 30-day mortality measures. 

2. HCAHPS Hospital Pledge and 

Beginning Date for Data Collection 

Under the FY 2008 RHQDAPU 

program, we are proposing that 

hospitals will need to submit HCAHPS

data to the QIO Clinical Warehouse 

beginning with discharges that occur in 

the third calendar quarter of 2007 (July 

through September discharges). In order 

to meet HCAHPS requirements for the 

RHQDAPU program, we are proposing 

that all hospitals, including hospitals 

new to HCAHPS and hospitals that 

have been collecting data since October 

1, 2006, must submit a formal pledge to 

CMS by July 1, 2007 stating that they 

will collect and submit HCAHPS data 

to the QIO Clinical Warehouse starting 


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with July 2007 discharges. We are 

proposing that to meet HCAHPS

requirements for the RHQDAPU 

program for FY 2008, all hospitals must 

submit this pledge to CMS. 

3. HCAHPS Dry Run 

We are proposing to require that 

hospitals that have not had experience 

collecting and submitting HCAHPS

data to the QIO Clinical Warehouse as 

a result of participating in the 2006 

voluntary initiative must participate in 

a dry run of the survey in March 2007. 

We are proposing to require the 

submission of March 2007 dry run data 

to the QIO Clinical Warehouse by July 

13, 2007 from those hospitals not yet 

collecting and submitting HCAHPS

data. 

4. HCAHPS Data Collection 

Requirements 

To collect HCAHPS data, we are 

proposing that a hospital can either 

contract with an approved HCAHPS

survey vendor that will conduct the 

survey and submit data on the hospital’s 

behalf to the QIO Clinical Warehouse, or 

a hospital can self-administer the survey 

without using a survey vendor provided 

that the hospital meets Minimum 

Survey Requirements as specified at 

(http://www.HCAHPSonline.org/ 

programapplication.asp). A current list 

of approved HCAHPS survey vendors 

can be found at http:// 

www.HCAHPSonline.org/ 

app_vendor.asp. 

5. HCAHPS Registration Requirements 

• We are proposing that HCAHPS

registration requirements for the 

RHQDAPU program will include: 

+ The hospital must be a registered 

user of QualityNet Exchange. Hospitals 

that are self-administering HCAHPS or 

survey vendors hired by the hospitals 

must collect and submit HCAHPS

survey person-level data electronically 

to the QIO Clinical Warehouse via 

QualityNet Exchange, using prescribed 

file specifications that can be found at 

http://www.HCAHPSonline.org/ 

techspecs.asp. 

6. Additional Steps for HCAHPS

Participation 

In order to participate in HCAHPS, 

we are proposing that hospitals that selfadminister the survey and survey 

vendors that collect and submit data on 

behalf of client hospitals must follow 

these steps: 

• Attend Hospital/Survey Vendor 

Training. Hospitals and survey vendors 

that intend to actually administer the 

survey must attend HCAHPS training. 

Hospitals contracting with a survey 

vendor or another hospital to administer 

the survey on behalf of the hospital do 

not need to attend training. The next 

training session will be offered via 

Webinar in late January 2007. Please see 

http://www.HCAHPSonline.org for 

updated information on training 

opportunities and registration. At a 

minimum, the hospital’s or survey 

vendor’s project manager must attend 

the HCAHPS training for administering 

the survey. Hospitals and survey 

vendors that attended training in 

February or April 2006 and are 

participating in the voluntary HCAHPS 

data submission beginning October 2006 

do not need to participate in the January 

2007 training sessions. In addition, we 

may hold short refresher training 

sessions for all hospitals selfadministering the survey and survey 

vendors in the spring of 2007. 

• Review and follow the HCAHPS

Quality Assurance Guidelines and 

Updates. HCAHPS Quality Assurance 

Guidelines have been developed to 

standardize the survey data collection 

process and to ensure comparability of 

data reported through HCAHPS. They 

are located on http:// 

www.hcahpsonline.org and will also be 

presented at the HCAHPS hospital/ 

survey vendor training. 

The HCAHPS Quality Assurance 

Guidelines (the Guidelines) provide 

detailed information regarding: 

technical support; sampling protocols; 

the four allowed modes of survey 

administration; data specifications and 

coding; data preparation and 

submission; data reporting and the 

exceptions process. The Guidelines 

describe technical support that is 

available to hospitals and survey 

vendors administering HCAHPS by 

using a toll-free number or by e-mail. It 

provides details regarding the protocol 

for sampling involving drawing a simple 

random sample each month from the 

sampling frame of eligible discharges. 

Sampling can be done at one time after 

the end of the month, or continuously 

throughout the month, as long as a 

simple random sample is generated for 

the month. The Guidelines include very 

specific information about the four 

allowed modes of survey 

administration: mail only, telephone 

only, a mixed methodology of mail with 

telephone follow up, and active 

interactive voice response (IVR). All 

modes of administration require 

following a standardized protocol. The 

Guidelines describe a standardized 

approach for the coding of all data from 

assigning the unique tracking number, 

the decision rules for capturing data, the 

file specifications, the file layout, the 

procedure for assigning disposition 

codes, the definition of a completed 

survey, and the procedure for 

calculating the total survey response 

rate. Data preparation and submission 

guidelines cover registration for data 

submission via the QualityNet 

Exchange, creation of data files, 

instructions for data submission via the 

QualityNet Exchange, and confirmation 

of accuracy of data. Data reporting 

covers internal and external reports; 

among them are the hospital preview 

reports and the public reports on CMS 

Hospital Compare. The Quality 

Assurance Guidelines describe the 

exceptions process to review requests 

for methodologies that vary from the 

standard HCAHPS protocols and the 

appeals process if an exception is 

denied. For the initial implementation 

phase of the HCAHPS survey, we are 

proposing that no exceptions to the four 

approved modes of survey 

administration will be allowed. 

In addition, hospitals/survey vendors 

must follow any updates that are posted 

on http://www.HCAHPSonline.org. 

• Develop Hospital/Survey Vendor 

HCAHPS Quality Assurance Plan. 

Hospitals self-administering the survey 

and survey vendors must develop a 

Quality Assurance Plan for survey 

administration in accordance with the 

Quality Assurance Guidelines presented 

at the HCAHPS hospital/survey vendor 

training and posted on http:// 

www.HCAHPS online.org/ 

programapplication.asp. The HCAHPS

Quality Assurance Plan should include 

the following: 

+ Organizational chart 

+ Work plan for survey 

implementation 

+ Description of survey procedures 

and quality controls 

+ Plans for quality assurance 

oversight of on-site work and of all 

subcontractors’ work (including survey 

vendor, if used) 

+ Confidentiality/Privacy and 

Security procedures in accordance with 

the Health Insurance Portability and 

Accountability Act (HIPAA). 

The hospital or survey vendor must 

make the HCAHPS  Quality Assurance 

Plan available to the HCAHPS project 

team upon request. The project team 

includes CMS, the Health Services 

Advisory Group (HSAG) that is helping 

CMS implement HCAHPS, and HSAG’s 

subcontractors for this project. 

• Attest to the Accuracy of the 

Organization’s Data Collection. 

Hospitals self-administering the survey 

and survey vendors must review and 

agree that the HCAHPS survey was 

administered in accordance with the 

HCAHPS Quality Assurance 

Guidelines. 


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• Participate in HCAHPS oversight 

activities. Hospitals and survey vendors 

must participate in a quality oversight 

process conducted by the HCAHPS

project team. Prior to July 2007, the 

purpose of the oversight activities will 

be to provide feedback to hospitals and 

survey vendors on data collection 

procedures. Starting in July 2007, CMS 

may ask hospitals/survey vendors to 

correct any problems that are found and 

provide follow-up documentation of 

corrections for review within a defined 

time period. If we find that the hospital 

has not made these corrections, CMS 

may determine that the hospital is not 

submitting appropriate HCAHPS data 

for the RHQDAPU program. 

As part of these activities, HCAHPS

project staff will review and discuss 

with survey vendors and hospitals selfadministering the survey their specific 

Quality Assurance Plans; survey 

management procedures; sampling and 

data collection protocols; and data 

preparation and submission. This 

review may take place in-person or 

through other means of communication. 

7. HCAHPS Survey Completion 

Requirements 

We are proposing that hospitals must 

submit complete HCAHPS data in 

accordance with the HCAHPS Quality 

Assurance Guidelines located at http:// 

www.HCAHPSonline.org and made 

available at the hospital/survey vendor 

training. These requirements specify 

that hospitals are required to survey a 

random sample of eligible discharges on 

a monthly basis. Hospitals should target 

to collect at least 300 completed surveys 

over the public reporting period. For the 

initial HCAHPS national 

implementation, the public reporting 

period is 9 months, from October 2006 

through June 2007. After this initial 

implementation, the public reporting 

period will be 12 months and hospitals 

should be targeting to collect at least 

300 completed HCAHPS surveys over 

a 12 month period. The initial public 

reporting period is 9 months, because of 

the broad interest of making HCAHPS 

results publicly available as quickly as 

possible. Smaller hospitals that cannot 

collect 300 completed HCAHPS

surveys during a public reporting period 

will only be required to collect as many 

completed surveys as possible. A small 

hospital is defined for the purposes of 

HCAHPS as any hospital that cannot 

achieve 300 completed HCAHPS

surveys during a public reporting 

period, because of its dearth of eligible 

hospital discharges during that period. 

For those hospitals that cannot collect 

300 completed HCAHPS surveys, we 

plan to note this on http:// 

www.hospitalcompare.hhs.gov that the 

results for those hospitals are based on 

less than 100 completed HCAHPS

surveys or between 100 and 299 

completed HCAHPS surveys. 

8. HCAHPS Public Reporting 

We propose to display HCAHPS data 

on our Web site for public viewing in 

accordance with section 

1886(b)(3)(B)(viii)(VII) of the Act, which 

states that the Secretary must report 

quality measures that relate to patients’

perspectives on care on our Web site. 

Before we display this information, 

hospitals will be permitted to review 

their data to be made public as we have 

recorded it. 

As we discussed above, there are 27 

questions included in the HCAHPS

survey. The survey is comprised of 

substantive questions that directly 

pertain to seven domains of primary 

importance to the target audience: 

Doctor communication, nurse 

communication; cleanliness and quiet of 

the hospital environment; 

responsiveness of hospital staff; pain 

management; communication about 

medicines; and discharge information. It 

also includes two overall questions that 

measure the patient’s overall 

satisfaction with the hospital and 

willingness to recommend the hospital. 

Each of the seven domains is 

constructed from two or three questions 

from the survey and is reported as a 

composite score. For public reporting 

purposes, the seven composite scores 

and two overall ratings will be 

displayed. There will be both national 

and state comparisons for each of the 

nine reported results. We are currently 

conducting testing with consumers to 

ensure that the HCAHPS displays on 

http://www.hospitalcompare.hhs.gov 

are consumer friendly. Generally, for 

CAHPS  measures in other settings we 

display bar graphs with the top response 

categories, such as the percent of people 

surveyed that gave the hospital a ‘‘10’’

for a 0 to 10 rating, or the percent that 

said their doctors ‘‘always’’

communicate well. Users of the site can 

‘‘drill down’’ to get more detailed 

information regarding the distribution 

for the response categories underlying 

the survey questions. 

9. Reporting HCAHPS Results for 

Multi-Campus Hospitals 

Currently, hospitals that share 

Medicare provider numbers combine 

their clinical data across campuses for 

submission and publication of their 

data. Our current plan for HCAHPS is 

for these data to be combined across 

campuses. However, we are considering 

ways in which data could potentially be 

displayed by campus rather than by 

hospital system in the future. As a 

starting point, we are trying to 

determine a way to identify those 

hospitals that share Medicare provider 

numbers, which will allow CMS to 

denote that the measures are made up 

of multiple campuses on 

http://www.hospitalcompare.hhs.gov. In 

the future, if feasible, we would like to 

move towards obtaining and reporting 

information at the campus level. We 

encourage comments regarding this 

issue. 

E. SCIP & Mortality Measure 

Requirements for the FY 2008 

RHQDAPU Program 

• We are proposing that hospitals be 

required to complete and return a 

written form on which they agree to 

participate in the RHQDAPU program 

for FY 2008. 

• For the SCIP measures, we are 

proposing to require hospitals to submit 

data starting with discharges that occur 

in CY 2007. Hospitals will be required 

to submit data on these measures to the 

QIO Clinical Warehouse beginning with 

discharges that occur in the first 

calendar year quarter of 2007 (January 

through March discharges). We are 

proposing that the deadline for hospitals 

to submit their data for first calendar 

quarter of 2007 will be August 15, 2007. 

• For the Mortality measures, we are 

proposing to use claims data that is 

already being collected for index 

hospitalizations to calculate the 

mortality rates, therefore, no additional 

data will need to be submitted by 

hospitals for these measures. Index 

hospitalization is the initial 

hospitalization for an episode of care. 

Claims data submitted to CMS for index 

hospitalizations occurring from July 

2005 through June 2006 (3rd quarter CY 

2005 through 2nd quarter CY 2006) will 

be used to calculate the mortality rates 

that will be used for FY 2008 annual 

payment determination. These rates will 

be posted on Hospital Compare in June 

2007. 

• We are proposing to display on our 

Web site data collected on the SCIP and 

Mortality measures for public viewing 

in accordance with section 

1886(b)(3)(B)(viii)(VII) of the Act. Before 

we display this information, hospitals 

will be permitted to review their data 

that are to be made public as we have 

recorded it. 

F. Conclusion 

We believe that our proposal to 

include HCAHPS, SCIP and Mortality 

measures as part of the FY 2008 IPPS 

RHQDAPU program’s reporting 

requirements meets the requirements of 


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section 1886(b)(3)(B)(viii)(III) of the Act. 

This provision states that we must 

expand for FY 2007 and each 

subsequent fiscal year, consistent with 

sections 1886(b)(3)(B)(viii)(IV) through 

1886(b)(3)(viii)(VII) of the Act, the set of 

measures that the Secretary determines 

to be ‘‘appropriate’’ for the measurement 

of care furnished by hospitals in 

inpatient settings beyond the original 

10-measure starter set of quality 

measures that applied in FY 2005 and 

FY 2006. 

Section 1886(b)(3)(B)(viii)(IV) of the 

Act requires us to begin to adopt the 

baseline set of performance measures set 

forth in the 2005 IOM report effective 

for payment beginning with FY 2007. 

We began to adopt these measures for 

FY 2007 and are now proposing to 

adopt additional measures, including 

several measures that are from this 

report. HCAHPS and the SCIP 

Infection 2 measures are measures set 

forth in the 2005 IOM report. Thus, we 

believe our proposal to expand the 

measure set to include HCAHPS and 

SCIP Infection 2 measures for the FY 

2008 IPPS RHQDAPU program meets 

this requirement of the Act. 

Section 1886(b)(3)(B)(viii)(V) of the 

Act states that effective for payments 

beginning with fiscal year 2008, we 

must add ‘‘other measures that reflect 

consensus among affected parties and, 

to the extent feasible and practicable,’’

include ‘‘measures set forth by one or 

more national consensus building 

entities.’’ In addition to proposing to 

add additional measures from the 

baseline measures found in the 2005 

IOM report, we are proposing to add 

additional SCIP quality measures and 

three 30-day mortality measures. In 

selecting these measures to adopt 

consistent with this section for the FY 

2008 payment update and thereafter, 

CMS is proposing to add standardized 

quality measures that have been 

adopted or endorsed by a national 

consensus building entity that utilizes a 

national consensus building process 

that endorses measures based on (1) its 

consideration of issues such as the 

validity, reliability, impact and 

feasibility of the measures, and (2) input 

from a wide variety of stakeholders 

including, but not limited to, health care 

consumers and patients, clinicians and 

providers, purchasers, and researchers. 

We believe that adopting measures 

that have been endorsed as a result of 

this process achieves the type of 

consensus that Congress envisioned in 

enacting section 5001(a) of Pub. L. 109–

171. The NQF is one consensus building 

entity that administers this process and 

takes these factors into account when 

endorsing measures. NQF is a voluntary 

consensus standard-setting organization 

established to standardize health care 

quality measurement and reporting, for 

its review and endorsement through its 

consensus development process. NQF 

endorsement, which occurs following a 

thorough, multi-stage review process, 

represents the consensus of numerous 

health care providers, consumer groups, 

professional associations, purchasers, 

Federal agencies, and research and 

quality organizations. We recognize that 

the 30-day Pneumonia mortality is not 

currently NQF-endorsed. We anticipate, 

however, that the NQF will endorse this 

measure soon. We do not plan to adopt 

the 30-day Pneumonia mortality 

measure unless it is endorsed by the 

NQF. 

The HQA is another such consensus 

building entity. The HQA is a publicprivate collaboration of numerous 

stakeholder groups. One goal of HQA is 

to identify a robust set of standardized 

and easy-to-understand hospital quality 

measures that would be used by all 

stakeholders in the health care system 

in order to improve quality of care and 

the ability of consumers to make 

informed health care choices. We also 

note that HQA currently relies on the 

NQF process as part of its process. 

CMS anticipates that other consensus 

building entities that take into account 

the issues of validity, reliability, impact 

and feasibility of the measures and 

involves a wide array of stakeholders 

may develop. 

XXIV. Files Available to the Public Via 

the Internet 

Addenda A and B to this proposed 

rule provide various data pertaining to 

the proposed CY 2007 payments for 

services under the OPPS. Addenda AA, 

BB, and CC to this proposed rule 

include various data pertaining the 

proposed ASC list of covered 

procedures and payment rates for 

procedures furnished in ASCs in CYs 

2007 and 2008, respectively. 

To conserve resources and to make 

Addendum B more relevant to the 

OPPS, we are including in Addendum 

B of this proposed rule HCPCS codes 

(including CPT codes) for services that 

are assigned a payable status indicator 

under the OPPS and HCPCS codes for 

which we are proposing a change in 

status indicator and/or APC assignment 

for CY 2007. A list of all active HCPCS 

codes, regardless of their assigned 

payable status, is available to the public 

on the CMS Web site at: http:// 

www.cms.hhs.gov/providers/hopps. 

For the convenience of the public, we 

are also including on this same CMS 

Web site a table that displays the 

HCPCS data in Addendum B sorted by 

APC assignment, identified as 

Addendum C. In addition, we are 

including on the CMS Web site, in a 

format that can be easily downloaded 

and manipulated, Addendum A. 

Similarly, we are including Addenda 

AA, BB, and CC on the CMS Web site 

at: http://www.cms.hhs.gov/center/ 

asc.asp. 

We are not including as addenda in 

this proposed rule, reprints of wage 

index related tables from the FY 2007 

IPPS proposed rule (71 FR 24235 

through 24272) as they would be used 

for the OPPS for CY 2007. Rather, we 

are providing a link on the CMS Web 

site at: http://www.cms.hhs.gov/ 

providers/hopps to all of the proposed 

FY 2007 IPPS wage index related tables. 

For additional assistance, contact Anita 

Heygster, (410) 786–4486. 

XXV. Collection of Information 

Requirements 

Under the Paperwork Reduction Act 

of 1995 (PRA), 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. 

The following information collection 

requirements included in this proposed 

rule and their associated burdens are 

subject to the PRA. 

We are soliciting public comment on 

each of the issues for the following 

section of this document that contain 

information collection requirements and 

are not currently approved by the OMB. 

Proposed Additional Quality Measures 

for FY 2008: Surgical Care Improvement 

Project (SCIP) 

Section 5001(a) of the Deficit 

Reduction Act of 2005 (DRA) (Pub. L. 

109–171) sets out new requirements for 

the IPPS Reporting Hospital Quality 

Data for Annual Payment Update 

(RHQDAPU) program. Under section 

1886(b)(3)(B)(viii)(V) of the Act, for 

payments beginning with FY 2008, we 


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are required to add other measures that 

reflect consensus among affected parties 

and, to the extent feasible and 

practicable, must include measures set 

forth by one or more national consensus 

building entities. In this proposed rule, 

we are setting out the additional 

measures that we propose to require for 

FY 2008. 

The burden associated with this 

section is the time and effort associated 

with collecting, copying and submitting 

the data. As part of the Surgical Care 

Improvement Project (SCIP), we 

estimate that there will be 

approximately 3,700 respondents per 

year. All of these hospitals must submit 

SCIP Infection 1 and 3 to receive the 

annual payment update covering FY 

2007. Additional surgical procedures 

covering approximately 6,000,000 

discharges annually will be sampled at 

a 10 percent rate per hospital, so an 

additional 600,000 discharges will be 

abstracted and submitted by hospitals 

for the additional SCIP measures (SCIP 

Infection 2 and VTE 1, 2). The 10 

percent sampling rate is a minimum 

threshold specified in the most current 

version of the joint CMS/JCAHO 

Hospital Quality Measures 

Specifications Manual. We estimate that 

it will take 450,000 hours (3/4 hour per 

sampled discharge) to abstract and 

submit data for these additional 

sampled discharges. 

In addition, hospitals must abstract 

and submit additional information 

needed for the additional SCIP measures 

covering the surgical procedures already 

covered in SCIP Infection 1 and 3. We 

estimate that about 275,000 discharges 

will be sampled and abstracted covering 

these surgical procedures. We estimate 

that it will take an additional 137,500 

hours (1⁄2 hour per sampled discharge) 

for hospitals to abstract and submit this 

additional information. Both estimates 

include overhead. 

In total, we estimate that an 

additional 587,500 hours will be used 

by hospitals to abstract and submit the 

additional SCIP measures. This estimate 

includes overhead. 

Further, we note that there is no 

additional burden associated with the 

incorporation of mortality outcome 

measures, as this information is 

currently collected with claims data. 

We have submitted a copy of this 

proposed rule to the OMB for its review 

of the aforementioned information 

collection requirements. 

This proposed rule also includes 

associated information collections for 

which CMS has obtained the OMB’s 

approval. The following is a discussion 

of these currently OMB approved 

collections. 

As discussed in section XXIII of this 

preamble, the IPPS RHQDAPU program 

expands upon the Hospital Quality 

Initiative which is intended to empower 

consumers with quality of care 

information to make more informed 

decisions about their health care while 

also encouraging hospitals and 

clinicians to improve the quality of care. 

The information collection associated 

with the IPPS RHQDAPU is the Hospital 

Quality Alliance (formerly known as the 

National Voluntary Hospital Reporting 

Initiative)—Hospital Quality Measures. 

The OMB approved this information 

collection under OMB control number 

0938–0918, with an expiration date of 

December 31, 2008. As a result of the 

increase from 10 to 21 quality measures, 

CMS created a revised information 

collection request to include the new 

quality measures. CMS announced the 

revised information collection in a 60- 

day Federal Register notice that 

published on June 9, 2006 (71 FR 

33458). CMS will publish a 30-day 

Federal Register notice prior to the 

submission of the revised information 

collection being proposed in this rule to 

OMB. 

Further, as discussed in section XXIII. 

of this preamble, for FY 2008, we are 

proposing to expand the IPPS 

RHQDAPU program to include the 

HCAHPS Survey, also known as the 

Hospital CAHPS or the CAHPS Hospital 

Survey. The HCAHPS Survey is 

composed of 27 questions: 18 

substantive questions that encompass 

critical aspects of the hospital 

experience (communication with 

doctors, communication with nurses, 

responsiveness of hospital staff, 

cleanliness and quietness of hospital 

environment, pain management, 

communication about medicines, and 

discharge information); four questions 

to skip patients to appropriate 

questions; three questions to adjust for 

the mix of patients across hospitals; and 

two questions to support 

congressionally-mandated reports. As 

explained in section XXIII. of this 

preamble, CMS published a Federal 

Register notice soliciting comments on 

the draft 27-item HCAHPS Survey in 

November 2005 (70 FR 67476). The 

OMB approved the HCAHPS Survey 

under OMB control number 0938–0981, 

with an expiration date of December 31, 

2007. 

Proposed Revised § 416.190(c)—Request 

for Review of Payment Amount 

The collection of information 

requirements at 5 CFR 1320 are 

applicable to requirements affecting 10 

or more entities. Proposed revised 

§ 416.190(c) would require that a 

request for review of the ASC payment 

amount for insertion of an IOL must 

include all the information that CMS 

specifies on its Web site. 

While this section of the proposed 

rule contains information collection 

requirements, we estimate that less than 

10 ASCs will be affected; therefore, we 

believe these collection requirements 

are exempt from OMB for review and 

approval, as specified at 5 CFR 

1320.3(c)(4). Consequently, this section 

of the proposed rule need not be 

reviewed by the OMB under the 

authority of the PRA. 

If you comment on any of these 

information collection and record 

keeping requirements, please mail 

copies directly to the following: 

Centers for Medicare & Medicaid 

Services, Office of Strategic 

Operations and Regulatory Affairs, 

Regulations Development Group, 

Attn: Melissa Musotto, CMS–1506–P, 

Room C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244– 

1850; and 

Office of Information and Regulatory 

Affairs, Office of Management and 

Budget, Room 10235, New Executive 

Office Building, Washington, DC 

20503, Attn: Carolyn Lovett, CMS 

Desk Officer, (CMS–1506–P), 

carolyn_lovett@omb.eop.gov. Fax 

(202) 395–6974. 

XXVI. Response to Comments 

Because of the large number of public 

comments we normally receive on 

Federal Register documents, we are not 

able to acknowledge or respond to them 

individually. We will consider all 

comments we receive by the date and 

time specified in the DATES section of 

this preamble, and, when we proceed 

with a subsequent document(s), we will 

respond to those comments in the 

preamble to that document(s). 

XXVII. Regulatory Impact Analysis 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Impact’’ at the beginning of 

your comment.) 

A. Overall Impact 

We have examined the impacts of this 

proposed rule as required by Executive 

Order 12866 (September 1993, 

Regulatory Planning and Review), the 

Regulatory Flexibility Act (RFA) 

(September 19, 1980, Pub. L. 96–354), 

section 1102(b) of the Social Security 

Act, the Unfunded Mandates Reform 

Act of 1995 (Pub. L. 104–4), and 

Executive Order 13132. 


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1. Executive Order 12866 

Executive Order 12866 (as amended 

by Executive Order 13258, which 

merely reassigns responsibility of 

duties) directs agencies to assess all 

costs and benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). A regulatory impact analysis 

(RIA) must be prepared for major rules 

with economically significant effects 

($100 million or more in any 1 year). 

We estimate that the effects of the 

OPPS provisions that would be 

implemented by this proposed rule 

would result in expenditures exceeding 

$100 million in any 1 year. We estimate 

that adding 14 procedures to the ASC 

list and implementing section 5103 of 

Pub. L. 109–171) in CY 2007 would 

result in savings to the Medicare 

program of approximately $150 million. 

We further estimate that the revised 

ASC payment system and expanded list 

of payable ASC services which we are 

proposing to implement in CY 2008 

would have no effect on Medicare 

expenditures compared to CY 2007. A 

more detailed discussion of the effects 

of the proposed changes to the ASC list 

of procedures for CY 2007 and the 

effects of proposed revisions to the ASC 

payment system in CY 2008 is provided 

in sections XXVII. C. and D. below. 

In addition, we estimate that the 

changes that we are proposing in section 

XIX. of this preamble to implement 

Medicare contracting reform mandated 

by section 911 of Pub. L. 108–173 have 

no economic effect on current Medicare 

payments in CY 2007. This aspect of our 

proposal would amend our current 

Medicare contractor regulations to 

conform them to the statutory changes 

mandated by Pub. L. 108–173 and in 

and of itself does not affect in any way 

Medicare’s coverage or payment policies 

for hospital outpatient services or any 

other covered Medicare services. 

Accordingly, we believe that this 

provision has no immediate economic 

effect on Medicare payments in CY 

2007. 

Further, we estimate that the changes 

that we are proposing in section XXIII. 

of this preamble to implement an 

expanded set of quality measures for the 

IPPS Reporting Hospital Quality Data 

for the Annual Payment Update 

(RHQDAPU) program in accordance 

with sections 1886(b)(3)(B)(viii)(III) and 

(IV) of the Act will not have a 

significant economic effect on Medicare 

payments to hospitals in CY 2007. A 

more detailed discussion of the effects 

of this proposal are included in section 

XXIII. of this preamble and section 

XXVII.F. below. 

However, we estimate the total 

increase (from changes in this proposed 

rule as well as enrollment, utilization, 

and case-mix changes) in expenditures 

under the OPPS for CY 2007 compared 

to CY 2006 to be approximately $2.98 

billion. Therefore, this proposed rule is 

an economically significant rule under 

Executive Order 12866, and a major rule 

under 5 U.S.C. 804(2). 

2. Regulatory Flexibility Act (RFA) 

The RFA requires agencies to 

determine whether a rule would have a 

significant economic impact on a 

substantial number of small entities. For 

purposes of the RFA, small entities 

include small businesses, nonprofit 

organizations, and small governmental 

agencies. Most hospitals and most other 

providers and suppliers are small 

entities, either by nonprofit status or by 

having revenues of $6 million to $29 

million in any 1 year (65 FR 69432). 

For purposes of the RFA, we have 

determined that approximately 37 

percent of hospitals and 73 percent of 

ambulatory surgery centers would be 

considered small entities according to 

the Small Business Administration 

(SBA) size standards. We do not have 

data available to calculate the 

percentages of entities in the 

pharmaceutical preparation 

manufacturing, biological products, or 

medical instrument industries that 

would be considered to be small entities 

according to the SBA size standards. For 

the pharmaceutical preparation 

manufacturing industry (NAICS 

325412), the size standard is 750 or 

fewer employees and $67.6 billion in 

annual sales (1997 business census). For 

biological products (except diagnostic) 

(NAICS 325414), with $5.7 billion in 

annual sales, and medical instruments 

(NAICS 339112), with $18.5 billion in 

annual sales, the standard is 50 or fewer 

employees (see the standards Web site 

at: http://www.sba.gov/regulations/ 

siccodes/). Individuals and States are 

not included in the definition of a small 

entity. 

Not for profit organizations are also 

considered to be small entities under 

the RFA. There are 2,163 voluntary 

hospitals that we consider to be not for 

profit organizations to which this 

proposed rule applies. 

3. Small Rural Hospitals 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 603 of the 

RFA. With the exception of hospitals 

located in certain New England 

counties, for purposes of section 1102(b) 

of the Act, we previously defined a 

small rural hospital as a hospital with 

fewer than 100 beds that is located 

outside of a Metropolitan Statistical 

Area (MSA) (or New England County 

Metropolitan Area (NECMA)). However, 

under the new labor market definitions 

that we adopted in the November 15, 

2004 final rule with comment period, 

for CY 2005 (consistent with the FY 

2005 IPPS final rule), we no longer 

employ NECMAs to define urban areas 

in New England. Therefore, we now 

define a small rural hospital as a 

hospital with fewer than 100 beds that 

is located outside of an MSA. Section 

601(g) of the Social Security 

Amendments of 1983 (Pub. L. 98–21) 

designated hospitals in certain New 

England counties as belonging to the 

adjacent NECMA. Thus, for purposes of 

the OPPS, we classify these hospitals as 

urban hospitals. We believe that the 

changes to the OPPS in this proposed 

rule would affect both a substantial 

number of rural hospitals as well as 

other classes of hospitals and that the 

effects on some may be significant 

although the proposed changes to the 

ASC payment system for CY 2007 and 

CY 2008 would have no effect on small 

rural hospitals. Therefore, we conclude 

that this proposed rule would have a 

significant impact on a substantial 

number of small entities. 

4. Unfunded Mandates 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (Pub. L. 

104–4) also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. That threshold 

level is currently approximately $120 

million. The maximum nationwide cost 

to hospitals will be $16.9 million for 

HCAHPS (Abt Report), $58.7 million 

in noncaptial costs for SCIP, and no cost 

for mortality measure. This proposed 

rule will not mandate any requirements 

for State, local, or tribal government, nor 

will it affect private sector costs. 

5. Federalism 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it publishes any rule 

(proposed or final) that imposes 

substantial direct costs on State and 

local governments, preempts State law, 


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or otherwise has Federalism 

implications. 

We have examined this proposed rule 

in accordance with Executive Order 

13132, Federalism, and have 

determined that it would not have an 

impact on the rights, roles, and 

responsibilities of State, local or tribal 

governments. As reflected in Table 49 

we estimate that OPPS payments to 

governmental hospitals (including State, 

local, and tribal governmental hospitals) 

would increase by 3.0 percent under 

this proposed rule. The proposals 

related to payments to ASCs in CYs 

2007 and 2008 would not affect 

payments to government hospitals. In 

addition, the proposals related to MACs 

and HCAHPS would not affect 

payments to government hospitals. 

B. Effects of Proposed OPPS Changes in 

This Proposed Rule 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘OPPS Impact’’ at the beginning 

of your comment.) 

We are proposing several changes to 

the OPPS that are required by the 

statute. We are required under section 

1833(t)(3)(C)(ii) of the Act to update 

annually the conversion factor used to 

determine the APC payment rates. We 

are also required under section 

1833(t)(9)(A) of the Act to revise, not 

less often than annually, the wage index 

and other adjustments. In addition, we 

must review the clinical integrity of 

payment groups and weights at least 

annually. Accordingly, in this proposed 

rule, we are proposing to update the 

conversion factor and the wage index 

adjustment for hospital outpatient 

services furnished beginning January 1, 

2007, as we discuss in sections II.C. and 

II.D., respectively, of this preamble. 

However, we are also proposing to 

reduce the update to the CY 2007 OPPS 

conversion factor by 2.0 percentage 

points for any hospital that is required 

to report quality data under the IPPS 

RHQDAPU for the FY 2007 update, and 

that fails to meet the requirements for 

receiving the full IPPS payment update 

in that payment year. We also are 

proposing to revise the relative APC 

payment weights using claims data from 

January 1, 2005, through December 31, 

2005, and updated cost report 

information. In response to a provision 

in Pub. L. 108–173 that we analyze the 

cost of outpatient services in rural 

hospitals relative to urban hospitals, we 

are proposing to continue increased 

payments to rural SCHs, including 

EACHs. Section II.F. of this preamble 

provides greater detail on this rural 

adjustment. Finally, we are not 

proposing to remove any device 

categories from pass-through payment 

status in CY 2007. 

Under this proposed rule, the update 

change to the conversion factor as 

provided by statute would increase total 

OPPS payments by 3.4 percent in CY 

2007. The update change to the OPPS 

conversion factor for any hospital that is 

required to report quality data under the 

IPPS RHQDAPU for the FY 2007 update, 

but fails to meet the requirements for 

receiving the full IPPS payment update 

in that payment year would increase 

OPPS payments by 1.4 percent in CY 

2007. The expiration of the one-time 

wage reclassification under section 508 

in April 2007 which is not budget 

neutral and an increase in the fixeddollar outlier threshold to account for 

the under estimation of outlier 

payments in CY 2006 results in a net 

increase of 3.0 percent. The proposed 

changes to the APC weights, changes to 

the wage indices, the continuation of a 

payment adjustment for rural SCHs, and 

the proposed expansion of the rural 

adjustment to EACHs would not 

increase OPPS payments because these 

changes to the OPPS are budget neutral. 

However, these updates do change the 

distribution of payments within the 

budget neutral system as shown in 

Table 49 and described in more detail 

in this section. 

1. Alternatives Considered 

Alternatives to the changes we are 

proposing to make and the reasons that 

we have chosen these options are 

discussed throughout this proposed 

rule. Some of the major issues discussed 

in this proposed rule and the options 

considered are discussed below. 

a. Alternatives Considered for CPT 

Coding and Payment Policy for 

Evaluation and Management Codes 

In section IX. of this preamble, we are 

proposing to create five new G-codes to 

replace CPT clinic E/M codes, five new 

G-codes for emergency visits provided 

in Type B emergency departments, five 

new G-codes for emergency visits 

provided in Type A emergency 

departments to replace CPT emergency 

department E/M codes, and two new Gcodes to replace CPT critical care codes. 

CMS instructed hospitals to report 

facility resources for clinic and 

emergency department visits using CPT 

E/M codes and to develop internal 

hospital guidelines to determine what 

level of visit to report for each patient. 

However, since the beginning of the 

OPPS, we have acknowledged that the 

CPT E/M codes do not adequately 

describe the facility resources required 

to perform the services. Therefore, we 

are proposing G-codes to be used by 

hospitals to report clinic and emergency 

visits, and critical care services, which 

describe hospital resource use. 

We acknowledge that it can be 

burdensome for providers to bill Gcodes rather than CPT codes. CPT has 

not yet created clinic and emergency 

department visit and critical care 

services codes that describe hospital 

resource utilization. In this case, 

because the current CPT E/M codes do 

not describe hospital visit resources, we 

have no alternative other than to create 

new G-codes. It is important to note that 

G-codes may be recognized by other 

payers. 

Some hospitals have requested that 

they be permitted to bill emergency visit 

codes under the OPPS for services 

furnished in a facility that meets CPT’s 

definition for reporting emergency visit 

E/M codes, except that these hospitals 

are not available 24 hours a day. For CY 

2007, we are proposing to establish a set 

of codes for visits provided in dedicated 

emergency departments that have an 

EMTALA obligation. These codes would 

be billed by Type B emergency 

departments, specifically those that do 

not meet the Type A requirements. We 

are also proposing to establish a 

separate set of codes for visits provided 

in a specific subset of dedicated 

emergency departments, called Type A 

emergency departments, that are open 

24 hours per day, 7 days per week and/ 

or that do not have an EMTALA 

obligation solely based on providing at 

least one-third of their outpatient visits 

for the treatment of emergency medical 

conditions on an urgent basis without 

requiring a previously scheduled 

appointment. An alternative to this 

policy is to continue to uphold past 

policy and allow only the Type A subset 

of dedicated emergency departments to 

bill emergency department codes. 

However, this would not allow us to 

determine whether visits to dedicated 

emergency departments or facilities that 

incur EMTALA obligations but do not 

meet more prescriptive expectations 

that are consistent with the CPT 

definition of an emergency department 

have different resource costs than visits 

to either clinics or the Type A subset of 

dedicated emergency departments that 

meet more prescriptive expectations, 

including 24 hours per day, 7 days per 

week availability. 

We must also establish payment rates 

for these new G-codes. For CY 2007, we 

are proposing to pay at five payment 

levels for both clinic and emergency 

department visits and one payment 

level for critical care services. We see 

meaningful differences among the 

median costs of five levels of clinic and 

emergency department codes that 


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suggest that five payment levels are 

more appropriate than three levels. In 

addition, providers have indicated that 

it is administratively burdensome to 

code for five levels, but receive payment 

at only three levels, as has been the 

historical policy in the OPPS. If future 

data indicate that three payment levels 

are more appropriate, we may revert 

back to three payment levels. An 

alternative to this policy is to continue 

paying at three payment levels for both 

clinic and emergency department visits 

and one payment level for critical care 

services. However, for the reasons 

described above, we are proposing to 

pay at five levels for clinic and 

emergency department visits for CY 

2007 to ensure that payments more 

accurately reflect the median costs of 

the services provided. 

For CY 2007, we are proposing to pay 

emergency visits to Type B dedicated 

emergency departments that are not part 

of the specific subset identified as Type 

A emergency departments at the same 

rate as clinic visits, consistent with 

current policy. This payment policy is 

similar to our current policy that 

requires services furnished in 

emergency departments that have an 

EMTALA obligation but do not meet the 

CPT definition of emergency 

department to be reported using CPT 

clinic visit E/M codes, resulting in 

payments based upon clinic visit APCs. 

While maintaining the same payment 

policy for CY 2007, the reporting of 

specific G-codes for emergency visits 

provided in Type B dedicated 

emergency departments would permit 

us to specifically collect and analyze the 

hospital resource costs of visits to these 

facilities in order to determine whether 

a future proposal of an alternative 

payment policy may be warranted. An 

alternative would be to provide 

payment for services billed by Type B 

emergency departments at payment 

rates other than the clinic visit rates. 

However, we do not know what the 

hospital facility costs of these visits 

would be because we are unable to 

identify these services in our historical 

claims data. In some respects, their costs 

may resemble the costs of visits to 

clinics because they may not be 

available 24 hours per day or may not 

require the same high state of readiness 

as Type A emergency departments. In 

other respects, their costs may resemble 

the costs of visits to Type A emergency 

departments because they both provide 

predominantly unscheduled visits. 

Therefore, we currently would have no 

accurate methodology for establishing 

payment rates that are appropriate for 

visits to Type B emergency departments. 

Therefore, consistent with past payment 

policies for certain services, such as 

drug administration, in which we 

maintained current payment policies 

while gathering more detailed cost data, 

we are proposing to continue payment 

to Type B emergency departments at 

clinic visit rates while we gather 

hospital claims data specific to these 

visits to review their costs. 

b. Options Considered for 

Brachytherapy Source Payments 

Pursuant to sections 1833(t)(2)(H) and 

1833(t)(16)(C) of the Act, we have paid 

for brachytherapy sources furnished on 

or after January 1, 2004, and before 

January 1, 2007, on a per source basis 

at an amount equal to the hospital’s 

charge adjusted to cost by application of 

the hospital specific overall CCR. For 

CY 2007, we are proposing to pay for 

brachytherapy sources at a 

prospectively based rate for each source, 

which is assigned to a source-specific 

APC. We are proposing to convert the 

median cost to a relative weight by 

dividing it by the median for APC 0606, 

to scale the unscaled weight for budget 

neutrality, and to multiply the scaled 

weight by the conversion factor to 

calculate the payment rate per source. 

This is our standard OPPS methodology 

for using median costs to calculate the 

payment for each APC. 

We considered establishing a per day 

payment for brachytherapy sources 

based on our CY 2005 claims data. 

While this alternative would be 

consistent with the philosophy of a 

prospective payment system and would 

mitigate the effects on payment of 

inaccurate coding of the number of 

sources used, we believe that a per day 

payment may not provide source 

payment variation specifically 

addressed to the hospital resources used 

under the unique clinical circumstances 

of each individual treatment. There is 

considerable clinical variation in the 

number of sources used for 

brachytherapy services, and we believe 

a per day payment based on an average 

number of sources used may not as 

accurately reflect appropriate payment 

for an individual Medicare beneficiary’s 

treatment as the per source payment 

methodology. Therefore, we are not 

proposing to set payments on a per day 

basis. 

We also considered continuing to 

make separate payment for sources of 

brachytherapy under the current 

methodology of hospital charges 

reduced to costs. Although hospitals are 

familiar with this methodology and this 

alternative is consistent with the 

requirement that sources be paid 

separately, we believe that to continue 

to pay on this basis would be 

inconsistent with the general 

methodology of a prospective payment 

system and would provide no incentive 

for a hospital to provide services 

efficiently and at the lowest cost. 

Therefore, for CY 2007, we are 

proposing to pay for each brachytherapy 

source on a per source rate that is 

calculated using our standard OPPS 

methodology. 

c. Options Considered for Payment of 

Radiopharmaceuticals 

In developing the payment policy 

proposal for separately payable 

radiopharmaceuticals for this CY 2007 

proposed rule, we considered three 

policy options. 

The first option we considered was to 

propose packaging additional 

radiopharmaceuticals, either through 

packaging payments for all 

radiopharmaceuticals with payments for 

the services with which they are billed 

or increasing the packaging threshold 

for radiopharmaceuticals from a cost of 

$55 per day to a higher amount. In 

contrast to other separately payable 

drugs where the administration of many 

drugs is reported with only a few drug 

administration HCPCS codes, only a 

small number of specific 

radiopharmaceuticals may be 

appropriately provided in the 

performance of each particular nuclear 

medicine procedure. Because the 

provision of nuclear medicine 

procedures always requires one or more 

radiopharmaceuticals, packaging more 

radiopharmaceuticals effectively results 

in some increases in the costs of the 

associated nuclear medicine procedures 

to reflect the greater packaging of the 

radiopharmaceuticals. A policy to 

package additional 

radiopharmaceuticals would be very 

consistent with the OPPS packaging 

principles and payment policies which 

generally provide appropriate payment 

for the ‘‘average’’ service and would 

provide greater administrative 

simplicity for hospitals. However, under 

a policy of increased packaging of 

radiopharmaceuticals, payments for 

certain nuclear medicine procedures 

could potentially be less than the costs 

of some of the packaged 

radiopharmaceuticals and relatively 

expensive and high volume 

radiopharmaceuticals could become 

packaged. In addition, our payment 

policy could discourage selection of the 

most clinically appropriate 

radiopharmaceutical for a particular 

nuclear medicine procedure, especially 

if that radiopharmaceutical were 

expensive and not commonly used so 

that its costs were not fully reflected in 


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the payment for the nuclear medicine 

procedure. 

The second option that we considered 

was to propose to continue the 

temporary CY 2006 methodology of 

paying for separately payable 

radiopharmaceuticals at charges 

reduced to cost, where payment would 

be determined using each hospital’s 

overall CCR, and establishing our 

radiopharmaceutical packaging 

threshold at $55, as we are proposing for 

other drugs for the CY 2007 OPPS. This 

policy would provide stability to the 

payment methodology for 

radiopharmaceuticals from CY 2006 to 

CY 2007. As we indicated for CY 2007, 

this payment methodology would 

provide an acceptable proxy for the 

average acquisition of the 

radiopharmaceutical along with its 

handling cost. However, as indicated 

previously, we stated in the CY 2006 

final rule with comment period that this 

payment policy was intended to be only 

a temporary policy, and that we would 

consider alternative methodologies on 

which to base radiopharmaceutical 

payments for the CY 2007 OPPS update. 

Paying for radiopharmaceuticals at cost 

provides hospitals with no incentive to 

supply radiopharmaceuticals in the 

most efficient manner. In addition, 

using hospitals’ overall CCRs to 

determine payments likely results in an 

overestimation of radiopharmaceutical 

cost, which are likely reported in 

several cost centers such as diagnostic 

radiology that have lower CCRs than 

hospitals’ overall CCRs. 

The third option that we considered 

and are proposing for CY 2007 is to 

establish prospective payment rates for 

separately payable 

radiopharmaceuticals using mean costs 

derived from the CY 2005 claims data, 

where the costs are determined using 

our standard methodology of applying 

hospital-specific departmental CCRs to 

radiopharmaceutical charges and 

defaulting to hospital-specific overall 

CCRs only if appropriate departmental 

CCRs are unavailable. This proposal 

establishes our packaging threshold for 

radiopharmaceuticals at $55, as 

proposed for other drugs under the CY 

2007 OPPS. We believe this option 

provides us with the most consistent, 

accurate, and efficient methodology for 

prospectively establishing payment 

rates for separately payable 

radiopharmaceuticals; in addition, this 

proposed methodology is consistent 

with how payment rates for other 

services are determined under the OPPS 

and provides for prospective payments 

that serve as appropriate proxies for the 

average acquisition costs of the 

radiopharmaceuticals along with their 

handling costs. 

2. Limitations of Our Analysis 

The distributional impacts presented 

here are the projected effects of the 

policy changes, as well as the statutory 

changes that would be effective for CY 

2007, on various hospital groups. We 

estimate the effects of individual policy 

changes by estimating payments per 

service while holding all other payment 

policies constant. We use the best data 

available but do not attempt to predict 

behavioral responses to our policy 

changes. In addition, we do not make 

adjustments for future changes in 

variables such as service volume, 

service-mix, or number of encounters. 

As we have done in previous proposed 

rules, we are soliciting comments and 

information about the anticipated effect 

of these proposed changes on hospitals 

and our methodology for estimating 

them. 

One limitation of our analysis in this 

proposed rule is that we are unable at 

this time to estimate the impact of our 

proposal to reduce the update to the CY 

2007 OPPS conversion factor by 2.0 

percentage points for any hospital that 

is required to report quality data under 

the IPPS RHQDAPU for the FY 2007 

update, and that fails to meet the 

requirements for receiving the full IPPS 

payment update in that payment year. 

As we discuss in section XXIII of the 

preamble of this proposed rule, we are 

unable at this time to determine how 

many hospitals will receive a reduced 

update in CY 2007. Determinations 

concerning which hospitals have failed 

to meet the requirements for receiving 

the full update to the OPPS conversion 

factor in CY 2007 will only become 

available on or about September 1, 2006. 

Experience with mandatory reporting 

of quality data under the IPPS RHQAPU 

indicates that only a small number of 

hospitals have failed to meet the 

requirements to receive the full update 

to their payments under the IPPS. 

However, the statute requires that the 

reduction to the update for those IPPS 

hospitals that fail to meet the quality 

reporting requirement will increase 

from 0.4 percentage point to 2.0 

percentage points for purposes of 

payment in FY 2007. This increase in 

the size of the update reduction 

significantly increases the already 

strong incentive to submit quality data. 

We therefore believe that the already 

small number of hospitals that fail to 

meet the requirements for receiving the 

full update may actually decrease 

significantly. We expect that only very 

few, if any, hospitals will fail to receive 

the full update to the OPPS conversion 

factor in CY 2007. However, due to the 

uncertainty concerning the degree to 

which the increased incentive to report 

quality data will affect hospital 

behavior, we are unable to predict with 

any confidence the number of hospitals 

that will receive the reduced update 

under the OPPS RHQDAPU, or to 

incorporate any specific data concerning 

the impact of this proposal into impact 

Table 49 below. 

We are also unable to determine the 

budget neutrality adjustment factor that 

will be necessary to ensure that 

estimated aggregate payments under the 

OPPS for CY 2007 do not change as a 

result of implementing the proposed 

OPPS RHQDAPU. We also expect, 

however, that the distributional impact 

of the proposal will be quite minimal. 

We also expect that any budget 

neutrality adjustment that we determine 

to be necessary once the determinations 

concerning compliance with the quality 

data reporting requirements become 

available will be correspondingly 

negligible. At the same time, any 

hospital that has reason to believe that 

it will not meet the requirements for 

receiving a full update under our 

proposal should be able to assess the 

potential impact of receiving the 

reduced update, simply by estimating 

the payments that the hospital will 

receive using the reduced conversion 

factor of $60.36, reflecting an update of 

1.4 percent, in place of the conversion 

factor of $61.551 reflecting the full 

proposed update of 3.4 percent. Over 

time, the proposed OPPS RHQDAPU 

may have a discernible, positive impact 

on the quality of care available to 

Medicare beneficiaries in hospital 

outpatient departments. Meanwhile, the 

impact analysis below assumes that 

there will be full compliance with the 

requirements of the proposed OPPS 

RHQDAPU for purposes of receiving the 

full update in CY 2007, that all OPPS 

outpatient departments will therefore 

receive payments reflecting the full 

update in CY 2007, and that no 

additional adjustment to the OPP 

conversion factor will be necessary to 

ensure budget neutrality in CY 2007. 

3. Estimated Impacts of This Proposed 

Rule on Hospitals 

The estimated increase in the total 

payments made under the OPPS is 

limited by the increase to the 

conversion factor set under the 

methodology in the statute. The 

distributional impacts presented do not 

include assumptions about changes in 

volume and service-mix. The enactment 

of Pub. L. 108–173 on December 8, 

2003, provided for the additional 

payment outside of the budget 


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neutrality requirement for wage indices 

for specific hospitals reclassified under 

section 508 through CY 2007. Table 49 

shows the estimated redistribution of 

hospital payments among providers as a 

result of a new APC structure, wage 

indices, and proposed adjustment for 

rural SCHs and EACHs, which are 

budget neutral; the estimated 

distribution of increased payments in 

CY 2007 resulting from the combined 

impact of the proposed APC 

recalibration, wage effects, the rural 

SCH and EACH adjustment, and the 

proposed market basket update to the 

conversion factor; and, finally, 

estimated payments considering all 

proposed payments for CY 2007 relative 

to all payments for CY 2006, including 

the impact of expiring wage provisions 

and changes in the outlier threshold. 

Because updates to the conversion 

factor, including the update of the 

market basket and the addition of 

money not dedicated to pass-through 

payments are applied uniformly, 

observed redistributions of payments in 

the impact table largely depends on the 

mix of services furnished by a hospital 

(for example, how the APCs for the 

hospital’s most frequently furnished 

services would change), the impact of 

the wage index changes on the hospital, 

and the impact of the payment 

adjustment for rural SCHs, including 

EACHs. However, total payments made 

under this system and the extent to 

which this proposed rule would 

redistribute money during 

implementation also would depend on 

changes in volume, practice patterns, 

and the mix of services billed between 

CY 2006 and CY 2007, which CMS 

cannot forecast. Overall, the proposed 

OPPS rates for CY 2007 would have a 

positive effect for all hospitals paid 

under the OPPS. Proposed changes 

would result in a 3.0 percent increase in 

Medicare payments to all hospitals, 

exclusive of transitional pass-through 

payments. Removing cancer and 

children’s hospitals because their 

payments are held harmless to the preBBA ratio between payment and cost 

suggests that proposed changes would 

result in a 3.1 percent increase in 

Medicare payments to all other 

hospitals. 

To illustrate the impact of the 

proposed CY 2007 changes, our analysis 

begins with a baseline simulation model 

that uses the final CY 2006 weights, the 

FY 2006 final post-reclassification IPPS 

wage indices without additional 

increases resulting from section 508 

reclassifications, and the final CY 2006 

conversion factor. Column 2 in Table 49 

reflects the independent effects of the 

proposed APC reclassification and 

recalibration changes. Column 3 reflects 

the effects of updated wage indices, and 

the adjustment for rural SCHs and 

EACHs. The clarification that the rural 

adjustment applies to EACHs is not 

shown separately because there are so 

few EACHs that the overall impact 

cannot be observed when payments are 

aggregated by type of hospital. These 

effects are budget neutral, which is 

apparent in the overall zero impact in 

payment for all hospitals in the top row. 

Column 2 shows the independent effect 

of changes resulting from the proposed 

reclassification of services codes among 

APC groups and the proposed 

recalibration of APC weights based on a 

complete year of CY 2005 hospital OPPS 

claims data and more recent cost report 

data. We modeled the independent 

effect of APC recalibration by varying 

only the weights, the final CY 2006 

weights versus the proposed CY 2007 

weights, in our baseline model, and 

calculating the percent difference in 

payments. 

Column 3 shows the impact of 

updating the wage index used to 

calculate payment by applying the 

proposed FY 2007 IPPS wage index, 

combined with the impact of the 

proposed 7.1 percent rural adjustment 

for SCHs and EACHs for services other 

than drugs, biologicals, brachytherapy 

sources, and those receiving passthrough payments. The OPPS wage 

index used in Column 3 does not 

include changes to the wage index for 

hospitals reclassified under section 508 

of Pub. L. 108–173. We modeled the 

independent effect of updating the wage 

index and the rural adjustment by 

varying only the wage index and the 

inclusion of EACHs, using the proposed 

CY 2007 scaled weights, and a CY 2006 

conversion factor that included a budget 

neutrality adjustment for changes in 

wage effects and the rural adjustment 

between CY 2006 and CY 2007. 

Column 4 demonstrates the combined 

‘‘budget neutral’’ impact of proposed 

APC recalibration, the wage index 

update, and the proposed rural 

adjustment for rural SCHs and EACHs 

on various classes of hospitals, as well 

as the impact of updating the 

conversion factor with the market basket 

update. We modeled the independent 

effect of proposed budget neutrality 

adjustments and the market basket 

update by using the weights and wage 

indices for each year, and using a CY 

2006 conversion factor that included the 

proposed market basket update and 

budget neutrality adjustments for 

differences in wages and the adjustment 

for rural SCHs and EACHs. 

Finally, Column 5 depicts the full 

impact of the proposed CY 2007 policy 

on each hospital group by including the 

effect of all the proposed changes for CY 

2007 and comparing them to all 

estimated payments in CY 2006, 

including those required by Pub. L. 

108–173. Column 5 shows the combined 

budget neutral effects of Columns 2 

through 4, plus the impact of increasing 

the outlier threshold after realigning the 

overall CCR calculation used to model 

the outlier threshold with the one used 

by the fiscal intermediary for payment, 

the impact of changing the percentage of 

total payments dedicated to transitional 

pass-through payments to 0.13 percent, 

and the expiration of payment for wage 

index increases for hospitals reclassified 

under section 508 of Pub. L. 108–173 in 

April 2007. As noted in section II.D. of 

this preamble, because section 508 

expires in April 2007 and OPPS 

operates on a calendar year basis, we 

used a blended wage index consisting of 

25 percent of the IPPS wage index with 

section 508 and 75 percent of the IPPS 

wage index after section 508 expires. 

We modeled the independent effect of 

all changes in Column 5 using the final 

weights for CY 2006 and the proposed 

weights for CY 2007. The wage indices 

in each year include wage index 

increases for hospitals eligible for 

reclassification under section 508 of 

Pub. L. 108–173, and in 2007, these 

provisions expire in April 2007. We 

used the final conversion factor for CY 

2006 of $59.511 and the proposed CY 

2007 conversion factor of $61.551. 

Column 5 also contains simulated 

outlier payments for each year. We used 

the charge inflation factor used in the 

proposed FY 2007 IPPS rule of 7.57 

percent (1.0757) to increase individual 

costs on the CY 2005 claims to reflect 

CY 2006 dollars, and we used the most 

recent overall CCR for each hospital as 

calculated for the APC median setting 

process. Using the CY 2005 claims and 

a 7.57 percent charge inflation factor, 

we currently estimate that actual outlier 

payments for CY 2006, using a multiple 

threshold of 1.75 and a fixed-dollar 

threshold of $1,250 would be 1.25 

percent of total payments, which is 0.25 

percent higher than the 1.0 percent that 

we projected in setting outlier policies 

for CY 2006, due to the differences in 

the calculation of the overall CCR, as 

discussed in section II.A.1.c. of this 

preamble. Outlier payments of 1.25 

percent appear in the CY 2006 

comparison in Column 5. We used the 

same set of claims and a charge inflation 

factor of 15.15 percent (1.1515) to model 

the CY 2007 outliers at 1.0 percent of 

total payments using a multiple 


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threshold of 1.75 and a proposed fixeddollar threshold of $1,825. 

Column 1: Total Number of Hospitals 

Column 1 in Table 49 shows the total 

number of hospital providers (3,922) for 

which we were able to use CY 2005 

hospital outpatient claims to model CY 

2006 and CY 2007 payments by classes 

of hospitals. We excluded all hospitals 

for which we could not accurately 

estimate CY 2006 or CY 2007 payment 

and entities that are not paid under the 

OPPS. The latter entities include CAHs, 

all-inclusive hospitals, and hospitals 

located in Guam, the U.S. Virgin 

Islands, Northern Marianas, American 

Samoa, and the State of Maryland. This 

process is discussed in greater detail in 

section II.A. of this preamble. At this 

time, we are unable to calculate a 

disproportionate share (DSH) variable 

for hospitals not participating in the 

IPPS. Hospitals for which we do not 

have a DSH variable are grouped 

separately and generally include 

psychiatric hospitals, rehabilitation 

hospitals, and LTCHs. Finally, section 

1833(t)(7)(D) of the Act permanently 

holds harmless cancer hospitals and 

children’s hospitals to the proportion of 

their pre-BBA payment relative to their 

costs. Because this proposed rule would 

not impact these hospitals negatively, 

we removed them from our impact 

analyses. We show the total number 

(3,864) of OPPS hospitals, excluding the 

hold-harmless cancer hospitals and 

children’s hospitals, on the second line 

of the table. 

Column 2: APC Recalibration 

The combined effect of the proposed 

APC reclassification and recalibration, 

in Column 2 are typical for APC 

recalibration. Overall, these changes 

have no impact on all urban hospitals, 

which show no projected change in 

payments, although some classes of 

urban hospitals experience decreases in 

payments. However, changes to the APC 

structure for CY 2007 tend to favor, 

slightly, urban hospitals that are not 

located in large urban areas. We 

estimate that large urban hospitals 

would experience a decline of 0.1 

percent, while ‘‘other’’ urban hospitals 

experience an increase of 0.1 percent. 

Urban hospitals with between 0 and 299 

beds experience increases, while the 

largest urban hospitals, those with beds 

greater than 299 experience decreases of 

0.1 to 0.2 percent. With regard to 

volume, all urban hospitals except those 

with volume less than 11,000 lines, 

experience increases in payments. The 

lowest volume hospitals experience the 

largest decrease of 7.1 percent, largely as 

a result of decreases in payment for 

partial hospitalization and 

psychotherapy services. Urban hospitals 

providing the highest volume of services 

demonstrate no projected change as a 

result of APC recalibration. Estimated 

decreases in payment for urban 

hospitals are also concentrated in some 

regions, specifically, Middle Atlantic, 

West North Central, and Pacific, with 

decreases of 0.3, 0.4, and 0.2 percent 

respectively. On the other hand, most 

other regions experience moderate 

increases and urban hospitals in the 

East South Central and New England 

experience no change as a result of APC 

recalibration. 

Overall, rural hospitals show a 

modest 0.1 percent increase as a result 

of changes to the APC structure, and 

this 0.1 percent increase appears to be 

concentrated in rural hospitals that are 

not rural SCHs, which experience a 0.2 

percent increase. Notwithstanding a 

modest overall increase in payments, 

there is substantial variation among 

classes of rural hospitals. Specifically, 

rural hospitals with more than 199 beds 

experience a decrease of 0.1 percent and 

rural hospitals with 150–199 beds 

experience the largest increase of 0.3 

percent. With regard to volume, all rural 

hospitals, except those with the lowest 

volume, experience increases in 

payments. The lowest volume hospitals 

experience the largest decrease of 3.5 

percent. Rural hospitals with greater 

than 5,000 lines of volume demonstrate 

projected increases of 0.1 to 0.4 percent 

as a result of APC recalibration. 

Increases ranging from 0.2 to 0.5 percent 

occur for rural hospitals in every region 

except New England, the Middle 

Atlantic, and the West North Central. 

The largest decreases are observed in 

New England (¥0.5 percent), Middle 

Atlantic (¥0.5), West North Central 

(¥0.2 percent) regions. 

Among other classes of hospitals, the 

largest observed impacts resulting from 

APC recalibration include an increase of 

0.1 percent for nonteaching hospitals 

and a decrease of 0.3 percent for major 

teaching hospitals. Urban hospitals that 

are treating DSH patients and are also 

teaching hospitals experience decreases 

of 0.1 percent. We project that hospitals 

for which a DSH percentage is not 

available, including psychiatric 

hospitals, rehabilitation hospitals, and 

long-term care hospitals would 

experience decreases in payments of 8.9 

percent, and for the urban subset, 9.2 

percent, largely as a result of proposed 

changes to partial hospitalization and 

psychotherapy payments. 

Classifying hospitals by type of 

ownership suggests that proprietary 

hospitals would gain 0.4 percent, while 

governmental and voluntary hospitals 

would experience neither gains nor 

losses (0.0 percent change). 

Column 3: New Wage Indices and the 

Effect of the Rural Adjustment 

Changes introduced by the proposed 

FY 2007 IPPS wage indices together 

with the effect of including EACHs in 

the rural adjustment would have a 

modest impact in CY 2007, decreasing 

payments to rural hospitals other than 

SCHs slightly and having no effect 

overall on urban hospitals. We estimate 

that rural SCHs would experience an 

increase in payments of 0.1 percent, 

while all other rural hospitals 

experience a decrease of 0.2 percent. 

With respect to volume, rural hospitals 

with moderate volume experience 

decreases of 0.2 percent. For both 

facility size and volume, no category of 

rural hospitals experiences an increase 

greater than 0.2 percent. Examining 

hospitals by region reveals slightly 

greater variability. We estimate that 

rural hospitals in several regions would 

experience decreases in payment up to 

0.7 percent due to wage changes, 

including New England, East South 

Central, South Atlantic, Mountain, and 

West South Central regions. However, 

rural hospitals in the remaining regions 

experience increases. We estimate that 

the Pacific region would see the largest 

increase of 0.6 percent. 

Overall, urban hospitals experience 

no change in payments as a result of the 

new wage indices and the rural 

adjustment. With respect to facility size, 

we estimate that urban hospitals with 

less than 100 and greater than 499 beds 

would experience a decrease in 

payments of 0.1 percent. Urban 

hospitals with 100–299 beds experience 

no change. Urban hospitals with 

between 300–499 beds have the largest 

increase of 0.1 percent. When 

categorized by volume, urban hospitals 

with the largest volume experience no 

change in payment as a result of 

changes to the wage index and the 

presence of the rural adjustment, and 

urban hospitals with the lowest volume 

experience a 0.2 percent increase in 

payment. We estimate that urban 

hospitals in the South Atlantic, East 

South Central, and West South Central 

regions would experience modest 

decreases due to wage changes and the 

effect of the rural adjustment of no more 

than 0.3 percent (except for urban 

hospitals in Puerto Rico, with a decrease 

of 1.8 percent). Urban hospitals in all 

other regions (except New England) 

would experience an increase of 0.1 to 

0.7 percent. Urban hospitals in the New 

England region would experience no 

change in payments. 


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Looking across other categories of 

hospitals, we estimate that updating the 

wage index and continuing the rural 

adjustment would lead major teaching 

hospitals to gain 0.1 percent and 

hospitals without graduate medical 

education programs are estimated to 

lose 0.1 percent. Hospitals serving 23–

35 percent low-income patients are 

estimated to gain 0.1 percent. Hospitals 

serving no low-income patients, for 

which the percent of low-income 

patients cannot be determined and those 

serving more than 35 percent lowincome patients lose 0.1 percent, 

whereas hospitals serving other 

percentages of low-income patients 

experience no change. Voluntary 

hospitals as classes would experience 

no change in payment due to wage 

changes and the effect of the rural 

adjustment. Governmental and 

proprietary hospitals would lose 0.1 

percent. 

Column 4: All Budget Neutrality 

Changes and Market Basket Update 

The addition of the market basket 

update alleviates any negative impacts 

on payments for CY 2007 created by the 

budget neutrality adjustments made in 

Columns 2, and 3, with the exception of 

urban hospitals with the lowest volume 

of services and hospitals not paid under 

IPPS, including psychiatric hospitals, 

rehabilitation hospitals, and LTCHs 

(DSH not available). In many instances, 

the redistribution of payments created 

by proposed APC recalibration offset 

those introduced by updating the wage 

indices. However, in a few instances, 

negative APC recalibration changes 

compound a reduction in payment from 

updating the wage index. 

We estimate that the cumulative 

impact of the budget neutrality 

adjustments and the addition of the 

market basket update would result in an 

increase in payments for urban hospitals 

of 3.4 percent, which is equal to the 

market basket update of 3.4 percent. 

Large urban hospitals would experience 

an increase of 3.3 percent and other 

urban hospitals would experience an 

increase of 3.6 percent. Urban hospitals 

with the lowest volume experience a 

negative market basket update, which is 

largely a function of the 7.1 percent 

decrease in payments attributable to 

changes to the APC structure. Urban 

hospitals with moderate volume have an 

increase of 2.3 percent while urban 

hospitals with volumes greater than 

10,999 lines have increases of 3.4 to 3.5 

percent. When we examine the impact 

of the cumulative effect of APC changes, 

wage index and rural adjustment 

changes, and the market basket on urban 

hospitals by region, we see that urban 

hospitals in five regions (New England, 

East North Central, West South Central, 

Mountain, and Pacific) would 

experience an increase that is equal to 

or higher than the market basket 

increase. Hospitals in the remaining five 

regions (Middle Atlantic, South 

Atlantic, East South Central, West North 

Central, and Puerto Rico) receive an 

increase that is less than the market 

basket. 

We estimate that the cumulative 

impact of budget neutrality adjustments 

and the market basket update would 

result in an overall increase for rural 

hospitals of 3.4 percent, with rural SCHs 

experiencing an update of 3.4 percent 

and other rural hospitals also 

experiencing an update of 3.4 percent. 

In general, rural hospitals with less than 

200 beds and rural hospitals with more 

than 5,000 lines of volume experience 

increases equal to or greater than the 

market basket update of 3.4 percent. We 

estimate that low-volume rural hospitals 

would experience no change (0.0 

percent). Rural hospitals demonstrate 

variability by region. We estimate that 

four regions (East North Central, West 

North Central, West South Central, and 

Pacific) would experience increases 

larger than the market basket update. 

We also estimate that rural hospitals in 

the five remaining regions (New 

England, Middle Atlantic, South 

Atlantic, East South Central, and 

Mountain) would receive increases that 

would be less than the market basket 

increase. 

The changes across columns for other 

classes of hospitals are fairly moderate 

and most show updates relatively close 

to the market basket update with the 

exception of hospitals not paid under 

the IPPS. These hospitals show negative 

payment updates as a result of changes 

to payment rates for partial 

hospitalization and psychotherapy 

services. Voluntary, proprietary and 

governmental hospitals also show an 

increase equal to or greater than the 

market basket. 

Column 5: All Proposed Changes for CY 

2007 

Column 5 compares all proposed 

changes for CY 2007 to final payment 

for CY 2006 and includes any additional 

dollars resulting from provisions in Pub. 

L. 108–173 in both years, changes in 

outlier payment percentages and 

thresholds, and the difference in passthrough estimates. Overall, we estimate 

that hospitals would gain 3.0 percent 

under this proposed rule in CY 2007 

relative to total spending in CY 2006. 

When we excluded cancer and 

children’s hospitals, which are held 

harmless, the gain is 3.1 percent. While 

hospitals would receive the 3.4 percent 

increase due to the market basket 

update appearing in Column 4 and the 

additional 0.04 percent for the reduction 

in the pass-through estimate between 

CY 2006 and CY 2007, we estimate that 

hospitals also experience a 0.25 percent 

loss due to outlier payments as a result 

of the increased threshold and the 

change to the overall CCR that is used 

to estimate outlier payments. In 

addition, there is a loss of 0.17 percent 

as a result of the expiration of the 

section 508 wage adjustment. 

In general, urban hospitals appear to 

experience the largest negative impacts 

from the combined effects of these 

factors. We estimate that hospitals in 

large urban areas would gain 3.0 percent 

in CY 2007 and hospitals in other urban 

areas would gain 3.1 percent. We 

estimate that low-volume urban 

hospitals would experience a decrease 

in total payments of 3.2 percent between 

CY 2006 and CY 2007, largely as a result 

of changes to payment for partial 

hospitalization, psychotherapy and 

radiation therapy services. Hospitals 

reporting 5,000 to 10,999 lines of 

volume show an increase of 1.9 percent 

but all hospitals with volume larger 

than 10,999 lines have increases equal 

to or greater than 3.1 percent. Urban 

hospitals in all regions other than the 

Mountain region have overall increases 

that are less than the market basket 

increase and which range from 2.5 to 3.3 

percent. Urban hospitals in the 

Mountain region are estimated to 

receive the largest increases for urban 

hospitals of 4.1 percent. 

Overall, rural hospitals experience 

increases similar to those observed for 

urban hospitals. Overall, we estimate 

that rural hospitals would experience an 

increase in payments of 3.1 percent, 

which is identical to the 3.1 percent 

increase we project for all hospitals 

when we exclude the 58 hospitals that 

are held harmless under the law. 

However, we also estimate that rural 

SCHs would experience an increase of 

2.8 percent, and that the other rural 

hospitals would only experience an 

increase of 3.3 percent. No category of 

rural hospitals experiences a decrease in 

payments between CY 2006 and CY 

2007, and rural hospitals in a few 

regions show increases comparable to, 

or better than, the market basket. Rural 

hospitals with fewer than 150 beds and 

rural hospitals with volumes greater 

than 4,999 lines experience increases of 

at least 3.0 percent, the national average 

overall increase for all hospitals. Across 

the regions, rural hospitals in five 

regions (South Atlantic, East North 

Central, East South Central, West South 

Central, and Pacific) are projected to 


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receive increases equal to or greater than 

the projected 3.0 percent increase for all 

hospitals. Rural hospitals in four regions 

(New England, Middle Atlantic, West 

North Central, and Mountain) are 

projected to receive overall increases 

that are less than the projected increase 

for all hospitals. We project that lowvolume rural hospitals would 

experience the lowest increase in 

overall payment of 0.8 percent (due 

largely to changes in payment for partial 

hospitalization, psychotherapy, and 

radiation therapy services). 

Among other classes of hospitals, we 

estimate that hospitals not paid under 

the IPPS (DSH Not Available) would 

experience decreases in payments 

between CY 2006 and CY 2007 of 5.4 

percent. We estimate that major 

teaching hospitals would experience an 

increase of 2.6 percent and that 

nonteaching hospitals would experience 

an increase of 3.2 percent. 

BILLING CODE 4120–01–P 


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BILLING CODE 4120–01–C 

4. Estimated Effect of This Proposed 

Rule on Beneficiaries 

For services for which the beneficiary 

pays a copayment of 20 percent of the 

payment rate, the beneficiary share of 

payment would increase for services for 

which OPPS payments would rise and 

would decrease for services for which 

OPPS payments would fall. For 

example, for an electrocardiogram (APC 

0099), the minimum unadjusted 

copayment in CY 2006 was $4.49. In 

this proposed rule, the minimum 

unadjusted copayment for APC 0099 is 

$4.72 because the OPPS payment for the 

service would increase under this 

proposed rule. In another example, for 

a Level IV Needle Biopsy (APC 0037), in 

the CY 2006 OPPS, the national 

unadjusted copayment in CY 2006 was 

$228.76, and the minimum unadjusted 

copayment was $114.38. In this 


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proposed rule, the national unadjusted 

copayment for APC 0037 is $228.76. 

The minimum unadjusted copayment 

for APC 0037 is $126.32, or 20 percent 

of the proposed payment for APC 0037. 

In all cases, the statute limits 

beneficiary liability for copayment for a 

service to the inpatient hospital 

deductible for the applicable year. For 

2006, the inpatient deductible is $962. 

In order to better understand the 

impact of changes in copayment on 

beneficiaries, we modeled the percent 

change in total copayment liability 

using CY 2005 claims. We estimate, 

using the claims of the 3,922 hospitals 

on which our modeling is based, that 

total beneficiary liability for copayments 

would decline as an overall percentage 

of total payments from 27.5 percent in 

CY 2006 (revised from 29 percent that 

we estimated for CY 2006 in the 

November 1, 2005 final rule with 

comment period 70 FR 68727) to 26.3 

percent in CY 2007. This estimated 

decline in beneficiary liability is a 

consequence of the APC recalibration 

and reconfiguration we are proposing 

for CY 2007. In particular, the proposed 

changes to the emergency department 

visit APCs would set the copayments for 

these high volume services to 20 percent 

of the proposed payment rates, resulting 

in a significant reduction in beneficiary 

copayments. 

5. Accounting Statement 

As required by OMB Circular A–4 

(available at http://www.whitehousegov/ 

omb/circulars/a004/a-4.pdf, in Table 50 

below, we have prepared an accounting 

statement showing the classification of 

the expenditures associated with the 

OPPS provisions of this proposed rule. 

This table provides our best estimate of 

the increase in Medicare payments 

under the OPPS as a result of the 

changes presented in this proposed rule 

on the data for 3,922 hospitals. All 

expenditures are classified as transfers 

to Medicare providers (that is, OPPS). 

TABLE 50.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES FROM CY 2006 TO CY 2007 

Category Transfers 

Annualized Monetized Transfers .............................................................. $1.0 Billion. 

From Whom to Whom .............................................................................. Federal Government to OPPS Medicare Providers. 

Category ................................................................................................... Transfers. 

Annualized Monetized Transfer ................................................................ $250 Million. 

From Whom to Whom .............................................................................. Increase in Premium Payments from Beneficiaries to Federal Government. 

Total ................................................................................................... $750 Million. 

6. Conclusion 

The changes in this proposed rule 

would affect all classes of hospitals. 

Some hospitals experience significant 

gains and others less significant gains, 

but almost all hospitals would 

experience positive updates in OPPS 

payments in CY 2007. Table 49 

demonstrates the estimated 

distributional impact of the OPPS 

budget neutrality requirements and an 

additional 3.0 percent increase in 

payments for CY 2007, after considering 

the proposed market basket increase, the 

cost of outliers, changes to the passthrough estimate and the elimination of 

the section 508 adjustment of Pub. L. 

108–173. The accompanying discussion, 

in combination with the rest of this 

proposed rule,2 constitutes a regulatory 

impact analysis. 

C. Effects of Proposed Changes to the 

ASC Payment System for CY 2007 

(If you choose to comment on issues 

in the section, please include the 

caption ‘‘CY 2007 ASC Impact’’ at the 

beginning of your comment.) 

We are proposing to add 14 surgical 

procedures to the Medicare list of ASC 

payable services and to implement 

section 5103 of Pub. L. 109–171, which 

requires the Secretary to substitute the 

OPPS payment amount for the ASC 

standard overhead amount if the 

standard overhead amount for facility 

services for surgical procedures 

performed in an ASC, without 

application of any geographic 

adjustment, exceeds the Medicare OPPS 

payment amount for the service for that 

year, without application of any 

geographic adjustment. This provision 

applies to surgical procedures furnished 

in ASCs on or after January 1, 2007, and 

before the effective date of the revised 

ASC payment system. Except for the 

payment changes required under section 

5103 of Pub. L. 109–171, we are 

proposing no changes in CY 2007 to the 

ASC payment rates that are currently in 

effect. 

The Office of the Actuary estimates 

that adding the 14 procedures we are 

proposing in section XVII. of this 

preamble and implementing the Pub. L. 

109–171 mandate would result in a 

savings to the Medicare program of 

approximately $150 million in CY 2007. 

1. Alternatives Considered 

We are issuing this proposed rule to 

meet a statutory requirement that we 

update the list of approved ASC 

procedures at least every two years. We 

implement the biennial update of the 

list through notice and comment in the 

Federal Register to give interested 

parties an opportunity to review and 

comment on proposed additions to and 

deletions from the ASC list. The last 

update of the ASC list through notice 

and comment was effective July 5, 2005. 

However, the statute requires us to 

update the list at least every 2 years, 

which means we must update the list by 

July 2007. 

2. Limitations of Our Analysis 

Without datasets related to classes of 

ASCs which parallel the data 

maintained in the Medicare providerspecific files for hospitals, we cannot 

model distributional impacts of the 

proposed CY 2007 changes in the ASC 

list and ASC payments similar to those 

we prepare for our OPPS impact 

analysis (see Table 49). The actuarial 

estimate of Medicare program costs or 

savings resulting from the update of the 

ASC list and implementation of section 

5103 of Pub. L. 109–171 in CY 2007 is 

based on estimated CY 2007 utilization. 

As we have done in previous proposed 

rules, we are soliciting comments and 

information about the anticipated effect 

of these changes that we are proposing 

for CY 2007 to gauge their impact on 

individual ASCs. 

3. Estimated Effects of This Proposed 

Rule on ASCs 

The CMS Office of the Actuary 

estimates that approximately 25 percent 

of the cases currently reported by 

hospitals using the 14 codes we are 

proposing to add to the ASC list would 

shift to the ASC setting in CY 2007. It 

estimates that the shift of these 

procedures to the less costly ASC setting 


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would result in modest savings for the 

Medicare program. 

Savings would also be realized 

because section 5103 of the Pub. L. 109–

171 would impose a payment limit for 

81 procedures on the current ASC list. 

The Office of the Actuary estimates that 

adding 14 surgical procedures to the 

ASC list and capping payment for 81 

procedures on the current ASC list 

would result in a combined savings to 

the Medicare program of approximately 

$150 million in CY 2007. We have not 

estimated the impact of our proposed 

changes for CY 2007 on Medicare 

expenditures in subsequent years 

because we are proposing to implement 

an entirely revised payment system in 

CY 2008. Our analysis of the impact of 

that proposed payment system is 

discussed in section XXVII.D. 

Currently, Medicare pays a facility fee 

to ASCs only for those procedures that 

have been approved for the ASC list. 

The addition of 14 surgical procedures 

to the ASC list would be beneficial to 

ASCs by making it possible for them to 

offer more surgical procedures to 

Medicare beneficiaries. We believe that 

approximately 25 percent of the annual 

hospital outpatient volume of the 14 

procedures proposed for addition to the 

ASC list would move to the ASC setting 

in CY 2007. To the extent that hospital 

outpatient utilization decreases and 

ASC utilization increases in CY 2007, 

the Medicare program would realize a 

savings because the ASC standard 

overhead amount for all procedures, 

including the proposed additions to the 

ASC list, would be equal to or lower 

than the payment rate for the same 

procedures under the OPPS. Because 

hospitals perform a much higher 

volume of ambulatory surgeries overall 

than are performed in ASCs, we do not 

expect significant hospital revenue 

losses to result from migration of 

procedures that we are proposing for 

addition to the ASC list to the ASC 

setting. 

4. Estimated Effects of This Proposed 

Rule on Beneficiaries 

The proposed changes for CY 2007 

would be positive for beneficiaries in at 

least two respects. First, for the 

procedures we are proposing to add to 

the ASC list in CY 2007, the beneficiary 

copayment amount would be lower 

when these procedures are performed in 

an ASC than if they were performed in 

a hospital outpatient department. The 

difference in copayment amounts is 

attributable to the difference in the 

coinsurance rate between the ASC 

payment system and the OPPS. That is, 

the coinsurance rate for all surgical 

procedures payable under the ASC 

benefit is 20 percent of the standard 

overhead amount, whereas the 

coinsurance rate for the same surgical 

procedures performed in a hospital 

outpatient setting ranges from 20 

percent to 40 percent under the OPPS. 

In addition, in accordance with section 

5103 of Pub. L. 109–171, no ASC 

payment rate in CY 2007 may be greater 

than the OPPS rate for a given 

procedure. Thus, due to the limitations 

on the ASC facility rate required by Pub. 

L. 109–171, beneficiaries will be assured 

a lower ASC copayment amount for 

procedures in CY 2007 than in previous 

years. The only exceptions would be 

when the ASC copayment amount 

exceeds the inpatient deductible. The 

statute requires that copayment amounts 

under the OPPS not exceed the 

inpatient deductible. 

Second, beneficiary access to services 

would be expanded by the proposed 

addition of 14 surgical procedures to the 

ASC list. Beneficiaries would have an 

additional setting from which to choose 

were it necessary for them to undergo 

one of the surgical procedures that we 

are proposing to add the ASC list in CY 

2007. 

5. Conclusion 

The impact on ASCs of proposed 

changes to the ASC payment system for 

CY 2007 would depend on an 

individual ASC’s mix of patients and its 

payers, specifically, the proportion of its 

patients who are Medicare beneficiaries, 

whether or not the ASC chooses to 

perform the procedures proposed for 

addition to the ASC list, and whether or 

not the ASC provides services that will 

be affected by the payment limits 

imposed by section 5103 of Pub. L. 109–

171. Overall, the Office of the Actuary 

estimates that the Medicare program 

would realize a $35 million savings as 

a result of implementing the changes 

proposed for CY 2007. 

6. Accounting Statement 

As required by OMB Circular A–4 

(available at http://www.whitehousegov/ 

omb/circulars/a004/a-4.pdf), in Table 

51 below, we have prepared an 

accounting statement showing the 

classification of the expenditures 

associated with the CY 2007 ASC 

provisions of this proposed rule. This 

table provides our best estimate of the 

reduction in Medicare payments under 

the ASC payment system as a result of 

the changes presented in this proposed 

rule for CY 2007. All expenditures are 

classified as transfers to Medicare 

providers (that is, ASC). 

TABLE 51.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED ASC EXPENDITURES FROM CY 2006 TO CY 2007 

Category Transfers 

Annualized Monetized Transfers .............................................................. $150 million savings. 

From Whom to Whom .............................................................................. Medicare ASC Suppliers to the Federal Government. 

Annualized Monetized Transfer ................................................................ $50 Million Impact. 

From Whom to Whom .............................................................................. Decrease in Premium from Beneficiaries to Federal Government. 

Total ................................................................................................... $100 million savings. 

D. Effects of Proposed Revisions to the 

ASC Payment System for CY 2008 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘CY 2008 ASC Impact’’ at the 

beginning of your comment.) 

In CY 2008, we are proposing to 

implement a completely revised 

Medicare ASC payment system that 

could have a far-reaching effect on the 

provision of outpatient surgical services 

for a number of years to come. First, we 

are proposing to greatly expand the list 

of procedures that would be eligible for 

payment of an ASC facility fee. Second, 

we also are proposing to move from a 

limited fee schedule based on nine 

disparate payment groups to a payment 

system incorporating relative payment 

weights and APC groups, which are key 

elements of the hospital OPPS. 

Implementation by January 1, 2008 of 

a revised ASC payment system designed 

to result in budget neutrality is 

mandated by section 626 of Pub. L. 108–

173. To set ASC payment rates for CY 

2008 under the revised system, we are 

proposing to multiply ASC relative 

payment weights for surgical procedures 

by an ASC conversion factor that we 

would calculate to result in the same 

aggregate expenditures for ASC services 


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in CY 2008 that we estimate would have 

been made if the revised payment 

system were not implemented. 

The effects of the expanded ASC list 

combined with significant changes in 

payment rates for ASC facility services 

would vary across ASCs, depending on 

whether or not the ASC limits its 

services to those in a particular surgical 

specialty area, the volume of specific 

services provided by the ASC, and the 

percentage of its patients that are 

Medicare beneficiaries. 

The Office of the Actuary estimates 

that the revised payment system 

proposed in section XVIII. of this 

preamble would result in neither 

savings nor costs for the Medicare 

program. That is, because it is designed 

to be budget neutral, the revised ASC 

payment system proposed for 

implementation in CY 2008 would 

neither increase nor decrease 

expenditures under Part B of Medicare. 

The Office of the Actuary further 

estimates that beneficiaries would save 

approximately $30 million under the 

revised ASC payment system proposed 

for implementation in CY 2008 because 

ASC payment rates would in all cases be 

lower than OPPS payment rates for the 

same services, and because beneficiary 

coinsurance for ASC services is a strict 

20 percent rather than the 20–40 percent 

coinsurance rates allowed under the 

OPPS. (The only exceptions would be 

when the copayment amount for a 

procedure under the revised ASC 

payment system exceeds the hospital 

inpatient deductible. Section 

1833(t)(8)(C)(i) of the Act provides that 

the copayment amount for a procedure 

paid under the OPPS cannot exceed the 

inpatient deductible established for the 

year in which the procedure is 

performed.) 

1. Alternatives Considered 

We are issuing this proposal to meet 

a statutory requirement to implement, 

no later than January 1, 2008, a revised 

payment system for ASCs. We are 

proposing to implement the revised 

payment system and expanded list 

through rulemaking in the Federal 

Register to afford interested parties an 

opportunity to comment on revisions 

we are proposing to the policies and 

rules for identifying surgical procedures 

that would be approved for payment of 

an ASC facility fee and the revisions we 

are proposing to the ASC ratesetting 

methodology and payment policies and 

regulations under the revised ASC 

payment system. 

Throughout section XVIII. of this 

preamble, we discuss the various 

options we considered as we developed 

proposals to redesign the ASC payment 

system in broad terms, and specific 

policies, such as those affecting 

payment for ancillary services related to 

surgical procedures, the definition of a 

surgical procedure, criteria for 

identifying procedures that are not 

safely or appropriately performed in an 

ASC, and so forth. 

Although we propose in section XVIII. 

of this preamble to phase in the new 

ASC payment rates under the revised 

payment system over a 2-year period, 

we initially considered fully 

implementing the new rates for ASC 

services furnished on or after January 1, 

2008. However, as we discuss below, 

our analysis of the effect that the change 

in payments might have on ASCs led us 

to propose implementation of payment 

rates in CY 2008 that would be based 

upon a 50/50 blend of the estimated 

current payment rate with the new 

payment rate. We believe that allowing 

a blended rate in the first year is 

appropriate in light of the adverse 

financial impact that some ASCs could 

potentially experience if they perform a 

high volume of procedures whose rates 

would significantly decrease under the 

revised system. We want to emphasize 

that our proposed blended payment is 

but one of the numerous provisions we 

propose in section XVIII. of this 

preamble as comprising the revised ASC 

payment system. That is, our proposal 

to make payment for a surgical 

procedure in the first year we 

implement the revised payment system 

of only 50 percent of the payment rate 

determined in accordance with the 

current payment system, would be built 

into and considered integral to full 

implementation of the revised ASC 

payment system proposed for CY 2008. 

2. Limitations of Our Analysis 

Without datasets related to classes of 

ASCs which parallel the data 

maintained in the Medicare providerspecific files for hospitals, we cannot 

model distributional impacts of the 

proposed CY 2007 changes in the ASC 

list and ASC payments similar to those 

that we prepare in our impact analysis 

for the OPPS (see Table 49 in section 

XXVII.B. above). The impacts presented 

here are the projected effects of the 

policy and statutory changes that would 

be effective for CY 2008, on aggregate 

ASC utilization and Medicare payments. 

We can only infer the effects of the 

revised payment system on different 

types of ASCs, for example, single or 

multispecialty, high or low volume, 

urban or nonurban ASCs, based on an 

overall comparison of procedure volume 

and facility payments between the 

current and the proposed payment 

system. Moreover, because ASCs are not 

required to file Medicare cost reports, 

we do not have those as a source of data 

to help evaluate whether or not the 

payments for ASC services are 

appropriate, taking into account the 

resources required by ASCs to perform 

different surgical procedures. 

Because the aggregated impact tables 

below are based upon a methodology 

that assumes no changes in service mix 

or volumes with respect to the most 

recent CY 2005 ASC data, our estimates 

of the percent change in allowed 

charges based on the revised payment 

system for CY 2008 are necessarily 

limited. We believe it is likely that the 

volumes and service mix of procedures 

provided in ASCs would change 

significantly in CY 2008 under the 

revised payment system, although we 

are unable to accurately project these 

changes. At this point, our data do not 

enable us to confidently estimate the net 

potential for migration of services 

among ambulatory care settings that 

might result from implementation of the 

proposed revised ASC payment system. 

As we have done in previous proposed 

rules, we rely on comments and 

information from stakeholders to 

mitigate the limitations in the data 

available to us for analysis of the impact 

these proposed changes would have on 

individual ASCs, on classes of specialty 

ASCs, on hospitals, on physicians and 

on beneficiaries. 

3. Estimated Effect of This Proposed 

Rule on ASCs 

Some ASCs are multispecialty 

facilities that perform the gamut of 

surgical procedures from excision of 

lesions to hernia repair to cataract 

extraction; others focus on a single 

specialty and perform only a limited 

range of surgical procedures, such as 

eye procedures or gastrointestinal 

procedures or orthopedic surgery. The 

combined effect on an individual ASC 

of the proposed revised CY 2008 

payment system and the proposed 

expanded list of procedures would 

depend on a number of factors 

including, but not limited to, the mix of 

services the ASC provides, the volume 

of specific services provided by the 

ASC, and the percentage of its patients 

who are Medicare beneficiaries. An 

individual ASC’s revenues from nonMedicare sources might or might not be 

affected by the Medicare payment 

changes depending on the mix of 

services it provides to its non-Medicare 

patients and the extent to which 

revenues from other payors are 

influenced by the Medicare payment 

rates. 

To estimate changes in Medicare 

payments for current ASC services, we 


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49692 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

compared estimated payment rates for 

CY 2008 under the current system with 

the estimated proposed payment rates 

for CY 2008 under the revised system. 

In analyzing these comparisons, we 

became concerned about the significant 

negative effect the new payment rates 

might have on Medicare revenues for 

certain surgical procedures that are 

frequently performed in ASCs. We also 

became concerned about the impact of 

the revised payment rates on ASCs that 

specialize in a limited number of 

surgical procedures for which payment 

would decrease under the new system. 

We do not want the revised payment 

system to cause procedures currently 

performed in high volume in ASCs to 

migrate to hospital outpatient 

departments in response to sudden 

payment reductions. On the contrary, 

we want to encourage procedures that 

are being frequently performed in ASCs 

at the present time to continue being 

performed in ASCs because, in all 

likelihood, the ASC has become an 

extremely efficient setting for high 

volume procedures, such as cataract 

extraction and colonoscopies. Moreover, 

we believe one of the positive outcomes 

of the revised ASC payment system 

could be to expand beneficiary and 

physician choice when it comes to 

selecting an appropriate site for 

ambulatory surgical services as a 

consequence of the expansion of 

surgical services available in the ASC 

setting and revised payment rates that 

pay more appropriately for ASC facility 

services. Therefore, to give ASCs 

additional time to reconfigure their case 

mix so that they can focus on achieving 

more efficient delivery of a broader 

range of services, we are proposing 

during the first year of the revised 

payment system (CY 2008) to pay ASCs 

using a blended rate, 50 percent of the 

CY 2007 ASC rate for surgical 

procedures on the CY 2007 ASC list 

added to 50 percent of the CY 2008 

proposed ASC rate. 

Table 52 shows the impact at the APC 

group level, sorted by APC group, of the 

revised payment system if we were to 

apply a 50/50 blend of the old ASC 

payment rate and the new ASC payment 

within the particular APC group. The 

APC groups shown in this table are 

those for which we estimate CY 2008 

allowed charges under the revised 

payment system would exceed $5 

million. Procedures assigned to these 

APCs account for the highest aggregate 

allowed charges under the current 

payment system. The following is an 

explanation of the information 

represented in Table 52: 

• Column 1—APC Group indicates 

the APC classification of procedures to 

which the ASC expenditures are 

attributed. For a listing of the individual 

HCPCS codes assigned to the APC 

groups, see Addendum C of this 

proposed rule, which can be found on 

the CMS Web site. 

• Column 2—Allowed Charges are the 

Medicare payment amounts for covered 

ASC surgical procedures. Allowed 

charges include both Medicare program 

payments and coinsurance and 

deductibles, which are the financial 

responsibility of the beneficiary. These 

amounts have been summed across all 

procedures provided within the 

particular APC by ASCs. The allowed 

charges are expressed in millions of 

dollars. 

• Column 3—CY 2008 Percent 

Change (under 50/50 Blend): The CY 

2008 impact of the revised ASC 

payment system under the transition is 

the percentage increase or decrease in 

allowed charges attributable to changes 

in the ASC payment rates for CY 2008 

under a 50/50 blend of the old ASC 

payment rate and the new ASC payment 

within the particular APC group. 

TABLE 52.—ESTIMATED CY 2008 IMPACT OF THE PROPOSED REVISED ASC PAYMENT SYSTEM ON AGGREGATE ALLOWED

CHARGES UNDER THE 50/50 BLEND, BY APC GROUP

APC group 

Allowed 

charges 

(in millions) 

CY 2008 

percent 

change 

(under 50/ 

50 Blend) 

0021—Level III Excision/ Biopsy ..................................................................................................................................... $7 20 

0022—Level IV Excision/ Biopsy ..................................................................................................................................... 12 34 

0027—Level IV Skin Repair ............................................................................................................................................ 6 33 

0028—Level I Breast Surgery ......................................................................................................................................... 7 25 

0041—Level I Arthroscopy .............................................................................................................................................. 56 35 

0042—Level II Arthroscopy ............................................................................................................................................. 14 108 

0051—Level III Musculoskeletal Procedures Except Hand and Foot ............................................................................. 17 55 

0053—Level I Hand Musculoskeletal Procedures .......................................................................................................... 20 17 

0054—Level II Hand Musculoskeletal Procedures ......................................................................................................... 6 39 

0055—Level I Foot Musculoskeletal Procedures ............................................................................................................ 36 28 

0057—Bunion Procedures ............................................................................................................................................... 9 60 

0075—Level V Endoscopy Upper Airway ....................................................................................................................... 14 27 

0140—Esophageal Dilation without Endoscopy .............................................................................................................. 10 ¥18 

0141—Level I Upper GI Procedures ............................................................................................................................... 233 ¥12 

0143—Lower GI Endoscopy ............................................................................................................................................ 427 ¥11 

0154—Hernia/Hydrocele Procedures .............................................................................................................................. 15 31 

0158—Colorectal Cancer Screening: Colonoscopy ........................................................................................................ 63 ¥15 

0160—Level I Cystourethroscopy and other Genitourinary Procedures ........................................................................ 26 ¥11 

0161—Level II Cystourethroscopy and other Genitourinary Procedures ....................................................................... 14 35 

0162—Level III Cystourethroscopy and other Genitourinary Procedures ...................................................................... 11 51 

0163—Level IV Cystourethroscopy and other Genitourinary Procedures ...................................................................... 5 20 

0184—Prostate Biopsy .................................................................................................................................................... 8 ¥18 

0203—Level IV Nerve Injections ..................................................................................................................................... 9 25 

0206—Level II Nerve Injections ...................................................................................................................................... 58 ¥17 

0207—Level III Nerve Injections ..................................................................................................................................... 209 ¥12 

0220—Level I Nerve Procedures .................................................................................................................................... 22 30 

0233—Level II Anterior Segment Eye Procedures ......................................................................................................... 8 17 

0234—Level III Anterior Segment Eye Procedures ........................................................................................................ 17 23 

0240—Level III Repair and Plastic Eye Procedures ....................................................................................................... 47 7 

0244—Corneal Transplant ............................................................................................................................................... 7 27 


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TABLE 52.—ESTIMATED CY 2008 IMPACT OF THE PROPOSED REVISED ASC PAYMENT SYSTEM ON AGGREGATE ALLOWED

CHARGES UNDER THE 50/50 BLEND, BY APC GROUP—Continued 

APC group 

Allowed 

charges 

(in millions) 

CY 2008 

percent 

change 

(under 50/ 

50 Blend) 

0246—Cataract Procedures with IOL Insert ................................................................................................................... 1,100 ¥2 

0247—Laser Eye Procedures Except Retinal ................................................................................................................. 97 ¥18 

0254—Level IV ENT Procedures .................................................................................................................................... 6 31 

0672—Level IV Posterior Segment Eye Procedures ...................................................................................................... 23 41 

0686—Level III Skin Repair ............................................................................................................................................. 54 ¥5 

All Other (APC categories less than $5 million) .............................................................................................................. 110 25 

Total .......................................................................................................................................................................... 2,785 0 

Table 53 below shows the impact of 

the revised payment system on total 

payments for selected high volume 

procedures during the first year the 

revised payment system is implemented 

(CY 2008). These are the most 

frequently performed procedures at 

ASCs under the current Medicare 

payment system. The HCPCS codes are 

sorted in descending order by estimated 

allowed charges. The percent change in 

this table again compares payment rates 

for CY 2008 under the current system 

with our estimate of the proposed 

payment rates for CY 2008, 

incorporating a 50/50 blend of the ASC 

payment under the current system and 

the ASC payment under the revised 

system. 

TABLE 53.—ESTIMATED CY 2008 IMPACT OF REVISED ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS FOR

SELECTED HIGH VOLUME PROCEDURES UNDER THE 50/50 BLEND

HCPCS 

Code Description 

Allowed 

charges 

(in millions) 

CY 2008 

percent 

change 

(50/50 

Blend) 

66984 ....... Cataract surg w/iol, 1 stage ...................................................................................................................... $1,062 ¥2 

43239 ....... Upper gi endoscopy, biopsy ..................................................................................................................... 166 ¥13 

45378 ....... Diagnostic colonoscopy ............................................................................................................................ 147 ¥11 

45380 ....... Colonoscopy and biopsy ........................................................................................................................... 112 ¥11 

45385 ....... Lesion removal colonoscopy .................................................................................................................... 108 ¥11 

66821 ....... After cataract laser surgery ...................................................................................................................... 97 ¥18 

62311 ....... Inject spine l/s (cd) .................................................................................................................................... 78 ¥12 

45384 ....... Lesion remove colonoscopy ..................................................................................................................... 45 ¥11 

64483 ....... Inj foramen epidural l/s ............................................................................................................................. 42 ¥12 

64476 ....... Inj paravertebral l/s add-on ....................................................................................................................... 39 ¥17 

G0121 ....... Colon ca scrn; not high rsk ....................................................................................................................... 37 ¥15 

66982 ....... Cataract surgery, complex ........................................................................................................................ 32 ¥2 

15823 ....... Revision of upper eyelid ........................................................................................................................... 29 ¥13 

43235 ....... Uppr gi endoscopy, diagnosis .................................................................................................................. 28 ¥1 

G0105 ....... Colorectal scrn; hi risk ind ........................................................................................................................ 26 ¥15 

64475 ....... Inj paravertebral l/s ................................................................................................................................... 25 ¥12 

52000 ....... Cystoscopy ................................................................................................................................................ 24 ¥10 

64484 ....... Inj foramen epidural add-on ...................................................................................................................... 20 ¥12 

67904 ....... Repair eyelid defect .................................................................................................................................. 18 4 

43248 ....... Uppr gi endoscopy/guide wire .................................................................................................................. 18 ¥13 

64721 ....... Carpal tunnel surgery ............................................................................................................................... 17 30 

29881 ....... Knee arthroscopy/surgery ......................................................................................................................... 17 41 

28285 ....... Repair of hammertoe ................................................................................................................................ 15 29 

64623 ....... Destr paravertebral n add-on .................................................................................................................... 15 ¥12 

62310 ....... Inject spine c/t ........................................................................................................................................... 13 ¥12 

29880 ....... Knee arthroscopy/surgery ......................................................................................................................... 12 41 

26055 ....... Incise finger tendon sheath ...................................................................................................................... 11 22 

Over time, we believe the current ASC 

payment system has served as an 

incentive to ASCs to focus on providing 

procedures for which they determine 

Medicare payments are adequate to 

support the ASC’s continued operation. 

In our analyses of the effects of the new 

payment rates, we found that the ASC 

payment rates for many of the 

procedures performed most frequently 

in ASCs are equal to or greater than the 

OPPS rates for the same procedures. 

Conversely, procedures for which the 

current ASC payment rates are lower 

than the OPPS rates for the same 

procedures tend to be performed less 

frequently in ASCs. We believe the 

proposed revised payment system 

represents a major stride towards 

encouraging greater efficiency in ASCs 

and promoting a significant increase in 

the scope and breadth of surgical 

procedures performed in ASCs because 

it would more appropriately distribute 


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49694 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

payments across the entire spectrum of 

surgical procedures, based on a coherent 

system of relative payment weights. As 

a consequence, we expect that there 

would be changes in the mix of 

procedures provided in ASCs under the 

proposed revised payment system 

because the revised payment system 

would encourage ASCs to expand their 

service mix beyond the handful of the 

most lucrative procedures which 

comprise the bulk of ASC utilization 

under the current Medicare payment 

system. 

There are also some procedures for 

which the current ASC and OPPS rates 

are roughly equivalent. Under the 

proposed revised payment system, those 

services would be paid a significantly 

lower amount than they are currently. 

We believe that in some cases the 

payment under the current ASC system 

is generous relative to ASC costs, so 

ASCs would in all likelihood continue 

performing those procedures under the 

proposed revised payment system. To 

the extent that ASCs determine that the 

new rates for specific services or types 

of procedures are inadequate relative to 

the costs of those services, we would 

expect a change in the mix of services 

the ASC provides. 

Table 53 identifies a number of high 

volume procedures for which ASC 

payments would decrease under the 

revised system, although payments 

would increase significantly for other 

high volume procedures. What Table 53 

does not show are the hundreds of other 

procedures currently on the ASC list 

that have very low volume, which we 

believe correlates with the low payment 

rates currently set for those procedures. 

Under the revised system, payment rates 

would increase significantly for 

numerous procedures that are currently 

underpaid when compared with 

payments for the same services under 

the OPPS. While an ASC may earn less 

from providing a service that has been 

its highest volume (and best paid) 

procedure under the current system 

because the payment rate for that 

procedure is lower under the revised 

payment system, that ASC may more 

than offset the reduction in revenues by 

beginning to perform other services for 

which the proposed rates under the 

revised system are significantly higher. 

The procedures displayed in Table 53 

(current high volume procedures) are 

the highest volume procedures under 

the current system but we expect that 

other procedures will become high 

volume procedures under the revised 

system. 

While Table 52 suggests that payment 

for some types of procedures would 

decrease and others would increase, 

considering multiple procedures as a 

clinically related group generally 

moderates some of the extreme 

increases and decreases in payments 

displayed in Table 53 for selected high 

volume procedures that are members of 

those groups. ASCs with particular 

capabilities for specializing in 

urological or gastrointestinal procedures 

could shift their focus to other related 

procedures in the same taxonomy 

whose payment rates were more 

favorable. Those specialty ASCs could 

potentially continue to draw upon their 

experiences and resources to perform 

other related services. 

The tables above show how payment 

for high volume procedures currently on 

the ASC list would be affected by 

changes in payment using the ASC 

relative payment weights and rate 

setting methodology proposed under the 

new payment system. We also propose 

to add in CY 2008 hundreds of surgical 

procedures to the already extensive list 

of services for which Medicare allows 

payment of an ASC facility fee, creating 

new opportunities for ASCs to expand 

their range of Medicare-approved 

surgical procedures. Table 54 suggests 

some of the potential for growth that 

ASCs could realize under the revised 

payment system. The codes in this table 

are selected high volume procedures 

currently performed predominantly in 

the office and/or hospital outpatient 

setting. We believe the payment rates for 

these procedures under the proposed 

revised system would make them 

attractive additions to the existing 

surgical choices that ASCs currently 

offer Medicare beneficiaries in the areas 

of gastroenterology, urology, and pain 

management. Note that we have 

included columns to show the MPFS 

nonfacility rate, office volume, and a 

column entitled ‘‘OPPS Rate Adjusted to 

CY 2008 ASC Rate’’ that shows the 

proposed blended CY 2008 payment 

rate for each procedures that is 

compared to the MPFS nonfacility rate 

to determine which is the proposed CY 

2008 rate. The procedures that are on 

the office-based list and, are therefore, 

subject to payment limitation (the lesser 

of the ASC rate or the MPFS nonfacility 

rate) are denoted with an asterisk. We 

have also denoted with an asterisk, 

those proposed CY 2008 ASC payments 

that are limited by the nonfacility rate. 

TABLE 54.—SELECTED HIGH VOLUME PROCEDURES PROPOSED FOR ASC PAYMENT FOR CY 2008 

CPT code Short descriptor 

Proposed 

CY 2007 

OPPS 

payment 

rate 

Proposed 

CY 2008 

MPFS 

nonfacilty 

rate 

Proposed 

CY 2008 

ASC payment rate 

OPPS or 

physician 

office volume 

Payment 

for officebased 

procedure 

if no payment cap 

45300* ..... Proctosigmoidoscopy dx ........................................................................ $295.48 $60.03 $60.03 39524 $183.19 

45330* ..... Diagnostic sigmoidoscopy ..................................................................... 295.48 81.86 81.86 42684 183.19 

46600* ..... Diagnostic anoscopy .............................................................................. 38.23 51.50 23.70 80577 23.70 

46934 ....... Destruction of hemorrhoids ................................................................... 792.64 177.36 177.36 34423 491.43 

47562 ....... Laparoscopic cholecystectomy .............................................................. 2,678.23 N/A 1,660.48 30,029 1,660.48 

47563 ....... Laparo cholecystectomy/graph .............................................................. 2,678.23 N/A 1,660.48 13,979 1,660.48 

50590 ....... Fragmenting of kidney stone ................................................................. 2,734.57 N/A 1,683.45 26,549.00 1,683.45 

53850* ..... Prostatic microwave thermotx ............................................................... 2,604.69 2,459.51 1,653.04 31796 1,653.04 

53852* ..... Prostatic rf thermotx .............................................................................. 2,604.69 2,320.01 1,653.04 8574 1,653.04 

61795 ....... Brain surgery using computer ............................................................... 338.56 N/A 209.90 1,067 209.90 

62368* ..... Analyze spine infusion pump ................................................................. 173.90 21.83 21.83 122336 107.82 

64450* ..... N block, other peripheral ....................................................................... 138.43 42.29 42.29 132194 85.83 

64612* ..... Destroy nerve, face muscle ................................................................... 138.43 68.90 68.90 35679 85.83 

64640* ..... Injection treatment of nerve ................................................................... 341.23 189.09 189.09 79126 211.56 


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Unlike hospital outpatient 

departments, ASCs typically provide 

only a select set of procedures, and 

those procedures are generally 

performed on a scheduled, elective 

basis, affording ASCs much greater 

control over their case mix and costs 

than is possible for a typical hospital 

outpatient department. We expect that, 

as a result of implementation of the 

changes proposed under the revised 

ASC payment system, some procedures 

for which payment would decrease 

could migrate to other ambulatory 

settings. Conversely, we expect ASC 

volume to increase for those procedures 

for which payment rates go up under 

the revised payment system. These 

decisions will be made at the individual 

ASC level, depending on its physician 

staff, types of patients and its payors, 

and other considerations. 

4. Estimated Effects of This Proposed 

Rule on Beneficiaries 

We estimate that the proposed 

changes for CY 2008 would be positive 

for beneficiaries in at least two respects. 

The ASC coinsurance rate is set at 20 

percent rather than between 20 percent 

and 40 percent as is the case under the 

OPPS. Because ASC payment rates 

under the revised payment system are 

lower than payment rates for the same 

procedures under the OPPS, the 

beneficiary copayment amount under 

the ASC payment system would 

generally be less than the OPPS 

copayment amount for like services. 

(The only exceptions would be when 

the ASC copayment amount exceeds the 

inpatient deductible. The statute 

requires that copayment amounts under 

the OPPS not exceed the inpatient 

deductible.) 

In addition to the potential for 

reduced copayments, beneficiary access 

to services could be expanded as a 

result of the addition of the proposed 

763 surgical procedures to the ASC list 

of services eligible for Medicare 

payment. We expect that ASCs would 

provide a broader range of surgical 

services under the revised system and 

that beneficiaries would benefit from 

having access to a greater variety of 

surgical procedures in ASCs. 

5. Conclusion 

The proposed changes to the ASC 

payment system for CY 2008 would 

affect each of the more than 4,000 ASCs 

currently approved for participation in 

the Medicare program. The effect on an 

individual ASC will depend on the 

ASC’s mix of patients, the proportion of 

their patients that are Medicare 

beneficiaries, the degree to which the 

payments for the procedures offered by 

the ASC are changed under the 

proposed revised system, and the degree 

to which the ASC chooses to provide a 

different set of procedures. The revised 

payment system is designed to result in 

the same aggregate amount of 

expenditures that would be made under 

the ASC benefit if the revised system 

were not implemented. The budget 

neutrality of the new payment system 

would not be affected by the proposed 

two year transition to full 

implementation of the new payment 

rates. 

E. Effects of the Medicare Contracting 

Reform Mandate 

(If you choose to comment on issues 

in this section, please include the 

caption ‘‘Medicare Contracting Reform 

Impact’’ at the beginning of your 

comment.) 

In section XIX. of this preamble, we 

discuss our proposal to revise the 

regulations under 42 CFR Part 421, 

Subpart B for Medicare intermediaries 

and carriers to conform the regulations 

to the statutory changes mandated by 

section 1874A of the Act as added by 

section 911 of Pub. L. 108–173, which 

took effect on October 1, 2005. As 

discussed in section XIX. of this 

preamble, section 1874A of the Act is 

intended to improve Medicare’s 

administrative services to beneficiaries 

and health care providers and to bring 

standard contracting principles to 

Medicare, such as competition and 

performance incentives, which the 

government has long applied to other 

Federal programs under the FAR. This 

provision requires that CMS replace its 

current claims payment contractors by 

October 1, 2011 with new contract 

entities referred to as MACs. We believe 

that this provision has no immediate 

economic effect on Medicare payments 

in CY 2007 because it is administrative 

in nature and does not change 

Medicare’s coverage and reimbursement 

policies for hospital outpatient services 

or any other covered Medicare services. 

F. Effects of Proposed Additional 

Quality Measures and Procedures for 

Hospital Reporting of Quality Data for 

IPPS FY 2008 

We have tried to minimize the costs 

of HCAHPS, including minimizing the 

impact on small/rural hospitals. While 

there are no capital or operational/ 

maintenance costs associated with the 

implementation of HCAHPS, there are 

costs for collecting the data. The 

nationwide cost of conducting the 

HCAHPS survey are estimated to be 

between $3.6 million and $16.9 million 

per year assuming approximately 3,700 

hospitals (see Abt Associates, Inc. 

report, http://www.cms.hhs.gov/ 

HospitalQualityInits/downloads/ 

HCAHPSCostsBenefits200512.pdf). 

We have reduced the burden for 

small/rural hospitals by making it 

possible to conduct the HCAHPS

survey without hiring a survey vendor; 

we have provided a free online data 

entry tool to simplify submission for 

reporting; we have required 

significantly fewer completed surveys of 

small hospitals than of larger hospitals; 

and we have permitted four different 

modes of survey administration, which 

will allow hospitals to administer the 

survey in the manner most familiar to 

them. 

In addition, hospitals that are selfadministering the survey (or their 

survey vendor, if the hospital chooses to 

employ one) beginning in 2007 will 

participate in free HCAHPS training 

offered via Webinar in January 2007. All 

hospitals that join in 2007 will be 

required to participate in a month-long 

dry run in March 2007. Hospitals that 

chose not to participate in HCAHPS

will not meet the HCAHPS

requirements necessary to receive the 

full market basket update for FY 2008. 

The costs of collecting HCAHPS

patient survey data will vary across 

hospitals depending on the method 

used to collect patient survey data, the 

number of patients surveyed, and 

whether HCAHPS is incorporated into 

their existing patient satisfaction 

surveys. While hospitals may choose to 

administer HCAHPS as a stand-alone 

survey, there are significant cost savings 

associated with combining HCAHPS

with existing surveys. Hospitals will 

have a financial incentive to administer 

a single survey that includes both 

HCAHPS and information necessary to 

support quality improvement activities. 

We have cited a cost/benefit report 

showing that the costs of conducting 

HCAHPS would be as follows. 

HCAHPS collected as a separate survey 

is between $11.00 and $15.25 per 

complete survey ($3,300 to $4,575 per 

hospital), assuming that 80–85 percent 

of hospitals collect HCAHPS by mail 

and the remainder by phone or active 

IVR. It would be considerably less 

expensive to combine HCAHPS with 

existing surveys. In a combined survey, 

it is estimated that it would cost only 

$3.26 per complete survey (or $978 per 

hospital) to incorporate the 27-item 

HCAHPS instrument into existing 

surveys. Depending on the proportion of 

hospitals that incorporate HCAHPS

into existing surveys, it is therefore 

estimated that the costs of HCAHPS is 

between $3.6 million and $16.9 million 

per year (Abt Associates, Inc. report, 

http://www.cms.hhs.gov/ 


sroberts on PROD1PC70 with PROPOSALS
49696 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

HospitalQualityInits/downloads/ 

HCAHPSCostsBenefits200512.pdf). 

We have made provisions to reduce 

the burden of the HCAHPS initiative 

for small/rural hospitals. As a cost 

savings provisions for all hospitals (but 

one that is particularly useful for small 

hospitals), a free on-line tool for data 

entry is available to hospitals choosing 

to conduct data entry themselves in lieu 

of contracting with a survey vendor for 

this service. The sample size 

requirements are reduced for small 

hospitals unable to achieve 300 

completed surveys. For all hospitals, we 

are allowing four modes of survey 

administration (mail, telephone, 

combination of mail and telephone, and 

active interactive voice recognition), 

and we are allowing for hospitals to 

either use a vendor or conduct the 

survey on their own. Additionally, we 

are allowing hospitals to integrate the 

HCAHPS survey with their own 

patient satisfaction surveys. This option 

provides significant cost savings to 

conduct HCAHPS annually: for the 

mail mode, it is estimated to cost $603 

per hospital; and for the telephone 

mode, it is estimated to be $2,478 per 

hospital. For hospitals collecting 100 

completed surveys, it costs about $326 

annually per hospital. CMS is providing 

free HCAHPS training and materials 

and the cost of reporting HCAHPS

results to CMS is minimal. 

The benefits of public reporting for 

hospitals are great. There are multiple 

reports of hospitals being motivated by 

these data and using them for 

improvement. Not only is there more 

consistent evidence regarding hospital 

impact, but there are also several welldesigned studies that have found at least 

some impact on hospital clinical 

performance (Abt report). 

HCAHPS provides many benefits to 

hospitals and also to society at-large. 

The HCAHPS initiative has taken 

substantial steps to assure that the 

survey will be credible, useful, and 

practical. First, the survey is designed to 

produce comparable data on the 

patient’s perspective on care that allows 

objective and meaningful comparisons 

between hospitals on domains that are 

important to consumers. Second, public 

reporting of the survey results is 

designed to create incentives for 

hospitals to improve their quality of 

care. Third, public reporting will serve 

to enhance public accountability in 

health care by increasing the 

transparency of the quality of hospital 

care provided in return for the public 

investment. For the public at-large, 

there is the potential benefit of 

improved health through improvements 

in hospital care. 

The intent of having the HCAHPS

initiative that resulted in a unique 

hospital survey is to provide one 

standardized instrument and 

accompanying data collection 

methodology that is in the public 

domain for measuring patients’

perspectives on hospital care. While 

many hospitals currently collect 

information on patients’ satisfaction 

with care, there is no one national 

standard for collecting or publicly 

reporting this information that would 

enable valid comparisons to be made 

across all hospitals. In order to make 

‘‘apples to apples’’ comparisons to 

support consumer choice, it is necessary 

to introduce a standard measurement 

approach. HCAHPS can be viewed as 

a core set of questions that can be 

combined with a broader, customized 

set of hospital-specific items. HCAHPS

is meant to complement the data 

hospitals currently collect to support 

improvements in internal customer 

services and quality related activities. 

• SCIP 

While there are no capital or 

operational/maintenance costs 

associated with the implementation of 

SCIP, our pilot study concluded that 

there will be costs associated with the 

collection of the data. The data 

collection costs have been calculated as 

follows: SCIP collection as additional 

measures has been calculated to be 

$75.00 and $100.00 per additional hour 

of data abstraction (approximately 

$16,000 per hospital). Depending on the 

proportion of hospitals that already 

collect these measures, it is estimated 

that the costs of collecting the 

additional measures is approximately 

$58.7 million dollars per year. For a 

detailed discussion of the data 

collection burden (burden hours) 

associated with these costs, please refer 

to the information collection section of 

the preamble. 

• Mortality 

The 30-day mortality measures for 

AMI, HF and Pneumonia are each 

individually calculated solely on 

administrative data already submitted to 

CMS for other purposes, such as claims 

submitted for payment by the hospitals. 

As no new or additional data will be 

required from hospitals to calculate the 

rates for these measures, we believe that 

there will be no measurable impact on 

the hospitals as a result of the inclusion 

of any or all of these measures in the 

RHQDAPU set. 

1. Alternatives Considered 

The HCAHPS survey and the SCIP 

and mortality measures are a subset of 

CMS’s larger Quality Initiative for both 

the Medicare and Medicaid programs. 

The Hospital Quality Initiative was 

established nationally in November 

2002 for nursing homes, and was 

expanded in 2003 to the nation’s home 

health care agencies and hospitals. The 

Hospital Quality Initiative supports 

significant improvement in the quality 

of hospital care that is integral to both 

the Medicare and Medicaid programs. 

This initiative aims to improve 

hospital’s quality of care by distributing 

objective and easy to understand data 

on hospital performance. The public 

availability of this information will 

encourage consumers and their 

physicians to discuss and make better 

informed decisions on how to get the 

best hospital care, create incentives for 

hospitals to improve care, and support 

public accountability. In all, improved 

care equates to the improvement of 

health for Medicare and Medicaid 

beneficiaries. 

HCAHPS, SCIP and Mortality 

measures parallel the trend in both the 

federal and many state governments to 

make hospital performance information 

(generally clinical processes or 

outcomes of care) publicly available. 

The goals of HCAHPS are to (1) 

Produce comparable data on the 

patient’s perspective on care to allow 

objective and meaningful comparisons 

between hospitals on domains that are 

important to consumer decision-making, 

(2) to have these data publicly reported 

to create incentives for hospitals to 

improve their quality of care, and (3) to 

enhance public accountability by 

providers by increasing the 

transparency of the quality of hospital 

care provided in return for the public 

investment. HCAHPS, SCIP and 

Mortality measures fit into a larger 

context of performance reporting 

developed by the Strategic Framework 

Board of the National Quality Forum. 

This is based on the assumption that 

consumers take value (both cost and 

quality) into account in any major 

purchasing decision. Public reporting of 

both the clinical measures and 

HCAHPS is vital to the value-based 

healthcare purchasing approach. Patient 

perspectives of care encompasses an 

important CMS priority, as indicated by 

the Agency’s support for programs 

related to the Institute of Medicine’s 

(IOM) call for public reporting, the 

Hospital Quality Initiative (HQI) and the 

Hospital Quality Alliance (HQA), a 

public-private measurement and 

reporting collaborative. 

The HCAHPS survey has been 

endorsed by the Hospital Quality 

Alliance. Implementing this survey 

fulfills the requirements 


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Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49697 

1886(b)(3)(B)(viii)(III) and (IV) of the Act 

that require CMS to expand the starter 

set of 10 quality measures used since FY 

2005. In expanding these measures, we 

must begin to adopt the baseline set of 

performance measures as set forth in a 

2005 report issued by the Institute of 

Medicine (IOM) of the National 

Academy of Sciences under section 

238(b) of Pub. L. 108–173, effective for 

payments beginning with FY 2007. The 

IOM measures include the Hospital 

Quality Alliance (HQA) measures, the 

Hospital Consumer Assessment of 

Healthcare Providers and Systems 

(HCAHPS) patient perspective survey, 

and three structural measures. 

No alternatives were discussed for the 

SCIP and mortality measures. 

2. Estimated Effects of This Proposed 

Rule 

a. Effects on Hospitals 

Hospitals will benefit from the 

information that the HCAHPS survey 

and the SCIP and Mortality measures 

data collection will provide. Hospitals 

are an essential part of the National 

Quality Forum’s Strategic Framework 

Board. We have made provisions that 

reduce the burden of the HCAHPS

initiative, especially for small/rural 

hospitals. The public reporting of 

HCAHPS results and additional quality 

measures may stimulate improvements 

in hospital quality of care in several 

ways. Hospitals can use the publicly 

reported data to benchmark their 

performance with other institutions. 

Consumers/patients would potentially 

seek care in hospitals that are publicly 

reported to perform well. 

CMS does not plan to make major 

revisions to the HCAHPS survey itself 

or to its implementation procedures 

soon after HCAHPS national 

implementation. With the core set of 

HCAHPS measures, hospitals will have 

the beginnings of a benchmark for 

trending of their hospital results over 

time. 

To promote its wide and rapid 

adoption, HCAHPS has been carefully 

designed to fit within the framework of 

patient satisfaction surveying that 

hospitals currently employ. Still, CMS 

fully understands that participation in 

the HCAHPS initiative will require 

some effort and expense on the part of 

hospitals that volunteer to take part. 

b. Effects on Other Providers 

Physicians will benefit by learning 

what surveyed consumers/patients 

answered about their quality of care 

during their hospital stays, as well as 

become informed about surgical care 

improvement and mortality rates. 

Studies indicate that providers are 

potentially affected by public reporting. 

They may be motivated to improve the 

quality of care they deliver with the 

availability of performance information. 

Primary care physicians are also users of 

this information during the referral 

process of patients to hospitals. Studies 

indicate that the public reporting of 

hospital quality indicators may spur 

internal hospital quality improvement 

and lead to changes in physician 

behavior within the hospital 

environment. 

c. Effects on the Medicare and Medicaid 

Programs 

Some potential benefits of publicly 

reporting quality information has been 

described in the literature as pertaining 

to consumers, providers and purchasers. 

Consumers (beneficiaries) could 

incorporate the quality information into 

their decision-making about hospital 

choices, and benefit from better care 

resulting from the additional measures 

as well as the questions asked by 

HCAHPS, such as questions about 

communication with providers (fewer 

medical errors due to patient feedback 

about medication effect) and discharge 

planning (fewer readmissions due to 

better patient awareness about what to 

expect when discharged) and the 

reporting of clinical measures. 

Providers could potentially be 

motivated to improve the quality of care 

they provide for results of more effective 

and efficient hospital operation. 

Providers could also use the information 

internally to improve communication 

and improve performance, use the 

information to justify the need to 

increase staff ratios, use the measures in 

choices about practitioner practice 

locales, use the information to improve 

their ratings on patient perspectives and 

potentially compete with one another in 

the area of improving accreditation 

results, and use the information to 

choose hospitals on the basis of quality 

of care for their patients. 

Purchasers could potentially benefit 

from this information for supporting 

shorter lengths of stay, availability of 

benchmarks, and availability of 

information to support purchasing 

decisions. 

G. Executive Order 12866 

In accordance with the provisions of 

Executive Order 12866, this proposed 

rule was reviewed by the OMB. 

List of Subjects 

42 CFR Part 410 

Health facilities, Health professions, 

Laboratories, Medicare, Rural areas, Xrays. 

42 CFR Part 414 

Administrative practice and 

procedure, Health facilities, Health 

professions, Kidney diseases, Medicare, 

Reporting and recordkeeping 

requirements. 

42 CFR Part 416 

Health facilities, Kidney diseases, 

Medicare, Reporting and recordkeeping 

requirements. 

42 CFR Part 419 

Hospitals, 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 485 

Grant program-health, Health 

facilities, Medicaid, Medicare, 

Reporting and recordkeeping 

requirements. 

42 CFR Part 488 

Administrative practice and 

procedure, Health facilities, Medicare, 

Reporting and recordkeeping 

requirements. 

For reasons stated in the preamble of 

this proposed rule, the Centers for 

Medicare & Medicaid Services is 

proposing to amend 42 CFR Chapter 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 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

2. Section 410.152 is amended by 

revising paragraph (i) to read as follows: 

§ 410.152 Amounts of payment. 

* * * * * 

(i) Amount of Payment: ASC facility 

services. (1) For ASC facility services 

furnished on or after July 1, 1987 and 

before January 1, 2008, in connection 

with the surgical procedures specified 

in part 416 of this chapter, Medicare 

Part B pays 80 percent of a standard 

overhead amount as specified in 

§ 416.120(c) of this chapter. 

(2) For ASC facility services furnished 

on or after January 1, 2008, in 

connection with the surgical procedures 

specified in part 416 of this chapter, 

Medicare Part B pays the lesser of 80 

percent of the actual charge, 80 percent 

of the prospective payment amount as 


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determined under Subpart F of Part 416 

of this chapter, or, under the limitation 

described in § 416.167(b)(3), the amount 

determined under Subpart B of Part 414 

of this chapter. 

* * * * * 

PART 414—PAYMENT FOR PART B 

MEDICAL AND OTHER HEALTH 

SERVICES 

3. The authority citation for Part 414 

continues to read as follows: 

Authority: Secs. 1102, 1871, and 1834(l) of 

the Social Security Act (42 U.S.C. 1302, 

1395hh, and 1395m(l)). 

4. Section 414.22 is amended by 

revising paragraph (b)(5)(i)(B) to read as 

follows: 

§ 414.22 Relative Value Units (RVUs). 

* * * * * 

(b) Practice Expense RVUs. 

* * * * * 

(5) * * * 

(i) * * * 

(B) Non-facility practice expense 

RVUs. The higher non-facility practice 

expense RVUs apply to services 

performed in a physician’s office, a 

patient’s home, an ASC if the physician 

is performing a procedure for which an 

ASC facility fee is not paid under Part 

416, a nursing facility, or a facility or 

institution other than a hospital or 

skilled nursing facility, community 

mental health center, or ASC performing 

an ASC approved procedure. 

* * * * * 

PART 416—AMBULATORY SURGICAL 

SERVICES 

5. The authority citation for part 416 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

6. Section 416.1 is amended by—

a. Revising paragraph (a)(2). 

b. Revising paragraph (a)(3). 

c. Adding new paragraphs (a)(4) and 

(a)(5). 

The revisions and additions read as 

follows: 

§ 416.1 Basis and scope. 

(a) * * * 

(2) Section 1833(i)(1)(A) of the Act 

requires the Secretary to specify the 

surgical procedures that can be 

performed safely on an ambulatory basis 

in an ambulatory surgical center. 

(3) Sections 1833(i)(2)(A) and (D), and 

1833(a)(1)(G) of the Act specify the 

amounts to be paid for facility services 

furnished in connection with the 

specified surgical procedures when they 

are performed in an ASC. 

(4) Section 1833(i)(2)(C) of the Act 

provides that if the Secretary has not 

updated amounts for ASC facility 

services furnished during a fiscal year 

through 2005 or a calendar year 

beginning with 2006, the amounts shall 

be increased by the percentage increase 

in the Consumer Price Index for all 

urban consumers as estimated by the 

Secretary for the 12-month period 

ending with the midpoint of the year 

involved, except that, in fiscal year 

2005, the last quarter of calendar year 

2005, and each of the calendar years 

2006 through 2009, the increase shall be 

zero percent. 

(5) Section 1833(i)(2)(E) of the act 

provides that with respect to surgical 

procedures furnished on or after January 

1, 2007, and before the effective date of 

the implementation of a revised 

payment system, the payment amount 

shall be the lesser of the ASC payment 

rate established under section 1833(i)(2) 

(A) of the act or the prospective 

payment rate for hospital outpatient 

department services established under 

section 1833(t)(3)(D). The lesser 

payment amount shall be determined 

prior to application of any geographic 

adjustment. 

* * * * * 

7. Section 416.2 is amended by—

a. Republishing the introductory test 

preceding the definitions 

b. Revising the definitions of 

‘‘Covered surgical procedures’’ and 

‘‘Facility services.’’

The republished introductory text 

preceding the definitions and revised 

definitions read as follows: 

§ 416.2 Definitions. 

As used in this part: 

* * * * * 

Covered surgical procedures means 

those surgical procedures that meet the 

criteria specified in §§ 416.65 or 

416.166, as applicable, and are 

published in the Federal Register. 

Facility services means services that 

are furnished in connection with 

covered surgical procedures performed 

in an ASC. 

8. The heading for Subpart D is 

revised to read as follows: 

Subpart D—Scope of Benefits for 

Services Furnished Before January 1, 

2008 

9. Section 416.65 is amended by—

a. Revising the introductory text. 

b. Revising paragraph (a)(4). 

The revisions read as follows: 

§ 416.65 Covered surgical procedures. 

Effective for services furnished before 

January 1, 2008, covered surgical 

procedures are those procedures that 

meet the standards described in 

paragraphs (a) and (b) of this section 

and are included in the list published in 

accordance with paragraph (c) of this 

section. 

(a) * * * 

(4) Are not otherwise excluded under 

§ 411.15 of this chapter. 

* * * * * 

10. A new § 416.76 is added to read 

as follows: 

§ 416.76 Applicability. 

The provisions of this subpart apply 

to facility services furnished before 

January 1, 2008. 

11. The heading for Subpart E is 

revised to read as follows: 

Subpart E—Prospective Payment 

System For Facility Services Furnished 

Before January 1, 2008 

§ 416.120 [Amended] 

12. In paragraph (a) of § 416.120, the 

cross-reference ‘‘Part 413’’ is removed 

and the cross-reference ‘‘Part 419’’

added in its place. 

13. A new § 416.121 is added to read 

as follows: 

§ 416.121 Applicability. 

The provisions of this subpart apply 

to facility services furnished before 

January 1, 2008. 

14. Section 416.125 is amended by 

adding a new paragraph (c) to read as 

follows: 

§ 416.125 ASC facility services payment 

rate. 

* * * * * 

(c) For services furnished on or after 

January 1, 2007, and before the effective 

date of implementation of a revised 

payment system, the ASC payment rate 

for a surgical procedure shall be the 

lesser of the ASC payment rate 

established under paragraph (a) of this 

section or the prospective payment rate 

for the procedure established under 

section 419.32. The lesser payment 

amount shall be determined prior to 

application of any geographic 

adjustment. 

§ 416.150 [Removed] 

15. Section 416.150 is removed. 

Subpart F—[Redesignated as Subpart 

G] 

16. Existing Subpart F is redesignated 

Subpart G 

17. A new Subpart F is added to read 

as follows: 


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Subpart F—Coverage, Scope of ASC 

Facility Services, and Prospective 

Payment System For Facility Services 

Furnished On Or After January 1, 2008 

Sec. 

416.160 Basis and scope. 

416.161 Applicability. 

416.163 General rules. 

416.164 Scope of ASC facility services. 

416.166 Covered surgical procedures. 

416.167 Basis of payment. 

416.171 Calculation of prospective payment 

rates for ASC services. 

416.172 Adjustments to national payment 

rates. 

416.173 Publication of revised payment 

methodologies and payment rates. 

416.178 Limitations on administrative and 

judicial review. 

§ 416.160 Basis and scope. 

(a) Statutory basis. (1) Section 

1833(a)(1)(G) of the Act provides that, 

beginning with the implementation date 

of a revised payment system for ASC 

facility services furnished in connection 

with a surgical procedure pursuant to 

section 1833(i)(1)(A) of the Act, the 

amount paid shall be 80 percent of the 

lesser of the actual charge for such 

services or the amount determined by 

the Secretary under the revised payment 

system. 

(2) Section 1833(i)(1)(A) of the Act 

requires the Secretary to specify the 

surgical procedures that can be 

performed safely on an ambulatory basis 

in an ASC. 

(3) Section 1833(i)(2)(D) of the Act 

requires the Secretary to implement a 

revised payment system for payment of 

surgical services furnished in ASCs. The 

statute requires that, in the year such 

system is implemented, the system shall 

be designed to result in the same 

amount of aggregate expenditures for 

such services as would be made if there 

were no requirement for a revised 

payment system. The revised payment 

system shall be implemented no earlier 

than January 1, 2006, and no later than 

January 1, 2008. There shall be no 

administrative or judicial review under 

section 1869 of the Act, section 1878 of 

the Act, or otherwise of the 

classification system, the relative 

weights, payment amounts, and the 

geographic adjustment factor, if any, of 

the revised payment system. 

(b) Scope. This subpart sets forth—

(1) The scope of ASC facility services 

and the criteria for determining the 

procedures for which Medicare pays an 

ASC facility fee; and 

(2) The methodologies by which 

Medicare determines payment amounts 

for ASC facility services. 

§ 416.161 Applicability. 

The provisions of this subpart apply 

to ASC facility services furnished on or 

after January 1, 2008. 

§ 416.163 General rules. 

(a) The services for which payment is 

made under this subpart are ASC 

facility services as specified in 

§ 416.164(a) furnished to Medicare 

beneficiaries by a participating ASC in 

connection with covered surgical 

procedures as determined by the 

Secretary in accordance with § 416.166. 

(b) Physician services, including 

surgical procedures and all preoperative 

and post-operative services that are 

performed by a physician, are paid in 

accordance with Part 414 of this 

chapter. 

(c) Items and services as specified in 

§ 416.164(b) for which payment may be 

made under other provisions of Part 410 

of this chapter are not included in the 

payment amount for ASC facility 

services. 

§ 416.164 Scope of ASC facility services. 

(a) Included services. ASC facility 

services include, but are not limited 

to—

(1) Nursing, technician, and related 

services; 

(2) Use of the facility where the 

surgical procedures are performed; 

(3) Items and services directly related 

to the pre-operative preparation of 

patients upon their admission to the 

ASC for surgery, to the performance of 

a surgical procedure(s) and to the postoperative and post-anesthesia care of 

patients prior to their discharge from the 

ASC. This includes, but is not limited 

to: Any laboratory testing performed 

under a Clinical Laboratory 

Improvement Amendments of 1988 

(CLIA) certificate of waiver; drugs and 

biologicals; medical and surgical 

supplies and equipment; surgical 

dressings; implanted prosthetic devices, 

accessories and supplies including 

intraocular lenses (IOLs); implanted 

DME, accessories and supplies; splints 

and casts and related devices; and 

imaging services or other diagnostic 

tests or interpretive services directly 

related to a surgical procedure; 

(4) Administrative, recordkeeping and 

housekeeping items and services; 

(5) Materials, including supplies and 

equipment for the administration and 

monitoring of anesthesia; and 

(6) Supervision of the services of an 

anesthetist by the operating surgeon. 

(b) Excluded services. Facility 

services do not include costs incurred to 

procure corneal tissue or items and 

services for which payment may be 

made under other provisions of Parts 

410 and 414 of this chapter, such as 

physicians’ services; X-ray or diagnostic 

procedures (other than those directly 

related to performance of the surgical 

procedure); ambulance services; leg, 

arm, back and neck braces other than 

those that serve the function of a cast or 

splint; artificial limbs; non-implantable 

prosthetic devices and durable medical 

equipment. In addition, they do not 

include anesthetist services furnished 

on or after January 1, 1989. 

§ 416.166 Covered surgical procedures. 

(a) Covered surgical procedures. 

Effective for services furnished on or 

after January 1, 2008, covered surgical 

procedures are those procedures that 

meet the general standards described in 

paragraph (b) of this section (whether 

commonly furnished in an ASC or a 

physician’s office) and are not excluded 

under paragraph (c) of this section. 

(b) General standards. Subject to the 

exclusions in paragraph (c) of this 

section, covered surgical procedures are 

surgical procedures specified by the 

Secretary that would not be expected to 

pose a significant safety risk to a 

Medicare beneficiary when performed 

in an ASC. 

(c) General exclusions. 

Notwithstanding paragraph (b) of this 

section, covered surgical procedures do 

not include those surgical and other 

medical procedures that—

(1) Generally result in extensive blood 

loss; 

(2) Require major or prolonged 

invasion of body cavities; 

(3) Directly involve major blood 

vessels; 

(4) Are generally emergent or lifethreatening in nature; 

(5) Standard medical practice dictates 

that the beneficiary will typically be 

expected to require active medical 

monitoring and care at midnight 

following the procedure; or, 

(6) Are otherwise excluded under 

§ 411.15 of this chapter. 

§ 416.167 Basis of payment. 

(a) Unit of payment. Under the ASC 

prospective payment system, 

prospectively determined amounts are 

paid for facility services furnished to 

Medicare beneficiaries in connection 

with designated surgical procedures. 

Surgical procedures are identified by 

codes established under the Centers for 

Medicare & Medicaid Services Common 

Procedure Coding System (HCPCS). The 

prospective payment rate for each 

procedure for which payment is allowed 

under the ASC payment system is 

determined according to the 

methodology described in § 416.171. 

The manner in which the Medicare 


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payment amount and the beneficiary 

copayment amount for each procedure 

are determined is described in 

§ 416.172. 

(b) Ambulatory payment classification 

(APC) groups and payment weights 

(1) ASC covered surgical procedures 

are classified using the APC groups 

described in § 419.31 of this chapter. An 

APC group consists of outpatient 

services and procedures that are 

comparable clinically and in terms of 

resources. 

(2) For purposes of calculating ASC 

national payment rates under the 

methodology described in § 416.171, 

except as specified in paragraph (b)(3), 

of this section, an ASC covered surgical 

procedure is assigned the applicable 

APC relative payment weight described 

in § 419.31 of this chapter. 

(3) Notwithstanding paragraph (b)(2) 

of this section, the relative payment 

weights for procedures paid in 

accordance with § 416.171(e) are 

determined so that the national ASC 

payment rate does not exceed the MPFS 

nonfacility amount paid for such 

procedures under Subpart B of Part 414 

of this chapter. 

§ 416.171 Calculation of prospective 

payment rates for ASC services. 

(a) Conversion factor for calendar year 

2008. CMS calculates a conversion 

factor so that payment for ASC services 

furnished in 2008 would result in the 

same aggregate amount of expenditures 

as would be made if the provisions in 

Subpart F did not apply. 

(b) Conversion factor for calendar 

year 2009 and subsequent years. The 

conversion factor for a calendar year is 

equal to the conversion factor calculated 

for the previous year adjusted as 

follows: 

(1) For calendar year 2009, the 

increase shall equal zero percent. 

(2) For calendar year 2010 and 

subsequent years, by the Consumer 

Price Index for all urban consumers 

(U.S. city average) as estimated by the 

Secretary for the 12-month period 

ending with the midpoint of the year 

involved. 

(c) Transitional payment rates for 

calendar year 2008. ASC payment rates 

for 2008 are a transitional blend of 50 

percent of the CY 2007 ASC payment 

rate for a surgical procedure on the CY 

2007 ASC list of surgical procedures 

and 50 percent of the payment rate for 

the procedure calculated under the 

methodology described in paragraph (d) 

of this section. 

(d) Payment rates for calendar year 

2009 and subsequent years. The 

national ASC payment rate for a covered 

surgical procedure designated in 

accordance with § 416.166 is the 

product of the conversion factor 

calculated under paragraph (a) or 

paragraph (b) of this section and the 

relative weight determined under 

§ 416.167(b). 

(e) Limitation on payment for certain 

ASC procedures. Notwithstanding the 

provisions of paragraph (c) and 

paragraph (d) of this section, if CMS 

determines that a covered procedure 

under § 416.166 of this part is 

commonly performed in physicians’

offices, payment for ASC facility 

services for such procedure shall be the 

lesser of the amount determined under 

paragraph (c) or paragraph (d) of this 

section or the amount paid for such 

procedure under Subpart B of Part 414 

of this chapter. 

(f) Budget neutrality. (1) For calendar 

year 2008, CMS adjusts the conversion 

factor in accordance with paragraph (a) 

to result in budget neutrality as 

estimated by CMS. 

(2) For calendar year 2009 and 

subsequent years, CMS adjusts the ASC 

relative payment weights under 

§ 416.167(b)(2) as needed so that any 

updates and adjustments made under 

§ 419.50(a) of this chapter are budget 

neutral as estimated by CMS. 

§ 416.172 Adjustments to national 

payment rates. 

(a) General rule. CMS establishes 

national prospective payment rates for 

ASC facility services to which certain 

adjustments are applied to determine 

Medicare program payment and 

beneficiary copayment amounts. 

(b) Lesser of actual charge or 

prospective rate. Payments to ASCs 

shall equal the lesser of 80 percent of: 

(1) the actual charge for the service; 

or, 

(2) the prospective rate determined 

under this subpart. 

(c) Geographic adjustment. National 

ASC payment rates established under 

§ 416.171 for covered surgical 

procedures are adjusted for variations in 

ASC labor costs across geographic areas 

using wage index values, labor and nonlabor percentages, and localities 

specified by the Secretary. 

(d) Deductibles and coinsurance. Part 

B deductible and coinsurance amounts 

apply as specified in § 410.152(a) and (i) 

of this chapter. 

(e) Payment reductions for multiple 

surgical procedures. (1) General rule. 

Except as provided in paragraph (e)(2) 

of this section, when more than one 

surgical procedure for which payment is 

made under the ASC prospective 

payment system is performed during an 

operative session, the Medicare program 

payment amount and the beneficiary 

copayment amount are based on—

(i) The full amounts for the procedure 

with the highest APC payment rate; and 

(ii) One-half of the full program and 

the beneficiary payment amounts for all 

other covered procedures. 

(2) Exception. The Secretary may 

apply any policies or procedures used 

with respect to multiple procedures 

under the prospective payment system 

for hospital outpatient department 

services under part 419 of this chapter 

as may be consistent with the equitable 

and efficient administration of part 416. 

§ 416.173 Publication of revised payment 

methodologies and payment rates. 

CMS will publish annually through 

notice and comment rulemaking in the 

Federal Register, the payment 

methodologies, payment rates and 

surgical procedures for which CMS will 

make an ASC facility payment, and 

other revisions as appropriate. 

§ 416.178 Limitations on administrative 

and judicial review. 

There is no administrative or judicial 

review under sections 1869 of the Act, 

section 1878 of the Act or otherwise of 

the following: 

(a) The APC classification system; 

(b) Relative payment weights; 

(c) Payment amounts; or 

(d) Geographic adjustment factors. 

18. Redesignated Subpart G is revised 

to read as follows: 

Subpart G—Adjustment in Payment 

Amounts for New Technology 

Intraocular Lenses Furnished by 

Ambulatory Service Centers 

Sec. 

416.180 Basis and scope. 

416.185 Process for establishing a new class 

of new technology IOLs. 

416.190 Request for review of payment 

amount. 

416.195 Determination of membership in 

new classes of new technology IOLs. 

416.200 Payment adjustment. 

§ 416.180 Basis and scope. 

(a) Basis. This subpart implements 

section 141 of Public Law 103–432, 

which provides for adjustments to 

payment amounts for new technology 

intraocular lenses (IOLs) furnished at 

ambulatory surgical centers (ASCs). 

(b) Scope. This subpart sets forth—

(1) The process for interested parties 

to request that CMS review the 

appropriateness of the ASC facility fee 

for insertion of an IOL. This process 

includes a review of whether that 

payment is reasonable and related to the 

cost of acquiring a lens determined by 

CMS as belonging to a class of new 

technology IOLs; 


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(2) Factors that CMS considers for 

determination of a new class of new 

technology IOLs; and 

(3) Application of the payment 

adjustment. 

§ 416.185 Process for establishing a new 

class of new technology IOLs. 

(a) Announcement of deadline for 

requests for review. CMS announces the 

deadline for each year’s requests for 

review of a new class of new technology 

IOLs in the final rule updating the ASC 

payment rates for that calendar year. 

(b) Announcement of new classes of 

new technology IOLs for which review 

requests have been made and 

solicitation of public comments. CMS 

announces the requests for review 

received in a calendar year and the 

deadline for public comments regarding 

the requests in the proposed rule 

updating the ASC payment rates for the 

following calendar year. The deadline 

for submission of public comments is 30 

days following the date of the 

publication of the proposed rule. 

(c) Announcement of determinations 

regarding requests for review. CMS 

announces its determinations for a 

calendar year in the final rule updating 

the ASC payment rates for the following 

calendar year. CMS publishes the codes 

and effective dates allowed for those 

lenses recognized by CMS as belonging 

to a class of new technology IOLs. New 

classes of new technology IOLs are 

effective 30 days following the date of 

publication of the final rule. 

§ 416.190 Request for review of payment 

amount. 

(a) When requests can be submitted. A 

request for review of the 

appropriateness of ASC payment for 

insertion of an IOL that might qualify 

for a payment adjustment as belonging 

to a new class of new technology IOLs 

must be submitted to CMS in 

accordance with the annual published 

deadline. 

(b) Who may submit a request. Any 

individual, partnership, corporation, 

association, society, scientific or 

academic establishment, or professional 

or trade organization able to furnish the 

information required in paragraph(c) of 

this section may request that CMS 

review the appropriateness of the 

payment amount provided under 

section 1833(i)(2)(A)(iii) of the Act with 

respect to an IOL that meets the criteria 

of a new technology IOL under 

§ 416.195. 

(c) Content of a request. In order to be 

accepted by CMS for review, a request 

for review of the ASC payment amount 

for insertion of an IOL must include all 

the information as specified by CMS. 

(d) Confidential information. In order 

for CMS to invoke the protection 

allowed under Exemption 4 of the 

Freedom of Information Act (5 U.S.C. 

552(b)(4)) and, with respect to trade 

secrets, the Trade Secrets Act (18 U.S.C. 

1905), the requestor must clearly 

identify all information that is to be 

characterized as confidential. 

§ 416.195 Determination of membership in 

new classes of new technology IOLs. 

(a) Factors to be considered. CMS uses 

the following criteria to determine 

whether an IOL qualifies for a payment 

adjustment as a member of a new class 

of new technology IOLs when inserted 

at an ASC. 

(1) The IOL is approved by the FDA. 

(2) Claims of specific clinical benefits 

and/or lens characteristics with 

established clinical relevance in 

comparison to currently available IOLs 

are approved by the FDA for use in 

labeling and advertising. 

(3) The IOL is not described by an 

active or expired class of new 

technology IOLs; that is, it does not 

share a predominant, class-defining 

characteristic associated with improved 

clinical outcomes with members of an 

active or expired class. 

(4) Evidence demonstrated that use of 

the IOL results in measurable, clinically 

meaningful, improved outcomes in 

comparison with use of currently 

available IOLs. Superior outcomes 

include: 

(i) Reduced risk of intraoperative or 

postoperative complication or trauma; 

(ii) Accelerated postoperative 

recovery; 

(iii) Reduced induced astigmatism; 

(iv) Improved postoperative visual 

acuity; 

(v) More stable postoperative vision; 

(vi) Other comparable clinical 

advantages. 

(b) CMS determination of eligibility 

for payment adjustment. CMS reviews 

the information submitted with a 

completed request for review, public 

comments submitted timely, and other 

pertinent information and makes a 

determination as follows: 

(1) The IOL is eligible for a payment 

adjustment as a member of a new class 

of new technology IOLs. 

(2) The IOL is a member of an active 

class of new technology IOLs and is 

eligible for a payment adjustment for the 

remainder of the period established for 

that class. 

(3) The IOL does not meet the criteria 

for designation as a new technology IOL 

and a payment adjustment is not 

appropriate. 

§ 416.200 Payment adjustment. 

(a) CMS establishes the amount of the 

payment adjustment for classes of new 

technology IOLs through proposed and 

final rulemaking in connection with 

ASC center services. 

(b) CMS adjusts the payment for 

insertion of an IOL approved as 

belonging to a class of new technology 

IOLs for the 5-year period of time 

established for that class. 

(c) Upon expiration of the 5-year 

period of the payment adjustment, 

payment reverts to the standard rate for 

IOL insertion procedures performed in 

ASCs. 

(d) ASCs that furnish an IOL 

designated by CMS as belonging to a 

class of new technology IOLs must 

submit claims using billing codes 

specified by CMS to receive the new 

technology IOL payment adjustment. 

PART 419—PROSPECTIVE PAYMENT 

SYSTEM FOR HOSPITAL OUTPATIENT 

DEPARTMENT SERVICES 

19. The authority citation for part 419 

continues to read as follows: 

Authority: Secs. 1102, 1833(t), and 1871 of 

the Social Security Act (42 U.S.C. 1302, 

1395l(t), and 1395hh). 

20. Section 419.21 is amended by 

revising the introductory text of 

paragraph (d) to read as follows: 

§ 419.21 Hospital outpatient services 

subject to the outpatient prospective 

payment system. 

* * * * * 

(d) The following medical and other 

health services furnished by a home 

health agency (HHA) to patients who are 

not under an HHA plan or treatment or 

by a hospice program furnishing 

services to patients outside the hospice 

benefit: 

* * * * * 

21. Section 419.43 is amended by 

adding a new paragraph (h) to read as 

follows: 

§ 419.43 Adjustments to national program 

payment and beneficiary copayment 

amounts. 

* * * * * 

(h) Applicable adjustments to 

conversion factor for CY 2007 and for 

subsequent calendar years. 

(1) General rule. For CY 2007, the 

applicable adjustment to the conversion 

factor specified in § 419.32(b)(iv) is 

reduced by 2.0 percentage points for any 

hospital that has its annual percentage 

change reduced under § 412.64(d)(2) of 

this chapter for the corresponding fiscal 

year. For subsequent years, the 

applicable adjustment to the conversion 

factor is reduced for any hospital that 


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fails to satisfy quality reporting 

requirements as designated by CMS. 

(2) Limitation. Any reduction to a 

hospital’s adjustment to its conversion 

factor specified in § 419.32(b)(iv) which 

occurs as a result of paragraph (h)(1) of 

this section will apply only to the 

calendar year involved and will not be 

taken into account in computing that 

hospital’s applicable adjustment for a 

subsequent calendar year. 

(3) Budget neutrality. For CY 2007 

and for each subsequent calendar year, 

CMS makes an adjustment to the 

conversion factor, so that estimated 

aggregate payments under the OPPS for 

such calendar year are not affected by 

any reductions to hospital adjustments 

which occur as a result of paragraph 

(h)(1) of this section. 

22. A new section 419.45 is added to 

read as follows: 

§ 419.45 Payment and copayment 

reduction for devices replaced under 

warranty or as a result of recall. 

(a) General rule. CMS reduces the 

amount of payment for an implanted 

device made under the hospital 

outpatient prospective payment system 

in accordance with § 419.66 for which 

CMS determines that a significant 

portion of the payment is attributable to 

the cost of an implanted device, when 

one of the following situations occur: 

(1) The device is replaced without 

cost to the provider or the beneficiary; 

or 

(2) The provider receives full credit 

for the cost of a replaced device. 

(b) Amount of reduction to the APC 

payment. The amount of the reduction 

to the APC payment made under 

paragraph (a) of this section is 

calculated in the same manner as the 

offset amount that would be applied if 

the device implanted in a procedure 

assigned to the APC had transitional 

pass-through status under § 419.66. 

(c) Amount of beneficiary copayment. 

The beneficiary copayment is calculated 

based on the APC payment after 

application of the reduction under 

paragraph (b) of this section. 

23. Section 419.70 is amended by—

a. Revising paragraph (d)(1). 

b. Redesignating paragraphs (d)(2) and 

(d)(3) as paragraphs (d)(3) and (d)(4), 

respectively. 

c. Adding a new paragraph (d)(2). 

The revisions and addition read as 

follows: 

§ 419.70 Transitional adjustment to limit 

decline in payments. 

* * * * * 

(d) Hold harmless provisions.—(1) 

Temporary treatment for small rural 

hospitals before January 1, 2006. For 

covered hospital outpatient services 

furnished in a calendar year before 

January 1, 2006, for which the 

prospective payment system amount is 

less than the pre-BBA amount, the 

amount of payment under this part is 

increased by the amount of that 

difference if the hospital—

(i) Is located in a rural area as defined 

in § 412.63(b) of this chapter or is 

treated as being located in a rural area 

under section 1886(d)(8)(E) of the Act; 

and 

(ii) Has 100 or fewer beds as defined 

in § 412.105(b) of this chapter. 

(2) Temporary treatment for small 

rural hospitals on or after January 1, 

2006. For covered hospital outpatient 

services furnished in a calendar year 

from January 1, 2006, through December 

31, 2008, for which the prospective 

payment system amount is less than the 

pre-BBA amount, the amount of 

payment under this paragraph is 

increased by 95 percent of that 

difference for services furnished during 

2006, 90 percent of that difference for 

services furnished during 2007, and 85 

percent of that difference for services 

furnished during 2008 if the hospital—

(i) Is located in a rural area as defined 

in § 412.63(b) of this chapter or is 

treated as being located in a rural area 

under section 1886(d)(8)(E) of the Act; 

(ii) Has 100 or fewer beds as defined 

in § 412.105(b) of this chapter; 

(iii) Is not a sole community hospital 

as defined in § 412.92 of this chapter; 

and 

(iv) Is not an essential access 

community hospital under § 412.109 of 

this chapter. 

* * * * * 

PART 421—MEDICARE CONTRACTING 

24. The heading of part 421 is revised 

to read as set out above. 

25. The authority citation for part 421 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

26. Section 421.3 is revised to read as 

follows: 

§ 421.3 Definitions. 

As used in this part—

Intermediary means an entity that has 

a contract with CMS (under statutory 

provisions in effect prior to October 1, 

2005) to determine and make Medicare 

payments for Part A or Part B benefits 

payable on a cost basis (or under the 

prospective payment system for 

hospitals) and to perform other related 

functions. For purposes of applying the 

performance criteria in § 421.120 and 

the performance standards in § 421.122 

and any adverse action resulting from 

that application, the term 

‘‘intermediary’’ also means a Blue Cross 

plan that has entered into a subcontract 

approved by CMS with the Blue Cross 

and Blue Shield Association to perform 

intermediary functions. 

27. Section 421.100 is amended by 

revising paragraph (i) to read as follows: 

§ 421.100 Intermediary functions. 

* * * * * 

(i) Dual intermediary responsibilities. 

Regarding the responsibility for service 

to provider-based HHAs and providerbased hospices, where the HHA or the 

hospice and its parent provider will be 

served by different intermediaries, the 

designated regional intermediary will 

process bills, make coverage 

determinations, and make payments to 

the HHAs and the hospices. The 

intermediary serving the parent 

provider will perform all fiscal 

functions, including audits and 

settlement of the Medicare cost reports 

and the HHA and hospice supplement 

worksheets. 

28. Section 421.103 is revised to read 

as follows: 

§ 421.103 Payment to providers. 

Providers are assigned to 

intermediaries in accordance with 

§ 421.104. As the Medicare 

Administrative Contractors (MACs) are 

implemented, providers are reassigned 

from intermediaries to MACs in 

accordance with § 412.404. 

29. Section 421.104 is revised to read 

as follows: 

§ 421.104 Assignment of providers of 

services to intermediaries during transition 

to Medicare administrative contractors 

(MACs). 

(a) Beginning October 1, 2005, CMS 

assigns providers of services and other 

entities that may bill Part A benefits to 

intermediaries in a manner that will 

best support the transition to Medicare 

administrative contractors (MACs) 

under section 1874A of the Act in 

accordance with Subpart E of this part. 

(b) These providers of services and 

other entities must continue to bill the 

intermediary that they were billing prior 

to October 1, 2005, until one of the 

following events occurs: 

(1) The intermediary’s agreement with 

CMS ends, and the provider or entity is 

directed by CMS to bill another CMS 

contractor. 

(2) The provider or entity is assigned 

to a MAC that has begun to administer 

claims within the geographic locale of 

the provider or entity. 

(3) CMS directs the provider or entity 

to begin billing another CMS contractor 

in order to support the implementation 


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of MACs under section 1874A of the Act 

and Subpart E of this part. 

(c) New providers of services and new 

entities will be assigned to the 

intermediary serving their geographic 

locale if no MAC has begun to 

administer Medicare claims in the 

locale. These providers or entities must 

continue to bill the intermediary until 

one of the events in paragraph (b) of this 

section occurs. 

(d) Providers or entities will only be 

granted exceptions to the provisions of 

paragraphs (b) or (c) of this section if 

CMS deems the exception to be in the 

compelling interest of the Medicare 

program. 

(e) CMS will notify the provider or 

entity, the outgoing intermediary, and 

the newly assigned intermediary of 

assignment or reassignment decisions. 

§ 421.105 [Removed] 

30. Section 421.105 is removed. 

§ 421.106 [Removed] 

31. Section 421.106 is removed. 

32. Section 421.112 is amended by—

a. Revising paragraph (a). 

b. Revising paragraph (b). 

The revisions read as follows: 

§ 421.112 Considerations relating to the 

effective and efficient administration of the 

program. 

(a) In order to accomplish the most 

effective and efficient administration of 

the Medicare program, the Secretary 

may make determinations with respect 

to the termination of an intermediary 

agreement, and CMS may make 

determinations with respect to renewal 

of an intermediary agreement under 

§ 421.110. 

(b) When taking the actions specified 

in paragraph (a) of this section, the 

Secretary or CMS will consider the 

performance of the individual 

intermediary in its Medicare operations 

using the factors contained in the 

performance criteria specified in 

§ 421.120 and the performance 

standards specified in section § 421.122. 

* * * * * 

33. Section 421.114 is revised to read 

as follows: 

§ 421.114 Assignment and reassignment 

of providers by CMS. 

CMS may assign or reassign any 

provider to any intermediary if it 

determines that the assignment or 

reassignment will be in the best 

interests of the Medicare program. 

§ 421.116 [Removed] 

34. Section 421.116 is removed. 

§ 421.117 [Removed] 

35. Section 421.117 is removed. 

§ 421.118 [Removed] 

36. Section 421.118 is removed. 

37. Reserve Subpart D and add a new 

Subpart E to Part 421 to read as follows: 

Subpart E—Medicare Administrative 

Contractors (MACs) 

Sec. 

421.400 Statutory basis and scope. 

421.401 Definitions. 

421.404 Assignment of providers and 

suppliers to MACs. 

§ 421.400 Statutory basis and scope. 

(a) Statutory basis. This subpart 

implements section 1874A of the Act, 

which provides for the transition of the 

claims processing functions and 

operations for both Medicare Part A and 

Part B intermediaries and carriers to 

Medicare administrative contractors 

(MACs). The transition will occur 

between October 1, 2005, and October 1, 

2011. MACs will be fully operational in 

distinct, nonoverlapping geographic 

jurisdictions by October 1, 2011. 

(b) Scope. This subpart specifies the 

requirements under which providers 

and suppliers will be assigned to MACs. 

§ 421.401 Definitions. 

For purposes of this subpart—

Appropriate MAC means a MAC that 

has a contract under section 1874A of 

the Act to perform a particular Medicare 

administrative function in relation to: 

(1) A particular individual entitled to 

benefits under Part A or enrolled under 

Part B, or both; 

(2) A specific provider of services or 

supplier; or 

(3) A class of providers of services or 

suppliers. 

Medicare administrative contractor 

(MAC) means an agency, organization, 

or other person with a contract under 

section 1874A of the Act. 

§ 421.404 Assignment of providers and 

suppliers to MACs. 

(a) Definitions. As used in this 

section—

Chain provider means a group of two 

or more providers under common 

ownership or control. 

Common control exists when an 

individual, a group of individuals, or an 

organization has the power, directly or 

indirectly, to significantly influence or 

direct the actions or policies of the 

group of suppliers or eligible providers. 

Common ownership exists when an 

individual, a group of individuals, or an 

organization possesses significant equity 

in the group of suppliers or eligible 

providers. 

Durable medical equipment, 

prosthetics, orthotics, and supplies 

(DMEPOS) means the types of services 

specified in § 421.210(b). 

Eligible provider means a hospital, 

skilled nursing facility, or critical access 

hospital that meets the definition of a 

provider under § 400.202 of this 

chapter. 

Home office means the entity that 

provides centralized management and 

administrative services to the individual 

providers or suppliers under common 

ownership and common control, such as 

centralized accounting, purchasing, 

personnel services, management 

direction and control, and other similar 

services. 

Ineligible provider means a provider 

under § 400.202 of this chapter that is 

not an eligible provider. 

Medicare benefit category means a 

category of covered benefits under Part 

A or Part B of the Medicare program (for 

example, inpatient hospital services, 

post-hospital extended care services, 

and physicians’ services). 

Provider has the same meaning as 

specified under § 400.202 of this 

chapter. 

Qualified chain provider means a 

chain provider comprised of—

(1) 10 or more eligible providers 

collectively totaling 500 or more 

certified beds; or 

(2) 5 or more eligible providers 

collectively totaling 300 or more 

certified beds, with eligible providers in 

3 or more continuous States. 

Supplier has the same meaning as 

specified in § 400.202 of this chapter. 

(b) Assignment of providers to MACs. 

(1) Providers enroll with and receive 

Medicare payment and other Medicare 

services from the MAC contracted by 

CMS to administer claims for the 

Medicare benefit category applicable to 

the provider’s covered services for the 

geographic locale in which the provider 

is physically located. 

(2) Qualified chain providers may 

request and receive an exception from 

the requirement of paragraph (b)(1) of 

this section from CMS. Upon CMS’

approval, a qualified chain provider 

may enroll with and bill on behalf of the 

eligible providers under its common 

ownership or common control to the 

MAC contracted by CMS to administer 

claims for the Medicare benefit category 

applicable to the eligible providers’

covered services for the geographic 

locale in which the qualified chain 

provider’s home office is physically 

located. 

(3) As MAC contractors become 

available, qualified chain providers, 

granted approval by CMS to enroll with 

and bill a single intermediary on behalf 

of their eligible member providers prior 

to October 1, 2005, will be assigned at 

an appropriate time to the MAC 

contracted by CMS to administer claims 


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for the applicable Medicare benefit 

category for the geographic locale in 

which the chain provider’s home office 

is physically located. The qualified 

chain provider will not need to request 

an exception to the requirement of 

paragraph (b)(1) of this section in order 

for this assignment to take effect. 

(4) CMS may grant an exception to the 

requirement of paragraph (b)(1) of this 

section to eligible providers that are not 

under the common ownership or 

common control of a qualified chain 

provider, as well as ineligible providers, 

only if CMS finds the exception will 

support the implementation of MACs or 

will serve some other compelling 

interest of the Medicare program. 

(c) Assignment of suppliers to MACs. 

(1) Suppliers, including physicians and 

other practitioners, but excluding 

suppliers of DMEPOS, enroll with and 

receive Medicare payment and other 

Medicare services from the MAC 

contracted by CMS to administer claims 

for the Medicare benefit category 

applicable to the supplier’s covered 

services for the geographic locale in 

which the supplier furnished such 

services. 

(2) Suppliers of DMEPOS receive 

Medicare payment and other Medicare 

services from the MAC assigned to 

administer claims for DMEPOS for the 

regional area in which the beneficiary 

receiving the DMEPOS resides. The 

terms of §§ 421.210 and 421.212 

continue to apply to suppliers of 

DMEPOS. 

(3) CMS may allow a group of ESRD 

suppliers under common ownership 

and common control to enroll with the 

MAC contracted by CMS to administer 

ESRD claims for the geographic locale in 

which the group’s home office is located 

only if—

(i) The group of ESRD suppliers 

requests such privileges; and 

(ii) CMS finds the exception will 

support the implementation of MACs or 

will serve some other compelling 

interest of the Medicare program. 

PART 485—CONDITIONS OF 

PARTICIPATION: SPECIALIZED 

PROVIDERS 

38. The authority citation for Part 485 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

39. Section 485.618 is amended by—

a. Revising paragraph (d)(1) 

introductory text. 

b. Redesignating paragraphs (d)(2) and 

(d)(3) as paragraphs (d)(3) and (d)(4), 

respectively. 

c. Adding a new paragraph (d)(2). 

d. In redesignated paragraph 

(d)(3)(iv), removing the cross-reference 

‘‘paragraph (d)(2)(iii)’’ and adding the 

cross-reference ‘‘paragraph (d)(3)(iii)’’ in 

its place. 

e. In redesignated paragraph (d)(4), 

removing the cross-reference ‘‘paragraph 

(d)(2)(iii)’’ and adding the crossreference ‘‘paragraph (d)(3)(iii)’’ in its 

place. 

The revisions and additions read as 

follows: 

§ 485.618 Condition of participation: 

Emergency services. 

* * * * * 

(d) Standard: Personnel. 

(1) Except as specified in paragraph 

(d)(3) of this section, there must be a 

doctor of medicine or osteopathy, a 

physician assistant, a nurse practitioner, 

or a clinical nurse specialist, with 

training or experience in emergency 

care, on call and immediately available 

by telephone or radio contact, and 

available onsite within the following 

timeframes: 

* * * * * 

(2) A registered nurse with training 

and experience in emergency care can 

be utilized to conduct specific medical 

screening examinations only if—

(i) The registered nurse is on site and 

immediately available at the CAH when 

a patient requests medical care; and 

(ii) The nature of the patient’s request 

for medical care is within the scope of 

practice of a registered nurse and 

consistent with applicable State laws. 

* * * * * 

PART 488—SURVEY, CERTIFICATION, 

AND ENFORCEMENT PROCEDURES 

40. The authority citation for part 488 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

41. In § 488.1, the definition of 

‘‘supplier’’ is revised to read as follows: 

§ 488.1 Definitions. 

* * * * * 

Supplier means any of the following: 

Independent laboratory; portable X-ray 

services; physical therapist in 

independent practice; ESRD facility; 

rural health clinic; Federally qualified 

health center; chiropractor; or 

ambulatory surgical center. 

* * * * * 

(Catalog of Federal Domestic Assistance 

Program No. 93.778, Medical Assistance 

Program) 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: July 28, 2006. 

Mark B. McClellan, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Dated: August 7, 2006. 

Michael O. Leavitt, 

Secretary. 


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ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0001 .... Level I Photochemotherapy .......................................................................... S 0.4896 30.14 7.00 6.03 

0002 .... Level I Fine Needle Biopsy/Aspiration .......................................................... T 1.0948 67.39 .................. 13.48 

0003 .... Bone Marrow Biopsy/Aspiration .................................................................... T 2.4295 149.54 .................. 29.91 

0004 .... Level I Needle Biopsy/ Aspiration Except Bone Marrow .............................. T 2.0863 128.41 .................. 25.68 

0005 .... Level II Needle Biopsy/Aspiration Except Bone Marrow .............................. T 3.8051 234.21 71.59 46.84 

0006 .... Level I Incision & Drainage ........................................................................... T 1.4821 91.22 21.76 18.24 

0007 .... Level II Incision & Drainage .......................................................................... T 10.9184 672.04 .................. 134.41 

0008 .... Level III Incision and Drainage ..................................................................... T 17.4686 1,075.21 .................. 215.04 

0009 .... Nail Procedures ............................................................................................ T 0.6803 41.87 .................. 8.37 

0010 .... Level I Destruction of Lesion ........................................................................ T 0.4829 29.72 8.14 5.94 

0011 .... Level II Destruction of Lesion ....................................................................... T 2.6478 162.97 .................. 32.59 

0012 .... Level I Debridement & Destruction ............................................................... T 0.8076 49.71 10.30 9.94 

0013 .... Level II Debridement & Destruction .............................................................. T 1.0876 66.94 .................. 13.39 

0015 .... Level III Debridement & Destruction ............................................................. T 1.6062 98.86 20.13 19.77 

0016 .... Level IV Debridement & Destruction ............................................................ T 2.6253 161.59 32.68 32.32 

0017 .... Level VI Debridement & Destruction ............................................................ T 17.7392 1,091.87 227.84 218.37 

0018 .... Biopsy of Skin/Puncture of Lesion ................................................................ T 1.0534 64.84 15.87 12.97 

0019 .... Level I Excision/ Biopsy ................................................................................ T 4.0123 246.96 71.87 49.39 

0020 .... Level II Excision/ Biopsy ............................................................................... T 6.5128 400.87 98.57 80.17 

0021 .... Level III Excision/ Biopsy .............................................................................. T 14.9563 920.58 219.48 184.12 

0022 .... Level IV Excision/ Biopsy ............................................................................. T 19.9760 1,229.54 354.45 245.91 

0023 .... Exploration Penetrating Wound .................................................................... T 4.1133 253.18 .................. 50.64 

0024 .... Level I Skin Repair ....................................................................................... T 1.4924 91.86 30.08 18.37 

0025 .... Level II Skin Repair ...................................................................................... T 5.0931 313.49 95.46 62.70 

0027 .... Level IV Skin Repair ..................................................................................... T 21.2645 1,308.85 329.72 261.77 

0028 .... Level I Breast Surgery .................................................................................. T 19.2250 1,183.32 303.74 236.66 

0029 .... Level II Breast Surgery ................................................................................. T 28.1505 1,732.69 .................. 346.54 

0030 .... Level III Breast Surgery ................................................................................ T 40.7495 2,508.17 763.55 501.63 

0031 .... Smoking Cessation Services ........................................................................ X 0.1716 10.56 .................. 2.11 

0033 .... Partial Hospitalization ................................................................................... P 3.3837 208.27 .................. 41.65 

0035 .... Arterial/Venous Puncture .............................................................................. T 0.2016 12.41 .................. 2.48 

0036 .... Level II Fine Needle Biopsy/Aspiration ......................................................... T 2.0147 124.01 .................. 24.80 

0037 .... Level IV Needle Biopsy/Aspiration Except Bone Marrow ............................ T 10.2616 631.61 228.76 126.32 

0038 .... Spontaneous MEG ........................................................................................ S 51.2627 3,155.27 .................. 631.05 

0039 .... Level I Implantation of Neurostimulator ........................................................ S 175.9328 10,828.84 .................. 2,165.77 

0040 .... Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve.S 56.3855 3,470.58 .................. 694.12 

0041 .... Level I Arthroscopy ....................................................................................... T 28.6279 1,762.08 .................. 352.42 

0042 .... Level II Arthroscopy ...................................................................................... T 45.0637 2,773.72 804.74 554.74 

0043 .... Closed Treatment Fracture Finger/Toe/Trunk .............................................. T 1.6914 104.11 .................. 20.82 

0045 .... Bone/Joint Manipulation Under Anesthesia .................................................. T 14.5502 895.58 268.47 179.12 

0047 .... Arthroplasty without Prosthesis .................................................................... T 32.7543 2,016.06 537.03 403.21 

0048 .... Level I Arthroplasty with Prosthesis ............................................................. T 47.1644 2,903.02 .................. 580.60 

0049 .... Level I Musculoskeletal Procedures Except Hand and Foot ....................... T 20.8214 1,281.58 .................. 256.32 

0050 .... Level II Musculoskeletal Procedures Except Hand and Foot ...................... T 25.0600 1,542.47 .................. 308.49 

0051 .... Level III Musculoskeletal Procedures Except Hand and Foot ..................... T 41.2543 2,539.24 .................. 507.85 

0052 .... Level IV Musculoskeletal Procedures Except Hand and Foot ..................... T 65.8846 4,055.26 .................. 811.05 

0053 .... Level I Hand Musculoskeletal Procedures ................................................... T 16.0343 986.93 253.49 197.39 

0054 .... Level II Hand Musculoskeletal Procedures .................................................. T 25.8425 1,590.63 .................. 318.13 

0055 .... Level I Foot Musculoskeletal Procedures ..................................................... T 20.2255 1,244.90 355.34 248.98 

0056 .... Level II Foot Musculoskeletal Procedures .................................................... T 41.2239 2,537.37 .................. 507.47 

0057 .... Bunion Procedures ....................................................................................... T 28.0970 1,729.40 475.91 345.88 

0058 .... Level I Strapping and Cast Application ........................................................ S 1.0504 64.65 .................. 12.93 

0060 .... Manipulation Therapy ................................................................................... S 0.4904 30.18 .................. 6.04 

0061 .... Laminectomy or Incision for Implantation of Neurostimulator Electrodes, 

Excluding Cranial Nerve.

S 84.2373 5,184.89 .................. 1,036.98 

0062 .... Level I Treatment Fracture/Dislocation ......................................................... T 25.6702 1,580.03 375.46 316.01 

0063 .... Level II Treatment Fracture/Dislocation ........................................................ T 37.5680 2,312.35 549.49 462.47 

0064 .... Level III Treatment Fracture/Dislocation ....................................................... T 56.4195 3,472.68 825.22 694.54 

0065 .... Level I Stereotactic Radiosurgery ................................................................. S 22.4428 1,381.38 .................. 276.28 

0066 .... Level II Stereotactic Radiosurgery ................................................................ S 47.2213 2,906.52 .................. 581.30 

0067 .... Level III Stereotactic Radiosurgery ............................................................... S 65.7255 4,045.47 .................. 809.09 

0068 .... CPAP Initiation .............................................................................................. S 1.3718 84.44 29.48 16.89 

0069 .... Thoracoscopy ................................................................................................ T 31.5464 1,941.71 591.64 388.34 

0070 .... Thoracentesis/Lavage Procedures ............................................................... T 3.6425 224.20 .................. 44.84 

0071 .... Level I Endoscopy Upper Airway ................................................................. T 0.7572 46.61 11.03 9.32 

0072 .... Level II Endoscopy Upper Airway ................................................................ T 1.4038 86.41 21.27 17.28 

0073 .... Level III Endoscopy Upper Airway ............................................................... T 3.8737 238.43 69.72 47.69 

0074 .... Level IV Endoscopy Upper Airway ............................................................... T 15.1300 931.27 295.70 186.25 


sroberts on PROD1PC70 with PROPOSALS
49706 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0075 .... Level V Endoscopy Upper Airway ................................................................ T 21.8010 1,341.87 445.92 268.37 

0076 .... Level I Endoscopy Lower Airway ................................................................. T 9.3905 577.99 189.82 115.60 

0077 .... Level I Pulmonary Treatment ....................................................................... S 0.3383 20.82 7.74 4.16 

0078 .... Level II Pulmonary Treatment ...................................................................... S 1.0381 63.90 14.55 12.78 

0079 .... Ventilation Initiation and Management ......................................................... S 2.7732 170.69 .................. 34.14 

0080 .... Diagnostic Cardiac Catheterization .............................................................. T 37.1008 2,283.59 838.92 456.72 

0081 .... Non-Coronary Angioplasty or Atherectomy .................................................. T 42.8894 2,639.89 .................. 527.98 

0082 .... Coronary Atherectomy .................................................................................. T 76.2006 4,690.22 1,008.90 938.04 

0083 .... Coronary Angioplasty and Percutaneous Valvuloplasty ............................... T 57.4937 3,538.79 .................. 707.76 

0084 .... Level I Electrophysiologic Evaluation ........................................................... S 9.9197 610.57 .................. 122.11 

0085 .... Level II Electrophysiologic Evaluation .......................................................... T 34.7086 2,136.35 .................. 427.27 

0086 .... Ablate Heart Dysrhythm Focus ..................................................................... T 47.1472 2,901.96 812.36 580.39 

0087 .... Cardiac Electrophysiologic Recording/Mapping ........................................... T 32.8298 2,020.71 .................. 404.14 

0088 .... Thrombectomy .............................................................................................. T 37.9652 2,336.80 655.22 467.36 

0089 .... Insertion/Replacement of Permanent Pacemaker and Electrodes .............. T 121.9402 7,505.54 1,682.28 1,501.11 

0090 .... Insertion/Replacement of Pacemaker Pulse Generator ............................... T 97.8357 6,021.89 1,612.80 1,204.38 

0091 .... Level II Vascular Ligation ............................................................................. T 34.6279 2,131.38 .................. 426.28 

0092 .... Level I Vascular Ligation .............................................................................. T 24.5817 1,513.03 306.56 302.61 

0093 .... Vascular Reconstruction/Fistula Repair without Device ............................... T 21.9703 1,352.29 .................. 270.46 

0094 .... Level I Resuscitation and Cardioversion ...................................................... S 2.4630 151.60 46.29 30.32 

0095 .... Cardiac Rehabilitation ................................................................................... S 0.5792 35.65 13.86 7.13 

0096 .... Non-Invasive Vascular Studies ..................................................................... S 1.5727 96.80 38.13 19.36 

0097 .... Cardiac and Ambulatory Blood Pressure Monitoring ................................... X 1.0245 63.06 23.79 12.61 

0098 .... Injection of Sclerosing Solution .................................................................... T 1.1035 67.92 .................. 13.58 

0099 .... Electrocardiograms ....................................................................................... S 0.3835 23.60 .................. 4.72 

0100 .... Cardiac Stress Tests .................................................................................... X 2.5352 156.04 41.44 31.21 

0101 .... Tilt Table Evaluation ..................................................................................... S 4.3122 265.42 100.24 53.08 

0103 .... Miscellaneous Vascular Procedures ............................................................. T 17.0436 1,049.05 223.63 209.81 

0104 .... Transcatheter Placement of Intracoronary Stents ........................................ T 87.9808 5,415.31 .................. 1,083.06 

0105 .... Revision/Removal of Pacemakers, AICD, or Vascular ................................ T 23.4666 1,444.39 370.40 288.88 

0106 .... Insertion/Replacement/Repair of Pacemaker and/or Electrodes ................. T 44.7574 2,754.86 .................. 550.97

0107 .... Insertion of Cardioverter-Defibrillator ............................................................ T 279.2049 17,185.34 .................. 3,437.07 

0108 .... Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads ............... T 370.5535 22,807.94 .................. 4,561.59 

0109 .... Removal of Implanted Devices ..................................................................... T 10.9541 674.24 .................. 134.85 

0110 .... Transfusion ................................................................................................... S 3.4570 212.78 .................. 42.56 

0111 .... Blood Product Exchange .............................................................................. S 11.7005 720.18 198.40 144.04 

0112 .... Apheresis, Photopheresis, and Plasmapheresis .......................................... S 30.6602 1,887.17 433.29 377.43 

0113 .... Excision Lymphatic System .......................................................................... T 21.3673 1,315.18 .................. 263.04 

0114 .... Thyroid/Lymphadenectomy Procedures ....................................................... T 37.1283 2,285.28 461.19 457.06 

0115 .... Cannula/Access Device Procedures ............................................................ T 29.4757 1,814.26 378.68 362.85 

0121 .... Level I Tube changes and Repositioning ..................................................... T 2.3431 144.22 43.80 28.84 

0122 .... Level II Tube changes and Repositioning .................................................... T 7.2859 448.45 .................. 89.69 

0123 .... Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant ............. S 23.2490 1,431.00 .................. 286.20 

0125 .... Refilling of Infusion Pump ............................................................................. T 2.2200 136.64 .................. 27.33 

0126 .... Level I Urinary and Anal Procedures ........................................................... T 1.0844 66.75 16.40 13.35 

0127 .... Level IV Stereotactic Radiosurgery .............................................................. S 126.8566 7,808.15 .................. 1,561.63 

0130 .... Level I Laparoscopy ...................................................................................... T 31.9353 1,965.65 659.53 393.13 

0131 .... Level II Laparoscopy ..................................................................................... T 43.5124 2,678.23 1,001.89 535.65 

0132 .... Level III Laparoscopy .................................................................................... T 70.8854 4,363.07 1,239.22 872.61 

0140 .... Esophageal Dilation without Endoscopy ...................................................... T 5.3134 327.05 91.40 65.41 

0141 .... Level I Upper GI Procedures ........................................................................ T 8.3070 511.30 143.38 102.26 

0142 .... Small Intestine Endoscopy ........................................................................... T 9.3878 577.83 152.78 115.57 

0143 .... Lower GI Endoscopy .................................................................................... T 8.8143 542.53 186.06 108.51 

0146 .... Level I Sigmoidoscopy and Anoscopy .......................................................... T 4.8005 295.48 64.40 59.10

0147 .... Level II Sigmoidoscopy and Anoscopy ......................................................... T 8.5644 527.15 .................. 105.43 

0148 .... Level I Anal/Rectal Procedures .................................................................... T 4.8970 301.42 .................. 60.28 

0149 .... Level III Anal/Rectal Procedures .................................................................. T 22.2336 1,368.50 293.06 273.70 

0150 .... Level IV Anal/Rectal Procedures .................................................................. T 29.4386 1,811.98 437.12 362.40 

0151 .... Endoscopic Retrograde Cholangio-Pancreatography (ERCP) ..................... T 19.8125 1,219.48 245.46 243.90 

0152 .... Level I Percutaneous Abdominal and Biliary Procedures ............................ T 19.4515 1,197.26 .................. 239.45 

0153 .... Peritoneal and Abdominal Procedures ......................................................... T 22.1758 1,364.94 397.95 272.99 

0154 .... Hernia/Hydrocele Procedures ....................................................................... T 29.1491 1,794.16 464.85 358.83 

0155 .... Level II Anal/Rectal Procedures ................................................................... T 12.8778 792.64 .................. 158.53 

0156 .... Level III Urinary and Anal Procedures ......................................................... T 3.5688 219.66 .................. 43.93 

0157 .... Colorectal Cancer Screening: Barium Enema .............................................. S 2.4974 153.72 .................. 30.74 

0158 .... Colorectal Cancer Screening: Colonoscopy ................................................. T 7.8134 480.92 .................. 120.23 

0159 .... Colorectal Cancer Screening: Flexible Sigmoidoscopy ................................ S 3.8973 239.88 .................. 59.97 

0160 .... Level I Cystourethroscopy and other Genitourinary Procedures ................. T 6.7325 414.39 105.06 82.88 

0161 .... Level II Cystourethroscopy and other Genitourinary Procedures ................ T 19.2766 1,186.49 249.36 237.30 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49707 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0162 .... Level III Cystourethroscopy and other Genitourinary Procedures ............... T 23.8562 1,468.37 .................. 293.67 

0163 .... Level IV Cystourethroscopy and other Genitourinary Procedures ............... T 35.1024 2,160.59 .................. 432.12

0164 .... Level II Urinary and Anal Procedures .......................................................... T 2.1159 130.24 .................. 26.05 

0165 .... Level IV Urinary and Anal Procedures ......................................................... T 18.2333 1,122.28 .................. 224.46 

0166 .... Level I Urethral Procedures .......................................................................... T 18.5138 1,139.54 .................. 227.91 

0168 .... Level II Urethral Procedures ......................................................................... T 28.5971 1,760.18 388.16 352.04 

0169 .... Lithotripsy ...................................................................................................... T 44.1144 2,715.29 1,009.47 543.06 

0170 .... Dialysis .......................................................................................................... S 6.8096 419.14 .................. 83.83 

0171 .... Level V Anal/Rectal Procedures ................................................................... T 37.2425 2,292.31 705.28 458.46 

0180 .... Circumcision .................................................................................................. T 20.7418 1,276.68 304.87 255.34 

0181 .... Penile Procedures ......................................................................................... T 32.9991 2,031.13 621.82 406.23 

0183 .... Testes/Epididymis Procedures ..................................................................... T 23.7072 1,459.20 .................. 291.84 

0184 .... Prostate Biopsy ............................................................................................. T 5.9892 368.64 96.27 73.73 

0188 .... Level II Female Reproductive Proc .............................................................. T 1.4050 86.48 .................. 17.30 

0189 .... Level III Female Reproductive Proc ............................................................. T 2.9902 184.05 .................. 36.81 

0190 .... Level I Hysteroscopy .................................................................................... T 21.4199 1,318.42 424.28 263.68 

0191 .... Level I Female Reproductive Proc ............................................................... T 0.1501 9.24 .................. 1.85 

0192 .... Level IV Female Reproductive Proc ............................................................. T 6.9265 426.33 .................. 85.27 

0193 .... Level V Female Reproductive Proc .............................................................. T 14.7958 910.70 .................. 182.14 

0194 .... Level VIII Female Reproductive Proc ........................................................... T 20.5113 1,262.49 397.84 252.50 

0195 .... Level IX Female Reproductive Proc ............................................................. T 28.7410 1,769.04 483.80 353.81 

0196 .... Dilation and Curettage .................................................................................. T 17.7635 1,093.36 338.23 218.67 

0197 .... Infertility Procedures ..................................................................................... T 4.4108 271.49 .................. 54.30 

0198 .... Pregnancy and Neonatal Care Procedures .................................................. T 1.4026 86.33 32.19 17.27 

0200 .... Level VII Female Reproductive Proc ............................................................ T 17.2607 1,062.41 248.39 212.48 

0201 .... Level VI Female Reproductive Proc ............................................................. T 18.5251 1,140.24 329.65 228.05 

0202 .... Level X Female Reproductive Proc .............................................................. T 42.8756 2,639.04 981.50 527.81 

0203 .... Level IV Nerve Injections .............................................................................. T 12.4432 765.89 240.33 153.18 

0204 .... Level I Nerve Injections ................................................................................ T 2.2491 138.43 40.13 27.69 

0206 .... Level II Nerve Injections ............................................................................... T 5.5439 341.23 75.55 68.25 

0207 .... Level III Nerve Injections .............................................................................. T 6.3788 392.62 86.92 78.52 

0208 .... Laminotomies and Laminectomies ............................................................... T 43.9030 2,702.27 .................. 540.45 

0209 .... Level II MEG, Extended EEG Studies and Sleep Studies ........................... S 11.4847 706.89 268.73 141.38 

0212 .... Nervous System Injections ........................................................................... T 3.0383 187.01 65.96 37.40 

0213 .... Level I MEG, Extended EEG Studies and Sleep Studies ............................ S 2.3133 142.39 53.58 28.48 

0214 .... Electroencephalogram .................................................................................. S 1.2353 76.03 28.24 15.21 

0215 .... Level I Nerve and Muscle Tests ................................................................... S 0.5760 35.45 .................. 7.09 

0216 .... Level III Nerve and Muscle Tests ................................................................. S 2.6729 164.52 .................. 32.90 

0218 .... Level II Nerve and Muscle Tests .................................................................. S 1.1993 73.82 .................. 14.76 

0220 .... Level I Nerve Procedures ............................................................................. T 17.7609 1,093.20 .................. 218.64 

0221 .... Level II Nerve Procedures ............................................................................ T 33.3035 2,049.86 463.62 409.97 

0222 .... Implantation of Neurological Device ............................................................. T 178.1307 10,964.12 .................. 2,192.82 

0223 .... Implantation or Revision of Pain Management Catheter ............................. T 29.2931 1,803.02 .................. 360.60 

0224 .... Implantation of Reservoir/Pump/Shunt ......................................................... T 45.6712 2,811.11 .................. 562.22 

0225 .... Implantation of Neurostimulator Electrodes, Cranial Nerve ......................... S 234.1628 14,412.95 .................. 2,882.59 

0226 .... Implantation of Drug Infusion Reservoir ....................................................... T 112.0147 6,894.62 .................. 1,378.92 

0227 .... Implantation of Drug Infusion Device ........................................................... T 183.1974 11,275.98 .................. 2,255.20 

0228 .... Creation of Lumbar Subarachnoid Shunt ..................................................... T 36.1603 2,225.70 .................. 445.14 

0229 .... Transcatherter Placement of Intravascular Shunts ...................................... T 66.0804 4,067.31 .................. 813.46 

0230 .... Level I Eye Tests & Treatments ................................................................... S 0.8126 50.02 14.97 10.00 

0231 .... Level III Eye Tests & Treatments ................................................................. S 2.1934 135.01 .................. 27.00 

0232 .... Level I Anterior Segment Eye Procedures ................................................... T 5.9800 368.07 92.21 73.61 

0233 .... Level II Anterior Segment Eye Procedures .................................................. T 14.9969 923.07 266.33 184.61 

0234 .... Level III Anterior Segment Eye Procedures ................................................. T 22.9479 1,412.47 511.31 282.49 

0235 .... Level I Posterior Segment Eye Procedures ................................................. T 4.0750 250.82 61.14 50.16 

0236 .... Level II Posterior Segment Eye Procedures ................................................ T 16.3433 1,005.95 .................. 201.19 

0237 .... Level III Posterior Segment Eye Procedures ............................................... T 26.9305 1,657.60 .................. 331.52 

0238 .... Level I Repair and Plastic Eye Procedures .................................................. T 2.8099 172.95 .................. 34.59 

0239 .... Level II Repair and Plastic Eye Procedures ................................................. T 6.9354 426.88 .................. 85.38 

0240 .... Level III Repair and Plastic Eye Procedures ................................................ T 17.0126 1,047.14 307.90 209.43 

0241 .... Level IV Repair and Plastic Eye Procedures ............................................... T 24.8502 1,529.55 384.47 305.91 

0242 .... Level V Repair and Plastic Eye Procedures ................................................ T 35.5217 2,186.40 597.36 437.28 

0243 .... Strabismus/Muscle Procedures .................................................................... T 21.2885 1,310.33 431.09 262.07 

0244 .... Corneal Transplant ....................................................................................... T 37.9446 2,335.53 803.26 467.11 

0245 .... Level I Cataract Procedures without IOL Insert ........................................... T 14.5427 895.12 217.05 179.02

0246 .... Cataract Procedures with IOL Insert ............................................................ T 23.5664 1,450.54 495.96 290.11 

0247 .... Laser Eye Procedures Except Retinal .......................................................... T 5.1266 315.55 104.31 63.11 

0248 .... Laser Retinal Procedures ............................................................................. T 5.0285 309.51 95.08 61.90 

0249 .... Level II Cataract Procedures without IOL Insert .......................................... T 28.5043 1,754.47 524.67 350.89 


sroberts on PROD1PC70 with PROPOSALS
49708 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0250 .... Nasal Cauterization/Packing ......................................................................... T 1.2021 73.99 25.50 14.80 

0251 .... Level I ENT Procedures ............................................................................... T 2.3768 146.29 .................. 29.26 

0252 .... Level II ENT Procedures .............................................................................. T 7.7261 475.55 111.84 95.11 

0253 .... Level III ENT Procedures ............................................................................. T 16.4494 1,012.48 282.29 202.50 

0254 .... Level IV ENT Procedures ............................................................................. T 23.1564 1,425.30 321.35 285.06 

0256 .... Level V ENT Procedures .............................................................................. T 37.7719 2,324.90 .................. 464.98 

0257 .... Level I Therapeutic Radiologic Procedures .................................................. S 0.9770 60.14 .................. 12.03 

0258 .... Tonsil and Adenoid Procedures ................................................................... T 22.7757 1,401.87 437.25 280.37 

0259 .... Level VI ENT Procedures ............................................................................. T 406.8232 25,040.37 8,698.43 5,008.07 

0260 .... Level I Plain Film Except Teeth .................................................................... X 0.7276 44.78 .................. 8.96 

0261 .... Level II Plain Film Except Teeth Including Bone Density Measurement ..... X 1.2515 77.03 .................. 15.41 

0262 .... Plain Film of Teeth ........................................................................................ X 0.5818 35.81 .................. 7.16 

0263 .... Level I Miscellaneous Radiology Procedures ............................................... X 1.7120 105.38 23.77 21.08 

0264 .... Level II Miscellaneous Radiology Procedures .............................................. X 2.9791 183.37 70.84 36.67 

0265 .... Level I Diagnostic and Screening Ultrasound .............................................. S 1.0145 62.44 23.63 12.49 

0266 .... Level II Diagnostic and Screening Ultrasound ............................................. S 1.5947 98.16 37.80 19.63 

0267 .... Level III Diagnostic and Screening Ultrasound ............................................ S 2.5166 154.90 60.80 30.98 

0268 .... Level I Ultrasound Guidance Procedures ..................................................... S 1.1967 73.66 .................. 14.73 

0269 .... Level II Echocardiogram Except Transesophageal ...................................... S 3.2432 199.62 75.60 39.92 

0270 .... Transesophageal Echocardiogram ............................................................... S 6.2689 385.86 141.32 77.17 

0272 .... Fluoroscopy ................................................................................................... X 1.2985 79.92 31.64 15.98 

0274 .... Myelography .................................................................................................. S 2.6182 161.15 64.46 32.23 

0275 .... Arthrography ................................................................................................. S 3.7021 227.87 69.09 45.57 

0276 .... Level I Digestive Radiology .......................................................................... S 1.4519 89.37 34.97 17.87 

0277 .... Level II Digestive Radiology ......................................................................... S 2.2764 140.11 54.63 28.02 

0278 .... Diagnostic Urography ................................................................................... S 2.4721 152.16 60.84 30.43 

0279 .... Level II Angiography and Venography ......................................................... S 9.6539 594.21 150.03 118.84 

0280 .... Level III Angiography and Venography ........................................................ S 20.9479 1,289.36 353.85 257.87 

0282 .... Miscellaneous Computerized Axial Tomography ......................................... S 1.5552 95.72 37.92 19.14 

0283 .... Computerized Axial Tomography with Contrast Material ............................. S 4.1858 257.64 102.17 51.53 

0284 .... Magnetic Resonance Imaging and Magnetic Resonance Angiography with 

Contras.

S 6.2589 385.24 148.40 77.05 

0288 .... Bone Density:Axial Skeleton ......................................................................... S 1.2005 73.89 .................. 14.78 

0293 .... Level V Anterior Segment Eye Procedures .................................................. T 50.6347 3,116.62 1,100.34 623.32 

0296 .... Level II Therapeutic Radiologic Procedures ................................................. S 2.7106 166.84 53.99 33.37 

0297 .... Level III Therapeutic Radiologic Procedures ................................................ S 3.6483 224.56 89.82 44.91 

0298 .... Level IV Therapeutic Radiologic Procedures ............................................... S 8.4904 522.59 209.02 104.52 

0299 .... Miscellaneous Radiation Treatment ............................................................. S 6.0322 371.29 .................. 74.26 

0300 .... Level I Radiation Therapy ............................................................................. S 1.5004 92.35 .................. 18.47 

0301 .... Level II Radiation Therapy ............................................................................ S 2.2670 139.54 .................. 27.91 

0302 .... Computer Assisted Navigational Procedures ............................................... S 5.5005 338.56 105.94 67.71 

0303 .... Treatment Device Construction .................................................................... X 2.9637 182.42 66.95 36.48 

0304 .... Level I Therapeutic Radiation Treatment Preparation ................................. X 1.6062 98.86 39.54 19.77 

0305 .... Level II Therapeutic Radiation Treatment Preparation ................................ X 4.0232 247.63 91.38 49.53 

0307 .... Myocardial Positron Emission Tomography (PET) imaging ......................... S 11.6773 718.75 287.49 143.75 

0308 .... Non-Myocardial Positron Emission Tomography (PET) imaging ................. S 14.0093 862.29 .................. 172.46 

0309 .... Level II Ultrasound Guidance Procedures .................................................... S 2.1284 131.01 .................. 26.20 

0310 .... Level III Therapeutic Radiation Treatment Preparation ............................... X 14.0578 865.27 325.27 173.05 

0312 .... Radioelement Applications ........................................................................... S 5.0185 308.89 .................. 61.78 

0313 .... Brachytherapy ............................................................................................... S 13.3939 824.41 .................. 164.88 

0314 .... Hyperthermic Therapies ................................................................................ S 3.6583 225.17 66.65 45.03 

0315 .... Level II Implantation of Neurostimulator ....................................................... T 235.5774 14,500.02 .................. 2,900.00 

0320 .... Electroconvulsive Therapy ............................................................................ S 5.5017 338.64 80.06 67.73 

0321 .... Biofeedback and Other Training ................................................................... S 1.3693 84.28 21.72 16.86 

0322 .... Brief Individual Psychotherapy ..................................................................... S 1.1749 72.32 .................. 14.46 

0323 .... Extended Individual Psychotherapy .............................................................. S 1.7170 105.68 .................. 21.14 

0324 .... Family Psychotherapy ................................................................................... S 2.2087 135.95 .................. 27.19 

0325 .... Group Psychotherapy ................................................................................... S 1.0787 66.40 14.51 13.28 

0330 .... Dental Procedures ........................................................................................ S 9.5891 590.22 .................. 118.04 

0332 .... Computerized Axial Tomography and Computerized Angiography without 

Contras.

S 3.1631 194.69 75.24 38.94 

0333 .... Computerized Axial Tomography and Computerized Angiography without 

Contrast followed by Contrast.

S 5.0020 307.88 121.52 61.58 

0335 .... Magnetic Resonance Imaging, Miscellaneous ............................................. S 4.6629 287.01 114.80 57.40 

0336 .... Magnetic Resonance Imaging and Magnetic Resonance Angiography 

without Cont.

S 5.8500 360.07 139.68 72.01 

0337 .... MRI and Magnetic Resonance Angiography without Contrast Material followed.S 8.3423 513.48 202.50 102.70 

0339 .... Observation ................................................................................................... S 7.1587 440.63 .................. 88.13 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49709 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0340 .... Minor Ancillary Procedures ........................................................................... X 0.6211 38.23 .................. 7.65 

0341 .... Skin Tests ..................................................................................................... X 0.0914 5.63 2.25 1.13 

0342 .... Level I Pathology .......................................................................................... X 0.0813 5.00 2.00 1.00 

0343 .... Level III Pathology ........................................................................................ X 0.5309 32.68 10.84 6.54 

0344 .... Level IV Pathology ........................................................................................ X 0.8107 49.90 15.66 9.98 

0345 .... Level I Transfusion Laboratory Procedures ................................................. X 0.2218 13.65 2.87 2.73 

0346 .... Level II Transfusion Laboratory Procedures ................................................ X 0.3494 21.51 4.39 4.30 

0347 .... Level III Transfusion Laboratory Procedures ............................................... X 0.7394 45.51 11.24 9.10 

0348 .... Fertility Laboratory Procedures ..................................................................... X 0.8928 54.95 .................. 10.99 

0350 .... Administration of flu and PPV vaccine ......................................................... S 0.4107 25.28 0.00 0.00 

0360 .... Level I Alimentary Tests ............................................................................... X 1.3789 84.87 33.88 16.97 

0361 .... Level II Alimentary Tests .............................................................................. X 3.9319 242.01 83.23 48.40 

0362 .... Contact Lens and Spectacle Services .......................................................... X 0.5328 32.79 .................. 6.56 

0363 .... Level I Otorhinolaryngologic Function Tests ................................................ X 0.8534 52.53 17.44 10.51 

0364 .... Level I Audiometry ........................................................................................ X 0.4637 28.54 7.06 5.71 

0365 .... Level II Audiometry ....................................................................................... X 1.2467 76.74 18.52 15.35 

0366 .... Level III Audiometry ...................................................................................... X 1.8175 111.87 26.14 22.37 

0367 .... Level I Pulmonary Test ................................................................................. X 0.6253 38.49 14.64 7.70 

0368 .... Level II Pulmonary Tests .............................................................................. X 0.9568 58.89 22.77 11.78 

0369 .... Level III Pulmonary Tests ............................................................................. X 2.8329 174.37 44.18 34.87 

0370 .... Allergy Tests ................................................................................................. X 1.0769 66.28 .................. 13.26 

0372 .... Therapeutic Phlebotomy ............................................................................... X 0.5814 35.79 10.09 7.16 

0373 .... Level I Neuropsychological Testing .............................................................. X 1.6262 100.09 .................. 20.02 

0374 .... Monitoring Psychiatric Drugs ........................................................................ X 1.1509 70.84 .................. 14.17 

0375 .... Ancillary Outpatient Services When Patient Expires .................................... S 57.3014 3,526.96 .................. 705.39 

0376 .... Level II Cardiac Imaging ............................................................................... S 4.9770 306.34 119.77 61.27 

0377 .... Level III Cardiac Imaging .............................................................................. S 6.7443 415.12 158.84 83.02 

0378 .... Level II Pulmonary Imaging .......................................................................... S 5.2084 320.58 128.23 64.12 

0379 .... Injection adenosine 6 MG ............................................................................. K .................. 29.90 .................. 5.98 

0381 .... Single Allergy Tests ...................................................................................... X 0.2151 13.24 .................. 2.65 

0382 .... Level II Neuropsychological Testing ............................................................. X 2.7541 169.52 67.80 33.90 

0384 .... GI Procedures with Stents ............................................................................ T 22.6777 1,395.84 292.31 279.17 

0385 .... Level I Prosthetic Urological Procedures ..................................................... S 79.3730 4,885.49 .................. 977.10 

0386 .... Level II Prosthetic Urological Procedures .................................................... S 135.7295 8,354.29 .................. 1,670.86 

0387 .... Level II Hysteroscopy ................................................................................... T 33.3029 2,049.83 655.55 409.97 

0388 .... Discography .................................................................................................. S 14.2706 878.37 289.72 175.67 

0389 .... Level I Non-imaging Nuclear Medicine ......................................................... S 1.4072 86.61 33.98 17.32

0390 .... Level I Endocrine Imaging ............................................................................ S 2.3732 146.07 58.42 29.21 

0391 .... Level II Endocrine Imaging ........................................................................... S 2.7556 169.61 66.18 33.92 

0392 .... Level II Non-imaging Nuclear Medicine ........................................................ S 2.0849 128.33 51.33 25.67 

0393 .... Red Cell/Plasma Studies .............................................................................. S 3.5902 220.98 82.04 44.20 

0394 .... Hepatobiliary Imaging ................................................................................... S 4.4705 275.16 102.61 55.03 

0395 .... GI Tract Imaging ........................................................................................... S 3.6937 227.35 89.73 45.47 

0396 .... Bone Imaging ................................................................................................ S 4.0166 247.23 95.02 49.45 

0397 .... Vascular Imaging .......................................................................................... S 2.2521 138.62 49.58 27.72 

0398 .... Level I Cardiac Imaging ................................................................................ S 4.2511 261.66 100.06 52.33 

0399 .... Nuclear Medicine Add-on Imaging ............................................................... S 1.5282 94.06 35.80 18.81 

0400 .... Hematopoietic Imaging ................................................................................. S 3.9304 241.92 93.22 48.38 

0401 .... Level I Pulmonary Imaging ........................................................................... S 3.2013 197.04 78.81 39.41 

0402 .... Brain Imaging ................................................................................................ S 4.8596 299.11 119.64 59.82 

0403 .... CSF Imaging ................................................................................................. S 3.4867 214.61 83.35 42.92 

0404 .... Renal and Genitourinary Studies Level I ...................................................... S 3.4235 210.72 84.28 42.14 

0405 .... Renal and Genitourinary Studies Level II ..................................................... S 4.1056 252.70 98.77 50.54 

0406 .... Level I Tumor/Infection Imaging ................................................................... S 3.9386 242.42 96.96 48.48 

0407 .... Level I Radionuclide Therapy ....................................................................... S 3.1506 193.92 77.56 38.78 

0408 .... Level II Tumor/Infection Imaging .................................................................. S 4.9998 307.74 .................. 61.55 

0409 .... Red Blood Cell Tests .................................................................................... X 0.1237 7.61 2.20 1.52 

0411 .... Respiratory Procedures ................................................................................ S 0.3793 23.35 .................. 4.67 

0412 .... IMRT Treatment Delivery .............................................................................. S 5.5021 338.66 .................. 67.73 

0413 .... Level II Radionuclide Therapy ...................................................................... S 5.1026 314.07 .................. 62.81 

0415 .... Level II Endoscopy Lower Airway ................................................................ T 21.8803 1,346.75 459.92 269.35 

0416 .... Level I Intravascular and Intracardiac Ultrasound and Flow Reserve ......... S 32.2182 1,983.06 .................. 396.61 

0417 .... Computerized Reconstruction ....................................................................... S 3.1140 191.67 .................. 38.33 

0418 .... Insertion of Left Ventricular Pacing Elect. .................................................... T 267.8870 16,488.71 .................. 3,297.74 

0421 .... Prolonged Physiologic Monitoring ................................................................ X 1.6486 101.47 .................. 20.29 

0422 .... Level II Upper GI Procedures ....................................................................... T 27.5493 1,695.69 448.81 339.14 

0423 .... Level II Percutaneous Abdominal and Biliary Procedures ........................... T 39.0235 2,401.94 .................. 480.39 

0425 .... Level II Arthroplasty with Prosthesis ............................................................ T 105.1666 6,473.11 1,378.01 1,294.62 

0426 .... Level II Strapping and Cast Application ....................................................... S 2.2728 139.89 .................. 27.98 


sroberts on PROD1PC70 with PROPOSALS
49710 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0427 .... Level III Tube Changes and Repositioning .................................................. T 11.5220 709.19 .................. 141.84 

0428 .... Level III Sigmoidoscopy and Anoscopy ........................................................ T 20.4902 1,261.19 .................. 252.24 

0429 .... Level V Cystourethroscopy and other Genitourinary Procedures ................ T 42.9327 2,642.55 .................. 528.51

0432 .... Health and Behavior Services ...................................................................... S 0.6006 36.97 .................. 7.39 

0433 .... Level II Pathology ......................................................................................... X 0.2571 15.82 5.93 3.16 

0434 .... Cardiac Defect Repair .................................................................................. T 87.3424 5,376.01 .................. 1,075.20 

0436 .... Level I Drug Administration .......................................................................... S 0.1769 10.89 .................. 2.18 

0437 .... Level II Drug Administration ......................................................................... S 0.4107 25.28 .................. 5.06 

0438 .... Level III Drug Administration ........................................................................ S 0.7892 48.58 .................. 9.72 

0439 .... Level IV Drug Administration ........................................................................ S 1.5841 97.50 .................. 19.50 

0440 .... Level V Drug Administration ......................................................................... S 1.8285 112.55 .................. 22.51 

0441 .... Level VI Drug Administration ........................................................................ S 2.5071 154.31 .................. 30.86 

0442 .... Dosimetric Drug Administration .................................................................... S 24.5410 1,510.52 .................. 302.10 

0443 .... Overnight Pulse Oximetry ............................................................................. X 0.9939 61.18 24.47 12.24 

0604 .... Level 1 Clinic Visits ....................................................................................... V 0.8083 49.75 .................. 9.95 

0605 .... Level 2 Clinic Visits ....................................................................................... V 1.0057 61.90 .................. 12.38 

0606 .... Level 3 Clinic Visits ....................................................................................... V 1.3546 83.38 .................. 16.68 

0607 .... Level 4 Clinic Visits ....................................................................................... V 1.7080 105.13 .................. 21.03 

0608 .... Level 5 Clinic Visits ....................................................................................... V 2.1226 130.65 .................. 26.13 

0609 .... Level 1 Type A Emergency Visits ................................................................ V 0.8323 51.23 .................. 10.25 

0613 .... Level 2 Type A Emergency Visits ................................................................ V 1.3728 84.50 .................. 16.90 

0614 .... Level 3 Type A Emergency Visits ................................................................ V 2.1692 133.52 .................. 26.70 

0615 .... Level 4 Type A Emergency Visits ................................................................ V 3.4790 214.14 .................. 42.83 

0616 .... Level 5 Type A Emergency Visits ................................................................ V 5.3773 330.98 .................. 66.20 

0617 .... Critical Care .................................................................................................. S 8.0167 493.44 .................. 98.69 

0621 .... Level I Vascular Access Procedures ............................................................ T 8.7841 540.67 .................. 108.13 

0622 .... Level II Vascular Access Procedures ........................................................... T 22.6984 1,397.11 .................. 279.42 

0623 .... Level III Vascular Access Procedures .......................................................... T 28.4646 1,752.02 .................. 350.40 

0624 .... Minor Vascular Access Device Procedures ................................................. X 0.5336 32.84 13.13 6.57 

0648 .... Breast Reconstruction with Prosthesis ......................................................... T 48.7796 3,002.43 .................. 600.49 

0651 .... Complex Interstitial Radiation Source Application ........................................ S 16.6585 1,025.35 .................. 205.07 

0652 .... Insertion of Intraperitoneal and Pleural Catheters ........................................ T 29.2259 1,798.88 .................. 359.78 

0653 .... Vascular Reconstruction/Fistula Repair with Device .................................... T 31.0004 1,908.11 .................. 381.62 

0654 .... Insertion/Replacement of a permanent dual chamber pacemaker .............. T 112.2347 6,908.16 .................. 1,381.63

0655 .... Insertion/Replacement/Conversion of a permanent dual chamber pacemaker.T 153.1524 9,426.68 .................. 1,885.34 

0656 .... Transcatheter Placement of Intracoronary Drug-Eluting Stents ................... T 106.8902 6,579.20 .................. 1,315.84 

0657 .... Placement of Tissue Clips ............................................................................ S 1.7625 108.48 .................. 21.70 

0658 .... Percutaneous Breast Biopsies ...................................................................... T 6.4482 396.89 .................. 79.38 

0659 .... Hyperbaric Oxygen ....................................................................................... S 1.5925 98.02 .................. 19.60 

0660 .... Level II Otorhinolaryngologic Function Tests ............................................... X 1.4988 92.25 29.07 18.45 

0661 .... Level V Pathology ......................................................................................... X 2.6066 160.44 64.17 32.09 

0662 .... CT Angiography ............................................................................................ S 4.9203 302.85 118.88 60.57 

0663 .... Level I Electronic Analysis of Neurostimulator Pulse Generators ................ S 1.0752 66.18 16.96 13.24 

0664 .... Level I Proton Beam Radiation Therapy ...................................................... S 18.4698 1,136.83 .................. 227.37 

0665 .... Bone Density:AppendicularSkeleton ............................................................. S 0.5569 34.28 .................. 6.86 

0667 .... Level II Proton Beam Radiation Therapy ..................................................... S 22.0972 1,360.10 .................. 272.02 

0668 .... Level I Angiography and Venography .......................................................... S 6.3684 391.98 88.26 78.40

0670 .... Level II Intravascular and Intracardiac Ultrasound and Flow Reserve ........ S 29.7322 1,830.05 536.10 366.01 

0672 .... Level IV Posterior Segment Eye Procedures ............................................... T 36.8820 2,270.12 .................. 454.02 

0673 .... Level IV Anterior Segment Eye Procedures ................................................. T 37.3057 2,296.20 649.56 459.24 

0674 .... Prostate Cryoablation ................................................................................... T 107.8298 6,637.03 .................. 1,327.41 

0675 .... Prostatic Thermotherapy ............................................................................... T 42.3176 2,604.69 .................. 520.94 

0676 .... Thrombolysis and Thrombectomy ................................................................ T 2.0612 126.87 .................. 25.37 

0678 .... External Counterpulsation ............................................................................. T 1.7263 106.26 .................. 21.25 

0679 .... Level II Resuscitation and Cardioversion ..................................................... S 5.5435 341.21 95.30 68.24 

0680 .... Insertion of Patient Activated Event Recorders ............................................ S 74.8877 4,609.41 .................. 921.88 

0681 .... Knee Arthroplasty ......................................................................................... T 173.0706 10,652.67 .................. 2,130.53 

0682 .... Level V Debridement & Destruction ............................................................. T 6.7529 415.65 158.65 83.13 

0683 .... Level II Photochemotherapy ......................................................................... S 2.6902 165.58 .................. 33.12 

0685 .... Level III Needle Biopsy/Aspiration Except Bone Marrow ............................. T 6.0729 373.79 115.47 74.76 

0686 .... Level III Skin Repair ..................................................................................... T 13.3433 821.29 .................. 164.26 

0687 .... Revision/Removal of Neurostimulator Electrodes ........................................ T 17.1830 1,057.63 423.05 211.53 

0688 .... Revision/Removal of Neurostimulator Pulse Generator Receiver ............... T 33.9521 2,089.79 835.91 417.96 

0689 .... Electronic Analysis of Cardioverter-defibrillators .......................................... S 0.5400 33.24 .................. 6.65 

0690 .... Electronic Analysis of Pacemakers and other Cardiac Devices .................. S 0.3628 22.33 8.67 4.47 

0691 .... Electronic Analysis of Programmable Shunts/Pumps .................................. S 2.8253 173.90 60.61 34.78 

0692 .... Level II Electronic Analysis of Neurostimulator Pulse Generators ............... S 1.9519 120.14 30.16 24.03 

0693 .... Breast Reconstruction ................................................................................... T 37.4843 2,307.20 731.74 461.44 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49711 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0694 .... Mohs Surgery ................................................................................................ T 3.4844 214.47 58.14 42.89 

0695 .... Level VII Debridement & Destruction ........................................................... T 20.5802 1,266.73 266.59 253.35 

0697 .... Level I Echocardiogram Except Transesophageal ....................................... S 1.6002 98.49 35.99 19.70 

0698 .... Level II Eye Tests & Treatments .................................................................. S 1.2244 75.36 16.52 15.07 

0699 .... Level IV Eye Tests & Treatments ................................................................. T 13.9509 858.69 .................. 171.74 

0700 .... Antepartum Manipulation .............................................................................. T 2.8011 172.41 .................. 34.48 

0701 .... Sr89 strontium ............................................................................................... K .................. 533.58 .................. 106.72 

0702 .... Sm 153 lexidronm ......................................................................................... K .................. 1,316.41 .................. 263.28 

0704 .... In111 satumomab ......................................................................................... K .................. 192.12 .................. 38.42 

0705 .... Tc99m tetrofosmin ........................................................................................ K .................. 73.81 .................. 14.76 

0722 .... Tc99m pentetate ........................................................................................... K .................. 56.77 .................. 11.35 

0723 .... Co57/58 ......................................................................................................... K .................. 149.44 .................. 29.89 

0724 .... Co57 cyano ................................................................................................... K .................. 63.74 .................. 12.75 

0726 .... Dexrazoxane HCl injection ........................................................................... K .................. 179.62 .................. 35.92 

0728 .... Filgrastim 300 mcg injection ......................................................................... K .................. 182.53 .................. 36.51 

0730 .... Pamidronate disodium /30 MG ..................................................................... K .................. 29.31 .................. 5.86 

0731 .... Sargramostim injection ................................................................................. K .................. 23.12 .................. 4.62 

0732 .... Mesna injection ............................................................................................. K .................. 7.87 .................. 1.57 

0735 .... Ampho b cholesteryl sulfate ......................................................................... K .................. 12.00 .................. 2.40 

0736 .... Amphotericin b liposome inj .......................................................................... K .................. 17.40 .................. 3.48 

0737 .... Nitrogen N–13 ammonia ............................................................................... K .................. 230.77 .................. 46.15 

0738 .... Rasburicase .................................................................................................. K .................. 110.36 .................. 22.07 

0739 .... Tc99m depreotide ......................................................................................... K .................. 67.91 .................. 13.58 

0740 .... Tc99m gluceptate ......................................................................................... K .................. 236.53 .................. 47.31 

0741 .... Cr51 chromate .............................................................................................. K .................. 167.62 .................. 33.52 

0742 .... Tc99m labeled rbc ........................................................................................ K .................. 132.95 .................. 26.59 

0743 .... Tc99m mertiatide .......................................................................................... K .................. 180.08 .................. 36.02 

0744 .... Plague vaccine, im ........................................................................................ K .................. 150.00 .................. 30.00 

0750 .... Dolasetron mesylate ..................................................................................... K .................. 6.76 .................. 1.35 

0763 .... Dolasetron mesylate oral .............................................................................. K .................. 47.52 .................. 9.50 

0764 .... Granisetron HCl injection .............................................................................. K .................. 6.80 .................. 1.36 

0765 .... Granisetron HCl 1 mg oral ............................................................................ K .................. 37.08 .................. 7.42 

0768 .... Ondansetron hcl injection ............................................................................. K .................. 3.69 .................. 0.74 

0769 .... Ondansetron HCl 8mg oral ........................................................................... K .................. 34.21 .................. 6.84 

0800 .... Leuprolide acetate /3.75 MG ........................................................................ K .................. 440.36 .................. 88.07 

0802 .... Etoposide oral 50 MG ................................................................................... K .................. 32.73 .................. 6.55 

0807 .... Aldesleukin/single use vial ............................................................................ K .................. 734.10 .................. 146.82 

0809 .... Bcg live intravesical vac ............................................................................... K .................. 110.48 .................. 22.10 

0810 .... Goserelin acetate implant ............................................................................. K .................. 197.59 .................. 39.52 

0811 .... Carboplatin injection ..................................................................................... K .................. 13.74 .................. 2.75 

0812 .... Carmus bischl nitro inj .................................................................................. K .................. 139.66 .................. 27.93 

0814 .... Asparaginase injection .................................................................................. K .................. 53.66 .................. 10.73 

0820 .... Daunorubicin ................................................................................................. K .................. 23.36 .................. 4.67 

0821 .... Daunorubicin citrate liposom ........................................................................ K .................. 55.72 .................. 11.14 

0823 .... Docetaxel ...................................................................................................... K .................. 294.48 .................. 58.90 

0827 .... Floxuridine injection ...................................................................................... K .................. 62.61 .................. 12.52 

0828 .... Gemcitabine HCl ........................................................................................... K .................. 116.59 .................. 23.32 

0830 .... Irinotecan injection ........................................................................................ K .................. 125.28 .................. 25.06 

0831 .... Ifosfomide injection ....................................................................................... K .................. 54.19 .................. 10.84 

0832 .... Idarubicin hcl injection .................................................................................. K .................. 265.53 .................. 53.11 

0834 .... Interferon alfa-2a inj ...................................................................................... K .................. 33.53 .................. 6.71 

0835 .... Inj cosyntropin per 0.25 MG ......................................................................... K .................. 63.55 .................. 12.71 

0836 .... Interferon alfa-2b inj ...................................................................................... K .................. 13.54 .................. 2.71 

0838 .... Interferon gamma 1–b inj .............................................................................. K .................. 289.87 .................. 57.97 

0840 .... Inj melphalan hydrochl 50 MG ...................................................................... K .................. 1,190.81 .................. 238.16 

0842 .... Fludarabine phosphate inj ............................................................................ K .................. 230.11 .................. 46.02 

0843 .... Pegaspargase/singl dose vial ....................................................................... K .................. 1,596.00 .................. 319.20 

0844 .... Pentostatin injection ...................................................................................... K .................. 2,000.96 .................. 400.19 

0849 .... Rituximab cancer treatment .......................................................................... K .................. 465.23 .................. 93.05 

0850 .... Streptozocin injection .................................................................................... K .................. 147.45 .................. 29.49 

0851 .... Thiotepa injection .......................................................................................... K .................. 45.38 .................. 9.08 

0852 .... Topotecan ..................................................................................................... K .................. 780.54 .................. 156.11 

0855 .... Vinorelbine tartrate/10 mg ............................................................................ K .................. 22.04 .................. 4.41 

0856 .... Porfimer sodium ............................................................................................ K .................. 2,481.76 .................. 496.35 

0858 .... Inj cladribine per 1 MG ................................................................................. K .................. 38.28 .................. 7.66 

0860 .... Plicamycin (mithramycin) inj ......................................................................... K .................. 173.66 .................. 34.73 

0861 .... Leuprolide acetate injeciton .......................................................................... K .................. 7.86 .................. 1.57 

0862 .... Mitomycin 5 MG inj ....................................................................................... K .................. 18.82 .................. 3.76 

0863 .... Paclitaxel injection ........................................................................................ K .................. 15.44 .................. 3.09 


sroberts on PROD1PC70 with PROPOSALS
49712 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

0864 .... Mitoxantrone hydrochl / 5 MG ...................................................................... K .................. 336.76 .................. 67.35 

0865 .... Interferon alfa-n3 inj ...................................................................................... K .................. 50.33 .................. 10.07 

0868 .... Oral aprepitant .............................................................................................. G .................. 4.63 .................. 0.93 

0876 .... Caffeine citrate injection ............................................................................... K .................. 3.34 .................. 0.67 

0884 .... Rho d immune globulin inj ............................................................................ K .................. 97.11 .................. 19.42 

0887 .... Azathioprine parenteral ................................................................................. K .................. 48.73 .................. 9.75 

0888 .... Cyclosporine oral 100 mg ............................................................................. K .................. 3.88 .................. 0.78 

0890 .... Lymphocyte immune globulin ....................................................................... K .................. 295.38 .................. 59.08 

0891 .... Tacrolimus oral per 1 MG ............................................................................. K .................. 3.40 .................. 0.68 

0892 .... Edetate calcium disodium inj ........................................................................ K .................. 39.80 .................. 7.96 

0895 .... Deferoxamine mesylate inj ........................................................................... K .................. 14.77 .................. 2.95 

0900 .... Alglucerase injection ..................................................................................... K .................. 38.85 .................. 7.77 

0901 .... Alpha 1 proteinase inhibitor .......................................................................... K .................. 3.21 .................. 0.64 

0902 .... Botulinum toxin a per unit ............................................................................. K .................. 4.85 .................. 0.97 

0903 .... Cytomegalovirus imm IV /vial ....................................................................... K .................. 755.79 .................. 151.16 

0906 .... RSV-ivig ........................................................................................................ K .................. 16.02 .................. 3.20 

0910 .... Interferon beta-1b / .25 MG .......................................................................... K .................. 91.34 .................. 18.27 

0911 .... Inj streptokinase /250000 IU ......................................................................... K .................. 78.75 .................. 15.75 

0912 .... Interferon alfacon-1 ....................................................................................... K .................. 3.92 .................. 0.78 

0913 .... Ganciclovir long act implant .......................................................................... K .................. 4,200.00 .................. 840.00 

0916 .... Injection imiglucerase /unit ........................................................................... K .................. 3.87 .................. 0.77 

0917 .... Adenosine injection ....................................................................................... K .................. 69.41 .................. 13.88 

0925 .... Factor viii ....................................................................................................... K .................. 0.68 .................. 0.14 

0926 .... Factor VIII (porcine) ...................................................................................... K .................. 0.66 .................. 0.13 

0927 .... Factor viii recombinant .................................................................................. K .................. 1.05 .................. 0.21 

0928 .... Factor ix complex .......................................................................................... K .................. 0.63 .................. 0.13 

0929 .... Anti-inhibitor .................................................................................................. K .................. 1.29 .................. 0.26 

0930 .... Antithrombin iii injection ................................................................................ K .................. 1.62 .................. 0.32 

0931 .... Factor IX non-recombinant ........................................................................... K .................. 0.88 .................. 0.18 

0932 .... Factor IX recombinant .................................................................................. K .................. 0.98 .................. 0.20 

0935 .... Clonidine hydrochloride ................................................................................ K .................. 62.71 .................. 12.54 

0949 .... Frozen plasma, pooled, sd ........................................................................... K 0.9060 55.77 .................. 11.15 

0950 .... Whole blood for transfusion .......................................................................... K 2.1824 134.33 .................. 26.87 

0952 .... Cryoprecipitate each unit .............................................................................. K 0.8571 52.76 .................. 10.55 

0954 .... RBC leukocytes reduced .............................................................................. K 2.8738 176.89 .................. 35.38 

0955 .... Plasma, frz between 8–24 hour .................................................................... K 1.1864 73.02 .................. 14.60 

0956 .... Plasma protein fract,5%,50ml ....................................................................... K 0.4016 24.72 .................. 4.94 

0957 .... Platelets, each unit ....................................................................................... K 0.9794 60.28 .................. 12.06 

0958 .... Plaelet rich plasma unit ................................................................................ K 2.5336 155.95 .................. 31.19 

0959 .... Red blood cells unit ...................................................................................... K 2.1045 129.53 .................. 25.91 

0960 .... Washed red blood cells unit ......................................................................... K 3.5028 215.60 .................. 43.12 

0961 .... Albumin (human),5%, 50ml .......................................................................... K .................. 25.48 .................. 5.10 

0963 .... Albumin (human), 5%, 250 ml ...................................................................... K .................. 72.09 .................. 14.42 

0964 .... Albumin (human), 25%, 20 ml ...................................................................... K .................. 26.79 .................. 5.36 

0965 .... Albumin (human), 25%, 50ml ....................................................................... K .................. 61.77 .................. 12.35 

0966 .... Plasmaprotein fract,5%,250ml ...................................................................... K 3.1309 192.71 .................. 38.54 

0967 .... Blood split unit .............................................................................................. K 2.2087 135.95 .................. 27.19 

0968 .... Platelets leukoreduced irrad ......................................................................... K 2.1192 130.44 .................. 26.09 

0969 .... RBC leukoreduced irradiated ........................................................................ K 3.7037 227.97 .................. 45.59 

1009 .... Cryoprecipitatereducedplasma ..................................................................... K 1.2990 79.95 .................. 15.99 

1010 .... Blood, l/r, cmv-neg ........................................................................................ K 2.1991 135.36 .................. 27.07 

1011 .... Platelets, hla-m, l/r, unit ................................................................................ K 10.5084 646.80 .................. 129.36 

1013 .... Platelets leukocytes reduced ........................................................................ K 1.5318 94.28 .................. 18.86 

1016 .... Blood, l/r, froz/degly/wash ............................................................................. K 1.4462 89.02 .................. 17.80 

1017 .... Plt, aph/pher, l/r, cmv-neg ............................................................................ K 6.1508 378.59 .................. 75.72 

1018 .... Blood, l/r, irradiated ....................................................................................... K 2.1765 133.97 .................. 26.79 

1019 .... Plate pheres leukoredu irrad ........................................................................ K 9.9841 614.53 .................. 122.91 

1020 .... Plt, pher, l/r cmv-neg, irr ............................................................................... K 11.7025 720.30 .................. 144.06 

1021 .... RBC, frz/deg/wsh, l/r, irrad ........................................................................... K 6.9189 425.87 .................. 85.17 

1022 .... RBC, l/r, cmv-neg, irrad ................................................................................ K 4.2818 263.55 .................. 52.71 

1045 .... I131 iodobenguate, dx .................................................................................. K .................. 429.55 .................. 85.91 

1052 .... Injection, voriconazole .................................................................................. K .................. 4.55 .................. 0.91 

1064 .... Th I131 so iodide cap millic .......................................................................... K .................. 14.54 .................. 2.91 

1083 .... Adalimumab injection .................................................................................... K .................. 304.40 .................. 60.88 

1084 .... Denileukin diftitox, 300 mcg .......................................................................... K .................. 1,391.05 .................. 278.21 

1086 .... Temozolomide ............................................................................................... K .................. 7.16 .................. 1.43 

1088 .... Iodine I–131 iodide cap, dx .......................................................................... K .................. 24.86 .................. 4.97 

1096 .... Tc99m exametazime ..................................................................................... K .................. 317.07 .................. 63.41 

1150 .... I131 iodide sol, rx ......................................................................................... K .................. 12.60 .................. 2.52 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49713 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

1166 .... Cytarabine liposome ..................................................................................... K .................. 374.75 .................. 74.95 

1167 .... Inj, epirubicin hcl, 2 mg ................................................................................. K .................. 24.47 .................. 4.89 

1178 .... BUSULFAN IV, 6 Mg .................................................................................... K .................. 24.87 .................. 4.97 

1203 .... Verteporfin injection ...................................................................................... K .................. 8.89 .................. 1.78 

1207 .... Octreotide injection, depot ............................................................................ K .................. 89.50 .................. 17.90 

1280 .... Corticotropin injection ................................................................................... K .................. 108.85 .................. 21.77 

1330 .... Ergonovine maleate injection ........................................................................ K .................. 27.56 .................. 5.51 

1436 .... Etidronate disodium inj ................................................................................. K .................. 70.73 .................. 14.15 

1491 .... New Technology—Level IA ($0–$10) ........................................................... S .................. 5.00 .................. 1.00 

1492 .... New Technology—Level IB ($10–$20) ......................................................... S .................. 15.00 .................. 3.00 

1493 .... New Technology—Level IC ($20–$30) ......................................................... S .................. 25.00 .................. 5.00 

1494 .... New Technology—Level ID ($30–$40) ......................................................... S .................. 35.00 .................. 7.00 

1495 .... New Technology—Level IE ($40–$50) ......................................................... S .................. 45.00 .................. 9.00 

1496 .... New Technology—Level IA ($0–$10) ........................................................... T .................. 5.00 .................. 1.00 

1497 .... New Technology—Level IB($10–$20) .......................................................... T .................. 15.00 .................. 3.00 

1498 .... New Technology—Level IC ($20–$30) ......................................................... T .................. 25.00 .................. 5.00 

1499 .... New Technology—Level ID($30–$40) .......................................................... T .................. 35.00 .................. 7.00 

1500 .... New Technology—Level IE ($40–$50) ......................................................... T .................. 45.00 .................. 9.00 

1502 .... New Technology—Level II ($50–$100) ........................................................ S .................. 75.00 .................. 15.00 

1503 .... New Technology—Level III ($100–$200) ..................................................... S .................. 150.00 .................. 30.00 

1504 .... New Technology—Level IV ($200–$300) ..................................................... S .................. 250.00 .................. 50.00 

1505 .... New Technology—Level V ($300–$400) ...................................................... S .................. 350.00 .................. 70.00 

1506 .... New Technology—Level VI ($400–$500) ..................................................... S .................. 450.00 .................. 90.00 

1507 .... New Technology—Level VII ($500–$600) .................................................... S .................. 550.00 .................. 110.00 

1508 .... New Technology—Level VIII ($600–$700) ................................................... S .................. 650.00 .................. 130.00 

1509 .... New Technology—Level IX ($700–$800) ..................................................... S .................. 750.00 .................. 150.00 

1510 .... New Technology—Level X ($800–$900) ...................................................... S .................. 850.00 .................. 170.00 

1511 .... New Technology—Level XI ($900–$1000) ................................................... S .................. 950.00 .................. 190.00 

1512 .... New Technology—Level XII ($1000–$1100) ................................................ S .................. 1,050.00 .................. 210.00 

1513 .... New Technology—Level XIII ($1100–$1200) ............................................... S .................. 1,150.00 .................. 230.00 

1514 .... New Technology—Level XIV ($1200–$1300) .............................................. S .................. 1,250.00 .................. 250.00 

1515 .... New Technology—Level XV ($1300–$1400) ............................................... S .................. 1,350.00 .................. 270.00 

1516 .... New Technology—Level XVI ($1400–$1500) .............................................. S .................. 1,450.00 .................. 290.00 

1517 .... New Technology—Level XVII ($1500–$1600) ............................................. S .................. 1,550.00 .................. 310.00 

1518 .... New Technology—Level XVIII ($1600–$1700) ............................................ S .................. 1,650.00 .................. 330.00 

1519 .... New Technology—Level IXX ($1700–$1800) .............................................. S .................. 1,750.00 .................. 350.00 

1520 .... New Technology—Level XX ($1800–$1900) ............................................... S .................. 1,850.00 .................. 370.00 

1521 .... New Technology—Level XXI ($1900–$2000) .............................................. S .................. 1,950.00 .................. 390.00 

1522 .... New Technology—Level XXII ($2000–$2500) ............................................. S .................. 2,250.00 .................. 450.00 

1523 .... New Technology—Level XXIII ($2500–$3000) ............................................ S .................. 2,750.00 .................. 550.00 

1524 .... New Technology—Level XIV ($3000–$3500) .............................................. S .................. 3,250.00 .................. 650.00 

1525 .... New Technology—Level XXV ($3500–$4000) ............................................. S .................. 3,750.00 .................. 750.00 

1526 .... New Technology—Level XXVI ($4000–$4500) ............................................ S .................. 4,250.00 .................. 850.00 

1527 .... New Technology—Level XXVII ($4500–$5000) ........................................... S .................. 4,750.00 .................. 950.00 

1528 .... New Technology—Level XXVIII ($5000–$5500) .......................................... S .................. 5,250.00 .................. 1,050.00 

1529 .... New Technology—Level XXIX ($5500–$6000) ............................................ S .................. 5,750.00 .................. 1,150.00 

1530 .... New Technology—Level XXX ($6000–$6500) ............................................. S .................. 6,250.00 .................. 1,250.00 

1531 .... New Technology—Level XXXI ($6500–$7000) ............................................ S .................. 6,750.00 .................. 1,350.00 

1532 .... New Technology—Level XXXII ($7000–$7500) ........................................... S .................. 7,250.00 .................. 1,450.00 

1533 .... New Technology—Level XXXIII ($7500–$8000) .......................................... S .................. 7,750.00 .................. 1,550.00 

1534 .... New Technology—Level XXXIV ($8000–$8500) .......................................... S .................. 8,250.00 .................. 1,650.00 

1535 .... New Technology—Level XXXV ($8500–$9000) ........................................... S .................. 8,750.00 .................. 1,750.00 

1536 .... New Technology—Level XXXVI ($9000–$9500) .......................................... S .................. 9,250.00 .................. 1,850.00 

1537 .... New Technology—Level XXXVII ($9500–$10000) ....................................... S .................. 9,750.00 .................. 1,950.00 

1539 .... New Technology—Level II ($50–$100) ........................................................ T .................. 75.00 .................. 15.00 

1540 .... New Technology—Level III ($100–$200) ..................................................... T .................. 150.00 .................. 30.00 

1541 .... New Technology—Level IV ($200–$300) ..................................................... T .................. 250.00 .................. 50.00 

1542 .... New Technology—Level V ($300–$400) ...................................................... T .................. 350.00 .................. 70.00 

1543 .... New Technology—Level VI ($400–$500) ..................................................... T .................. 450.00 .................. 90.00 

1544 .... New Technology—Level VII ($500—$600) .................................................. T .................. 550.00 .................. 110.00 

1545 .... New Technology—Level VIII ($600–$700) ................................................... T .................. 650.00 .................. 130.00 

1546 .... New Technology—Level IX ($700–$800) ..................................................... T .................. 750.00 .................. 150.00 

1547 .... New Technology—Level X ($800–$900) ...................................................... T .................. 850.00 .................. 170.00 

1548 .... New Technology—Level XI ($900–$1000) ................................................... T .................. 950.00 .................. 190.00 

1549 .... New Technology—Level XII ($1000–$1100) ................................................ T .................. 1,050.00 .................. 210.00 

1550 .... New Technology—Level XIII ($1100–$1200) ............................................... T .................. 1,150.00 .................. 230.00 

1551 .... New Technology—Level XIV ($1200–$1300) .............................................. T .................. 1,250.00 .................. 250.00 

1552 .... New Technology—Level XV ($1300–$1400) ............................................... T .................. 1,350.00 .................. 270.00 

1553 .... New Technology—Level XVI ($1400–$1500) .............................................. T .................. 1,450.00 .................. 290.00 


sroberts on PROD1PC70 with PROPOSALS
49714 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

1554 .... New Technology—Level XVII ($1500–$1600) ............................................. T .................. 1,550.00 .................. 310.00 

1555 .... New Technology—Level XVIII ($1600–$1700) ............................................ T .................. 1,650.00 .................. 330.00 

1556 .... New Technology—Level XIX ($1700–$1800) .............................................. T .................. 1,750.00 .................. 350.00 

1557 .... New Technology—Level XX ($1800–$1900) ............................................... T .................. 1,850.00 .................. 370.00 

1558 .... New Technology—Level XXI ($1900–$2000) .............................................. T .................. 1,950.00 .................. 390.00 

1559 .... New Technology—Level XXII ($2000–$2500) ............................................. T .................. 2,250.00 .................. 450.00 

1560 .... New Technology—Level XXIII ($2500–$3000) ............................................ T .................. 2,750.00 .................. 550.00 

1561 .... New Technology—Level XXIV ($3000–$3500) ............................................ T .................. 3,250.00 .................. 650.00 

1562 .... New Technology—Level XXV ($3500–$4000) ............................................. T .................. 3,750.00 .................. 750.00 

1563 .... New Technology—Level XXVI ($4000–$4500) ............................................ T .................. 4,250.00 .................. 850.00 

1564 .... New Technology—Level XXVII ($4500–$5000) ........................................... T .................. 4,750.00 .................. 950.00 

1565 .... New Technology—Level XXVIII ($5000–$5500) .......................................... T .................. 5,250.00 .................. 1,050.00 

1566 .... New Technology—Level XXIX ($5500–$6000) ............................................ T .................. 5,750.00 .................. 1,150.00 

1567 .... New Technology—Level XXX ($6000–$6500) ............................................. T .................. 6,250.00 .................. 1,250.00 

1568 .... New Technology—Level XXXI ($6500–$7000) ............................................ T .................. 6,750.00 .................. 1,350.00 

1569 .... New Technology—Level XXXII ($7000–$7500) ........................................... T .................. 7,250.00 .................. 1,450.00 

1570 .... New Technology—Level XXXIII ($7500–$8000) .......................................... T .................. 7,750.00 .................. 1,550.00 

1571 .... New Technology—Level XXXIV ($8000–$8500) .......................................... T .................. 8,250.00 .................. 1,650.00 

1572 .... New Technology—Level XXXV ($8500–$9000) ........................................... T .................. 8,750.00 .................. 1,750.00 

1573 .... New Technology—Level XXXVI ($9000–$9500) .......................................... T .................. 9,250.00 .................. 1,850.00 

1574 .... New Technology—Level XXXVII ($9500–$10000) ....................................... T .................. 9,750.00 .................. 1,950.00 

1600 .... Tc99m sestamibi ........................................................................................... K .................. 82.58 .................. 16.52 

1603 .... TL201 thallium .............................................................................................. K .................. 27.18 .................. 5.44 

1604 .... In111 capromab ............................................................................................ K .................. 928.19 .................. 185.64 

1605 .... Abciximab injection ....................................................................................... K .................. 452.96 .................. 90.59 

1606 .... Injection anistreplase 30 u ............................................................................ K .................. 2,265.46 .................. 453.09 

1607 .... Eptifibatide injection ...................................................................................... K .................. 13.31 .................. 2.66 

1608 .... Etanercept injection ...................................................................................... K .................. 154.12 .................. 30.82 

1609 .... Rho(D) immune globulin h, sd ...................................................................... K .................. 13.57 .................. 2.71 

1611 .... Hylan G–F 20 injection ................................................................................. K .................. 196.99 .................. 39.40 

1612 .... Daclizumab, parenteral ................................................................................. K .................. 345.07 .................. 69.01 

1613 .... Trastuzumab ................................................................................................. K .................. 54.59 .................. 10.92 

1629 .... Nonmetabolic act d/e tissue ......................................................................... K .................. 15.20 .................. 3.04 

1630 .... Hep b ig, im .................................................................................................. K .................. 118.61 .................. 23.72 

1631 .... Baclofen intrathecal trial ............................................................................... K .................. 70.20 .................. 14.04 

1632 .... Metabolic active D/E tissue .......................................................................... K .................. 27.56 .................. 5.51 

1633 .... Alefacept ....................................................................................................... K .................. 26.03 .................. 5.21 

1642 .... In111 ibritumomab, dx .................................................................................. K .................. 1,344.34 .................. 268.87 

1643 .... Y90 ibritumomab, rx ...................................................................................... K .................. 12,130.20 .................. 2,426.04 

1644 .... I131 tositumomab, dx ................................................................................... K .................. 1,368.17 .................. 273.63 

1645 .... I131 tositumomab, rx .................................................................................... K .................. 11,868.78 .................. 2,373.76 

1646 .... In111 oxyquinoline ........................................................................................ K .................. 306.51 .................. 61.30 

1647 .... In111 pentetate ............................................................................................. K .................. 262.81 .................. 52.56 

1648 .... Tc99m arcitumomab ..................................................................................... K .................. 255.95 .................. 51.19 

1650 .... Tc99m succimer ............................................................................................ K .................. 84.79 .................. 16.96 

1651 .... F18 fdg .......................................................................................................... K .................. 235.56 .................. 47.11 

1654 .... Rb82 rubidium ............................................................................................... K .................. 239.83 .................. 47.97 

1655 .... Tinzaparin sodium injection .......................................................................... K .................. 2.18 .................. 0.44 

1670 .... Tetanus immune globulin inj ......................................................................... K .................. 90.71 .................. 18.14 

1671 .... Ga67 gallium ................................................................................................. K .................. 22.73 .................. 4.55 

1672 .... Tc99m bicisate .............................................................................................. K .................. 254.46 .................. 50.89 

1675 .... P32 Na phosphate ........................................................................................ K .................. 117.11 .................. 23.42 

1676 .... P32 chromic phosphate ................................................................................ K .................. 222.35 .................. 44.47 

1677 .... In111 pentetreotide ....................................................................................... K .................. 185.60 .................. 37.12 

1678 .... Tc99m fanolesomab ..................................................................................... K .................. 527.31 .................. 105.46 

1680 .... Acetylcysteine injection ................................................................................. K .................. 1.86 .................. 0.37 

1682 .... Aprotonin, 10,000 kiu .................................................................................... K .................. 2.32 .................. 0.46 

1683 .... Basiliximab .................................................................................................... K .................. 1,388.81 .................. 277.76 

1684 .... Corticorelin ovine triflutal .............................................................................. K .................. 4.22 .................. 0.84 

1685 .... Darbepoetin alfa, non-esrd ........................................................................... K .................. 3.00 .................. 0.60 

1686 .... Epoetin alfa, non-esrd ................................................................................... K .................. 9.25 .................. 1.85 

1687 .... Digoxin immune fab (ovine) .......................................................................... K .................. 527.46 .................. 105.49 

1688 .... Ethanolamine oleate ..................................................................................... K .................. 71.57 .................. 14.31 

1689 .... Fomepizole .................................................................................................... K .................. 11.82 .................. 2.36 

1690 .... Hemin ............................................................................................................ K .................. 6.59 .................. 1.32 

1691 .... Iron dextran 165 injection ............................................................................. K .................. 12.30 .................. 2.46 

1692 .... Iron dextran 267 injection ............................................................................. K .................. 10.17 .................. 2.03 

1693 .... Lepirudin ....................................................................................................... K .................. 146.38 .................. 29.28 

1694 .... Ziconotide injection ....................................................................................... G .................. 6.20 .................. 1.24 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49715 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

1695 .... Nesiritide injection ......................................................................................... K .................. 29.72 .................. 5.94 

1696 .... Palifermin injection ........................................................................................ K .................. 11.37 .................. 2.27 

1697 .... Pegaptanib sodium injection ......................................................................... G .................. 1,107.54 .................. 221.51 

1700 .... Inj secretin synthetic human ......................................................................... K .................. 20.31 .................. 4.06 

1701 .... Treprostinil injection ...................................................................................... K .................. 53.51 .................. 10.70 

1703 .... Ovine, 1000 USP units ................................................................................. K .................. 133.77 .................. 26.75 

1704 .... Inj Vonwillebrand factor iu ............................................................................ K .................. 0.87 .................. 0.17 

1705 .... Factor viia ..................................................................................................... K .................. 1.08 .................. 0.22 

1707 .... Non-human, metabolic tissue ....................................................................... K .................. 1.64 .................. 0.33 

1709 .... Azacitidine injection ...................................................................................... K .................. 4.09 .................. 0.82 

1710 .... Clofarabine injection ..................................................................................... G .................. 116.68 .................. 23.34 

1711 .... Histrelin implant ............................................................................................ K .................. 2,019.82 .................. 403.96 

1712 .... Paclitaxel injection ........................................................................................ G .................. 8.73 .................. 1.75 

1713 .... Inj Fe-based MR contrast,1ml ...................................................................... K .................. 30.12 .................. 6.02 

1716 .... Brachytx source, Gold 198 ........................................................................... K 0.4493 27.65 .................. 5.53 

1717 .... Brachytx source, HDR Ir–192 ....................................................................... K 2.1922 134.93 .................. 26.99 

1718 .... Brachytx source, Iodine 125 ......................................................................... K 0.5754 35.42 .................. 7.08 

1719 .... Brachytx sour, Non-HDR Ir–192 ................................................................... K 0.5108 31.44 .................. 6.29 

1720 .... Brachytx sour, Palladium 103 ....................................................................... K 0.7945 48.90 .................. 9.78 

1738 .... Oxaliplatin ..................................................................................................... K .................. 8.47 .................. 1.69 

1739 .... Pegademase bovine, 25 iu ........................................................................... K .................. 164.50 .................. 32.90 

1740 .... Diazoxide injection ........................................................................................ K .................. 110.88 .................. 22.18 

1741 .... Urofollitropin, 75 iu ........................................................................................ K .................. 48.84 .................. 9.77 

1820 .... Generator neuro rechg bat sys ..................................................................... H .................. .................. .................. ..................

2210 .... Methyldopate hcl injection ............................................................................ K .................. 9.86 .................. 1.97 

2616 .... Brachytx source, Yttrium-90 ......................................................................... K 272.7710 16,789.33 .................. 3,357.87 

2632 .... Brachytx sol, I–125, per mCi ........................................................................ K 0.3139 19.32 .................. 3.86 

2633 .... Brachytx source, Cesium-131 ....................................................................... K 1.4622 90.00 .................. 18.00 

2634 .... Brachytx source, HA, I–125 .......................................................................... K 0.4172 25.68 .................. 5.14 

2635 .... Brachytx source, HA, P–103 ........................................................................ K 0.8820 54.29 .................. 10.86 

2636 .... Brachytx linear source, P–103 ...................................................................... K 0.6360 39.15 .................. 7.83 

2637 .... Brachytx, Ytterbium-169 ............................................................................... K 0.4172 25.68 .................. 5.14 

2731 .... Immune globulin, powder .............................................................................. K .................. 22.05 .................. 4.41 

2732 .... Immune globulin, liquid ................................................................................. K .................. 28.82 .................. 5.76 

2770 .... Quinupristin/dalfopristin ................................................................................. K .................. 108.03 .................. 21.61 

2940 .... Somatrem injection ....................................................................................... K .................. 583.74 .................. 116.75 

3030 .... Sumatriptan succinate / 6 MG ...................................................................... K .................. 51.75 .................. 10.35 

3032 .... Dtp/hib vaccine, im ....................................................................................... K .................. 68.91 .................. 13.78 

3038 .... Inj biperiden lactate/5 mg ............................................................................. K .................. 88.36 .................. 17.67 

3039 .... Inj metaraminol bitartrate .............................................................................. K .................. 17.68 .................. 3.54 

3040 .... Penicillin g benzathine inj ............................................................................. K .................. 67.86 .................. 13.57 

3041 .... Bivalirudin ...................................................................................................... K .................. 1.62 .................. 0.32 

3042 .... Foscarnet sodium injection ........................................................................... K .................. 10.69 .................. 2.14 

3043 .... Gamma globulin 1 CC inj ............................................................................. K .................. 10.59 .................. 2.12 

3045 .... Meropenem ................................................................................................... K .................. 3.76 .................. 0.75 

3046 .... Octreotide inj, non-depot .............................................................................. K .................. 4.34 .................. 0.87 

3047 .... Melphalan oral 2 MG .................................................................................... K .................. 4.39 .................. 0.88 

3048 .... Doxorubic hcl 10 MG vl chemo .................................................................... K .................. 6.23 .................. 1.25 

3049 .... Cyclophosphamide lyophilized ...................................................................... K .................. 5.47 .................. 1.09 

3050 .... Sermorelin acetate injection ......................................................................... K .................. 1.73 .................. 0.35 

7000 .... Amifostine ..................................................................................................... K .................. 448.41 .................. 89.68 

7005 .... Gonadorelin hydroch/ 100 mcg .................................................................... K .................. 178.59 .................. 35.72 

7011 .... Oprelvekin injection ....................................................................................... K .................. 243.39 .................. 48.68 

7015 .... Oral busulfan ................................................................................................. K .................. 1.95 .................. 0.39 

7028 .... Fosphenytoin, 50 mg .................................................................................... K .................. 5.18 .................. 1.04 

7034 .... Somatropin injection ..................................................................................... K .................. 43.73 .................. 8.75 

7035 .... Teniposide, 50 mg ........................................................................................ K .................. 264.26 .................. 52.85 

7036 .... Urokinase 250,000 IU inj .............................................................................. K .................. 453.41 .................. 90.68 

7038 .... Monoclonal antibodies .................................................................................. K .................. 860.94 .................. 172.19 

7041 .... Tirofiban HCl ................................................................................................. K .................. 7.61 .................. 1.52 

7042 .... Capecitabine, oral, 150 mg ........................................................................... K .................. 3.60 .................. 0.72 

7043 .... Infliximab injection ......................................................................................... K .................. 53.73 .................. 10.75 

7045 .... Inj trimetrexate glucoronate .......................................................................... K .................. 144.39 .................. 28.88 

7046 .... Doxorubicin hcl liposome inj ......................................................................... K .................. 367.56 .................. 73.51 

7048 .... Alteplase recombinant .................................................................................. K .................. 31.06 .................. 6.21 

7049 .... Filgrastim 480 mcg injection ......................................................................... K .................. 289.59 .................. 57.92 

7051 .... Leuprolide acetate implant ............................................................................ K .................. 2,157.81 .................. 431.56 

7308 .... Aminolevulinic acid hcl top ........................................................................... K .................. 99.92 .................. 19.98 

7316 .... Sodium hyaluronate injection ........................................................................ K .................. 112.04 .................. 22.41 


sroberts on PROD1PC70 with PROPOSALS
49716 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

9001 .... Linezolid injection .......................................................................................... K .................. 23.50 .................. 4.70 

9002 .... Tenecteplase injection .................................................................................. K .................. 2,059.01 .................. 411.80 

9003 .... Palivizumab, per 50 mg ................................................................................ K .................. 609.62 .................. 121.92 

9004 .... Gemtuzumab ozogamicin ............................................................................. K .................. 2,265.57 .................. 453.11 

9005 .... Reteplase injection ........................................................................................ K .................. 754.71 .................. 150.94 

9006 .... Tacrolimus injection ...................................................................................... K .................. 135.17 .................. 27.03 

9012 .... Arsenic trioxide ............................................................................................. K .................. 32.92 .................. 6.58 

9015 .... Mycophenolate mofetil oral ........................................................................... K .................. 2.50 .................. 0.50 

9018 .... Botulinum toxin type B .................................................................................. K .................. 7.85 .................. 1.57 

9019 .... Caspofungin acetate ..................................................................................... K .................. 32.19 .................. 6.44 

9020 .... Sirolimus, oral ............................................................................................... K .................. 6.84 .................. 1.37 

9022 .... IM inj interferon beta 1–a .............................................................................. K .................. 97.99 .................. 19.60 

9023 .... Rho d immune globulin 50 mcg .................................................................... K .................. 14.13 .................. 2.83 

9024 .... Amphotericin b lipid complex ........................................................................ K .................. 11.10 .................. 2.22 

9031 .... Arbutamine HCl injection .............................................................................. K .................. 160.00 .................. 32.00 

9032 .... Baclofen 10 MG injection .............................................................................. K .................. 191.50 .................. 38.30 

9033 .... Cidofovir injection .......................................................................................... K .................. 757.03 .................. 151.41 

9038 .... Inj estrogen conjugate 25 MG ...................................................................... K .................. 57.78 .................. 11.56 

9040 .... Intraocular Fomivirsen na ............................................................................. K .................. 210.00 .................. 42.00 

9042 .... Glucagon hydrochloride/1 MG ...................................................................... K .................. 62.42 .................. 12.48 

9044 .... Ibutilide fumarate injection ............................................................................ K .................. 249.01 .................. 49.80 

9046 .... Iron sucrose injection .................................................................................... K .................. 0.36 .................. 0.07 

9047 .... Itraconazole injection .................................................................................... K .................. 36.23 .................. 7.25 

9051 .... Urea injection ................................................................................................ K .................. 69.10 .................. 13.82 

9054 .... Metabolically active tissue ............................................................................ K .................. 15.01 .................. 3.00 

9100 .... I131 serum albumin, dx ................................................................................ K .................. 36.78 .................. 7.36 

9104 .... Antithymocyte globuln rabbit ......................................................................... K .................. 301.48 .................. 60.30 

9108 .... Thyrotropin injection ...................................................................................... K .................. 766.61 .................. 153.32 

9110 .... Alemtuzumab injection .................................................................................. K .................. 525.75 .................. 105.15 

9112 .... Inj perflutren lip micros,ml ............................................................................. K .................. 61.25 .................. 12.25 

9115 .... Zoledronic acid .............................................................................................. K .................. 200.82 .................. 40.16 

9119 .... Injection, pegfilgrastim 6mg .......................................................................... K .................. 2,142.79 .................. 428.56 

9120 .... Injection, Fulvestrant ..................................................................................... K .................. 80.31 .................. 16.06 

9121 .... Injection, argatroban ..................................................................................... K .................. 16.40 .................. 3.28 

9122 .... Triptorelin pamoate ....................................................................................... K .................. 300.90 .................. 60.18 

9124 .... Daptomycin injection ..................................................................................... K .................. 0.31 .................. 0.06 

9125 .... Risperidone, long acting ............................................................................... K .................. 4.73 .................. 0.95 

9126 .... Natalizumab injection .................................................................................... G .................. 6.39 .................. 1.28 

9133 .... Rabies ig, im/sc ............................................................................................ K .................. 63.98 .................. 12.80 

9134 .... Rabies ig, heat treated ................................................................................. K .................. 68.58 .................. 13.72 

9135 .... Varicella-zoster ig, im ................................................................................... K .................. 149.08 .................. 29.82 

9137 .... Bcg vaccine, percut ...................................................................................... K .................. 115.46 .................. 23.09 

9139 .... Rabies vaccine, im ........................................................................................ K .................. 155.25 .................. 31.05 

9140 .... Rabies vaccine, id ......................................................................................... K .................. 118.49 .................. 23.70 

9141 .... Measles-rubella vaccine, sc .......................................................................... K .................. 44.62 .................. 8.92 

9142 .... Chicken pox vaccine, sc ............................................................................... K .................. 66.84 .................. 13.37 

9143 .... Meningococcal vaccine, sc ........................................................................... K .................. 84.46 .................. 16.89 

9144 .... Encephalitis vaccine, sc ................................................................................ K .................. 99.15 .................. 19.83 

9145 .... Meningococcal vaccine, im ........................................................................... K .................. 143.12 .................. 28.62 

9148 .... I123 iodide cap, dx ....................................................................................... K .................. 27.44 .................. 5.49 

9156 .... Nonmetabolic active tissue ........................................................................... K .................. 66.39 .................. 13.28 

9157 .... LOCM < = 149 mg/ml iodine, 1ml ................................................................ K .................. 0.30 .................. 0.06 

9158 .... LOCM 150–199mg/ml iodine,1ml ................................................................. K .................. 1.84 .................. 0.37 

9159 .... LOCM 200–249mg/ml iodine,1ml ................................................................. K .................. 1.25 .................. 0.25 

9160 .... LOCM 250–299mg/ml iodine,1ml ................................................................. K .................. 0.32 .................. 0.06 

9161 .... LOCM 300–349mg/ml iodine,1ml ................................................................. K .................. 0.34 .................. 0.07 

9162 .... LOCM 350–399mg/ml iodine,1ml ................................................................. K .................. 0.21 .................. 0.04 

9163 .... LOCM > = 400 mg/ml iodine,1ml ................................................................. K .................. 0.30 .................. 0.06 

9164 .... Inj Gad-base MR contrast,1ml ...................................................................... K .................. 2.88 .................. 0.58 

9165 .... Oral MR contrast ........................................................................................... K .................. 8.87 .................. 1.77 

9167 .... Valrubicin ...................................................................................................... K .................. 76.03 .................. 15.21 

9202 .... Inj octafluoropropane mic,ml ......................................................................... K .................. 40.75 .................. 8.15 

9203 .... Inj perflexane lip micros,ml ........................................................................... K .................. 8.22 .................. 1.64 

9207 .... Bortezomib injection ...................................................................................... K .................. 29.81 .................. 5.96 

9208 .... Agalsidase beta injection .............................................................................. K .................. 126.00 .................. 25.20 

9209 .... Laronidase injection ...................................................................................... K .................. 23.64 .................. 4.73 

9210 .... Palonosetron HCl .......................................................................................... K .................. 17.51 .................. 3.50 

9213 .... Pemetrexed injection .................................................................................... K .................. 40.90 .................. 8.18 

9214 .... Bevacizumab injection .................................................................................. K .................. 56.36 .................. 11.27 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49717 

ADDENDUM A.—OPPS PROPOSED LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS

(SI), RELATIVE WEIGHTS, PAYMENT RATES, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued 

APC Group title SI Relative 

weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copyment 

9215 .... Cetuximab injection ....................................................................................... K .................. 49.39 .................. 9.88 

9216 .... Abarelix injection ........................................................................................... K .................. 66.20 .................. 13.24 

9217 .... Leuprolide acetate suspnsion ....................................................................... K .................. 242.99 .................. 48.60 

9219 .... Mycophenolic acid ........................................................................................ K .................. 2.15 .................. 0.43 

9220 .... Sodium hyaluronate ...................................................................................... K .................. 197.62 .................. 39.52 

9222 .... Graftjacket SftTis .......................................................................................... K .................. 883.78 .................. 176.76 

9224 .... Injection, galsulfase ...................................................................................... K .................. 1,503.23 .................. 300.65 

9225 .... Fluocinolone acetonide ................................................................................. G .................. 19,345.00 .................. 3,869.00 

9227 .... Injection, micafungin sodium ........................................................................ G .................. 1.98 .................. 0.40 

9228 .... Injection, tigecycline ...................................................................................... G .................. 0.96 .................. 0.19 

9300 .... Omalizumab injection .................................................................................... K .................. 16.34 .................. 3.27 

9500 .... Platelets, irradiated ....................................................................................... K 2.0957 128.99 .................. 25.80 

9501 .... Platelet pheres leukoreduced ....................................................................... K 7.9414 488.80 .................. 97.76 

9502 .... Platelet pheresis irradiated ........................................................................... K 6.6959 412.14 .................. 82.43 

9503 .... Fr frz plasma donor retested ........................................................................ K 1.1915 73.34 .................. 14.67 

9504 .... RBC deglycerolized ...................................................................................... K 5.7106 351.49 .................. 70.30 

9505 .... RBC irradiated .............................................................................................. K 3.2600 200.66 .................. 40.13 

9506 .... Granulocytes, pheresis unit .......................................................................... K 4.1030 252.54 .................. 50.51 

9507 .... Platelets, pheresis ......................................................................................... K 7.5381 463.98 .................. 92.80 

9508 .... Plasma 1 donor frz w/in 8 hr ........................................................................ K 1.1677 71.87 .................. 14.37 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

10121 ....... Remove foreign body ................................................................... 2 $920.58 $446.00 ......... $89.20 

10180 ....... Complex drainage, wound ............................................................ 2 $1,075.21 $446.00 ......... $89.20 

11010 ....... Debride skin, fx ............................................................................. 2 $246.96 $246.96 Y ..... $49.39 

11011 ....... Debride skin/muscle, fx ................................................................ 2 $246.96 $246.96 Y ..... $49.39 

11012 ....... Debride skin/muscle/bone, fx ....................................................... 2 $246.96 $246.96 Y ..... $49.39 

11042 ....... Debride skin/tissue ....................................................................... 2 $161.59 $161.59 Y ..... $32.32 

11043 ....... Debride tissue/muscle .................................................................. 2 $161.59 $161.59 Y ..... $32.32 

11044 ....... Debride tissue/muscle/bone ......................................................... 2 $415.65 $415.65 Y ..... $83.13 

11404 ....... Exc tr-ext b9+marg 3.1–4 cm ....................................................... 1 $920.58 $333.00 ......... $66.60 

11406 ....... Exc tr-ext b9+marg > 4.0 cm ........................................................ 2 $920.58 $446.00 ......... $89.20 

11424 ....... Exc h-f-nk-sp b9+marg 3.1–4 ....................................................... 2 $920.58 $446.00 ......... $89.20 

11426 ....... Exc h-f-nk-sp b9+marg > 4 cm ..................................................... 2 $1,229.54 $446.00 ......... $89.20 

11444 ....... Exc face-mm b9+marg 3.1–4 cm ................................................. 1 $400.87 $333.00 ......... $66.60 

11446 ....... Exc face-mm b9+marg > 4 cm ..................................................... 2 $1,229.54 $446.00 ......... $89.20 

11450 ....... Removal, sweat gland lesion ........................................................ 2 $1,229.54 $446.00 ......... $89.20 

11451 ....... Removal, sweat gland lesion ........................................................ 2 $1,229.54 $446.00 ......... $89.20 

11462 ....... Removal, sweat gland lesion ........................................................ 2 $1,229.54 $446.00 ......... $89.20 

11463 ....... Removal, sweat gland lesion ........................................................ 2 $1,229.54 $446.00 ......... $89.20 

11470 ....... Removal, sweat gland lesion ........................................................ 2 $1,229.54 $446.00 ......... $89.20 

11471 ....... Removal, sweat gland lesion ........................................................ 2 $1,229.54 $446.00 ......... $89.20 

11604 ....... Exc tr-ext mlg+marg 3.1–4 cm ..................................................... 2 $400.87 $400.87 Y ..... $80.17 

11606 ....... Exc tr-ext mlg+marg > 4 cm ......................................................... 2 $920.58 $446.00 ......... $89.20 

11624 ....... Exc h-f-nk-sp mlg+marg 3.1–4 ..................................................... 2 $920.58 $446.00 ......... $89.20 

11626 ....... Exc h-f-nk-sp mlg+mar > 4 cm ..................................................... 2 $1,229.54 $446.00 ......... $89.20 

11644 ....... Exc face-mm malig+marg 3.1–4 .................................................. 2 $920.58 $446.00 ......... $89.20 

11646 ....... Exc face-mm mlg+marg > 4 cm ................................................... 2 $1,229.54 $446.00 ......... $89.20 

11770 ....... Removal of pilonidal lesion ........................................................... 3 $1,229.54 $510.00 ......... $102.00 

11771 ....... Removal of pilonidal lesion ........................................................... 3 $1,229.54 $510.00 ......... $102.00 

11772 ....... Removal of pilonidal lesion ........................................................... 3 $1,229.54 $510.00 ......... $102.00 

11960 ....... Insert tissue expander(s) .............................................................. 2 $1,308.85 $446.00 ......... $89.20 

11970 ....... Replace tissue expander .............................................................. 3 $2,539.24 $510.00 ......... $102.00 

11971 ....... Remove tissue expander(s) .......................................................... 1 $1,229.54 $333.00 ......... $66.60 

12005 ....... Repair superficial wound(s) .......................................................... 2 $91.86 $91.86 Y ..... $18.37 

12006 ....... Repair superficial wound(s) .......................................................... 2 $91.86 $91.86 Y ..... $18.37 

12007 ....... Repair superficial wound(s) .......................................................... 2 $91.86 $91.86 Y ..... $18.37 

12016 ....... Repair superficial wound(s) .......................................................... 2 $91.86 $91.86 Y ..... $18.37 

12017 ....... Repair superficial wound(s) .......................................................... 2 $91.86 $91.86 Y ..... $18.37 

12018 ....... Repair superficial wound(s) .......................................................... 2 $91.86 $91.86 Y ..... $18.37 

12020 ....... Closure of split wound .................................................................. 1 $91.86 $91.86 Y ..... $18.37 

12021 ....... Closure of split wound .................................................................. 1 $91.86 $91.86 Y ..... $18.37 


sroberts on PROD1PC70 with PROPOSALS
49718 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

12034 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12035 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12036 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12037 ....... Layer closure of wound(s) ............................................................ 2 $313.49 $313.49 Y ..... $62.70

12044 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12045 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12046 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12047 ....... Layer closure of wound(s) ............................................................ 2 $313.49 $313.49 Y ..... $62.70

12054 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12055 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12056 ....... Layer closure of wound(s) ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

12057 ....... Layer closure of wound(s) ............................................................ 2 $313.49 $313.49 Y ..... $62.70

13100 ....... Repair of wound or lesion ............................................................ 2 $313.49 $313.49 Y ..... $62.70

13101 ....... Repair of wound or lesion ............................................................ 3 $313.49 $313.49 Y ..... $62.70

13102 ....... Repair wound/lesion add-on ......................................................... 1 $91.86 $91.86 Y ..... $18.37 

13120 ....... Repair of wound or lesion ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

13121 ....... Repair of wound or lesion ............................................................ 3 $91.86 $91.86 Y ..... $18.37 

13122 ....... Repair wound/lesion add-on ......................................................... 1 $91.86 $91.86 Y ..... $18.37 

13131 ....... Repair of wound or lesion ............................................................ 2 $91.86 $91.86 Y ..... $18.37 

13132 ....... Repair of wound or lesion ............................................................ 3 $91.86 $91.86 Y ..... $18.37 

13133 ....... Repair wound/lesion add-on ......................................................... 1 $91.86 $91.86 Y ..... $18.37 

13150 ....... Repair of wound or lesion ............................................................ 3 $313.49 $313.49 Y ..... $62.70

13151 ....... Repair of wound or lesion ............................................................ 3 $91.86 $91.86 Y ..... $18.37 

13152 ....... Repair of wound or lesion ............................................................ 3 $313.49 $313.49 Y ..... $62.70

13160 ....... Late closure of wound .................................................................. 2 $1,308.85 $446.00 ......... $89.20 

14000 ....... Skin tissue rearrangement ............................................................ 2 $821.29 $446.00 ......... $89.20 

14001 ....... Skin tissue rearrangement ............................................................ 3 $1,308.85 $510.00 ......... $102.00 

14020 ....... Skin tissue rearrangement ............................................................ 3 $821.29 $510.00 ......... $102.00 

14021 ....... Skin tissue rearrangement ............................................................ 3 $821.29 $510.00 ......... $102.00 

14040 ....... Skin tissue rearrangement ............................................................ 2 $821.29 $446.00 ......... $89.20 

14041 ....... Skin tissue rearrangement ............................................................ 3 $821.29 $510.00 ......... $102.00 

14060 ....... Skin tissue rearrangement ............................................................ 3 $821.29 $510.00 ......... $102.00 

14061 ....... Skin tissue rearrangement ............................................................ 3 $821.29 $510.00 ......... $102.00 

14300 ....... Skin tissue rearrangement ............................................................ 4 $1,308.85 $630.00 ......... $126.00 

14350 ....... Skin tissue rearrangement ............................................................ 3 $1,308.85 $510.00 ......... $102.00 

15000 ....... Wound prep, 1st 100 sq cm ......................................................... 2 $313.49 $313.49 Y ..... $62.70 

15001 ....... Wound prep, addl 100 sq cm ....................................................... 1 $313.49 $313.49 Y ..... $62.70 

15040 ....... Harvest cultured skin graft ............................................................ 2 $91.86 $91.86 Y ..... $18.37

15050 ....... Skin pinch graft ............................................................................. 2 $313.49 $313.49 Y ..... $62.70 

15100 ....... Skin splt grft, trnk/arm/leg ............................................................. 2 $1,308.85 $446.00 ......... $89.20 

15101 ....... Skin splt grft t/a/l, add-on ............................................................. 3 $1,308.85 $510.00 ......... $102.00 

15110 ....... Epidrm autogrft trnk/arm/leg ......................................................... 2 $1,308.85 $446.00 ......... $89.20 

15111 ....... Epidrm autogrft t/a/l add-on .......................................................... 1 $1,308.85 $333.00 ......... $66.60 

15115 ....... Epidrm a-grft face/nck/hf/g ........................................................... 2 $1,308.85 $446.00 ......... $89.20 

15116 ....... Epidrm a-grft f/n/hf/g addl ............................................................. 1 $1,308.85 $333.00 ......... $66.60 

15120 ....... Skn splt a-grft fac/nck/hf/g ............................................................ 2 $1,308.85 $446.00 ......... $89.20 

15121 ....... Skn splt a-grft f/n/hf/g add ............................................................ 3 $1,308.85 $510.00 ......... $102.00 

15130 ....... Derm autograft, trnk/arm/leg ......................................................... 2 $1,308.85 $446.00 ......... $89.20 

15131 ....... Derm autograft t/a/l add-on .......................................................... 1 $1,308.85 $333.00 ......... $66.60 

15135 ....... Derm autograft face/nck/hf/g ........................................................ 2 $1,308.85 $446.00 ......... $89.20 

15136 ....... Derm autograft, f/n/hf/g add ......................................................... 1 $1,308.85 $333.00 ......... $66.60 

15150 ....... Cult epiderm grft t/arm/leg ............................................................ 2 $1,308.85 $446.00 ......... $89.20 

15151 ....... Cult epiderm grft t/a/l addl ............................................................ 1 $1,308.85 $333.00 ......... $66.60 

15152 ....... Cult epiderm graft t/a/l +% ........................................................... 1 $1,308.85 $333.00 ......... $66.60 

15155 ....... Cult epiderm graft, f/n/hf/g ............................................................ 2 $1,308.85 $446.00 ......... $89.20 

15156 ....... Cult epidrm grft f/n/hfg add ........................................................... 1 $1,308.85 $333.00 ......... $66.60 

15157 ....... Cult epiderm grft f/n/hfg +% ......................................................... 1 $1,308.85 $333.00 ......... $66.60 

15200 ....... Skin full graft, trunk ....................................................................... 3 $821.29 $510.00 ......... $102.00 

15201 ....... Skin full graft trunk add-on ........................................................... 2 $313.49 $313.49 Y ..... $62.70 

15220 ....... Skin full graft sclp/arm/leg ............................................................ 2 $821.29 $446.00 ......... $89.20 

15221 ....... Skin full graft add-on .................................................................... 2 $313.49 $313.49 Y ..... $62.70 

15240 ....... Skin full grft face/genit/hf .............................................................. 3 $821.29 $510.00 ......... $102.00 

15241 ....... Skin full graft add-on .................................................................... 3 $313.49 $313.49 Y ..... $62.70 

15260 ....... Skin full graft een & lips ............................................................... 2 $821.29 $446.00 ......... $89.20 

15261 ....... Skin full graft add-on .................................................................... 2 $313.49 $313.49 Y ..... $62.70 

15300 ....... Apply skinallogrft, t/arm/lg ............................................................ 2 $313.49 $313.49 Y ..... $62.70 

15301 ....... Apply sknallogrft t/a/l addl ............................................................ 1 $313.49 $313.49 Y ..... $62.70 

15320 ....... Apply skin allogrft f/n/hf/g ............................................................. 2 $313.49 $313.49 Y ..... $62.70 

15321 ....... Aply sknallogrft f/n/hfg add ........................................................... 1 $313.49 $313.49 Y ..... $62.70 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49719 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

15330 ....... Aply acell alogrft t/arm/leg ............................................................ 2 $313.49 $313.49 Y ..... $62.70 

15331 ....... Aply acell grft t/a/l add-on ............................................................. 1 $313.49 $313.49 Y ..... $62.70 

15335 ....... Apply acell graft, f/n/hf/g ............................................................... 2 $313.49 $313.49 Y ..... $62.70 

15336 ....... Aply acell grft f/n/hf/g add ............................................................. 1 $313.49 $313.49 Y ..... $62.70 

15400 ....... Apply skin xenograft, t/a/l ............................................................. 2 $313.49 $313.49 Y ..... $62.70 

15401 ....... Apply skn xenogrft t/a/l add .......................................................... 2 $313.49 $313.49 Y ..... $62.70 

15420 ....... Apply skin xgraft, f/n/hf/g .............................................................. 2 $313.49 $313.49 Y ..... $62.70 

15421 ....... Apply skn xgrft f/n/hf/g add ........................................................... 1 $313.49 $313.49 Y ..... $62.70 

15430 ....... Apply acellular xenograft .............................................................. 2 $313.49 $313.49 Y ..... $62.70 

15431 ....... Apply acellular xgraft add ............................................................. 1 $313.49 $313.49 Y ..... $62.70 

15570 ....... Form skin pedicle flap .................................................................. 3 $1,308.85 $510.00 ......... $102.00 

15572 ....... Form skin pedicle flap .................................................................. 3 $1,308.85 $510.00 ......... $102.00 

15574 ....... Form skin pedicle flap .................................................................. 3 $1,308.85 $510.00 ......... $102.00 

15576 ....... Form skin pedicle flap .................................................................. 3 $821.29 $510.00 ......... $102.00 

15600 ....... Skin graft ....................................................................................... 3 $1,308.85 $510.00 ......... $102.00 

15610 ....... Skin graft ....................................................................................... 3 $1,308.85 $510.00 ......... $102.00 

15620 ....... Skin graft ....................................................................................... 4 $1,308.85 $630.00 ......... $126.00 

15630 ....... Skin graft ....................................................................................... 3 $1,308.85 $510.00 ......... $102.00 

15650 ....... Transfer skin pedicle flap ............................................................. 5 $1,308.85 $717.00 ......... $143.40 

15732 ....... Muscle-skin graft, head/neck ........................................................ 3 $1,308.85 $510.00 ......... $102.00 

15734 ....... Muscle-skin graft, trunk ................................................................ 3 $1,308.85 $510.00 ......... $102.00 

15736 ....... Muscle-skin graft, arm .................................................................. 3 $1,308.85 $510.00 ......... $102.00 

15738 ....... Muscle-skin graft, leg .................................................................... 3 $1,308.85 $510.00 ......... $102.00 

15740 ....... Island pedicle flap graft ................................................................ 2 $821.29 $446.00 ......... $89.20 

15750 ....... Neurovascular pedicle graft .......................................................... 2 $1,308.85 $446.00 ......... $89.20 

15760 ....... Composite skin graft ..................................................................... 2 $1,308.85 $446.00 ......... $89.20 

15770 ....... Derma-fat-fascia graft ................................................................... 3 $1,308.85 $510.00 ......... $102.00 

15775 ....... Hair transplant punch grafts ......................................................... 3 $313.49 $313.49 Y ..... $62.70

15776 ....... Hair transplant punch grafts ......................................................... 3 $313.49 $313.49 Y ..... $62.70

15820 ....... Revision of lower eyelid ................................................................ 3 $1,308.85 $510.00 ......... $102.00 

15821 ....... Revision of lower eyelid ................................................................ 3 $1,308.85 $510.00 ......... $102.00 

15822 ....... Revision of upper eyelid ............................................................... 3 $1,308.85 $510.00 ......... $102.00 

15823 ....... Revision of upper eyelid ............................................................... 5 $821.29 $717.00 ......... $143.40 

15824 ....... Removal of forehead wrinkles ...................................................... 3 $1,308.85 $510.00 ......... $102.00 

15825 ....... Removal of neck wrinkles ............................................................. 3 $1,308.85 $510.00 ......... $102.00 

15826 ....... Removal of brow wrinkles ............................................................ 3 $1,308.85 $510.00 ......... $102.00 

15828 ....... Removal of face wrinkles ............................................................. 3 $1,308.85 $510.00 ......... $102.00 

15829 ....... Removal of skin wrinkles .............................................................. 5 $1,308.85 $717.00 ......... $143.40 

15831 ....... Excise excessive skin tissue ........................................................ 3 $1,229.54 $510.00 ......... $102.00 

15832 ....... Excise excessive skin tissue ........................................................ 3 $1,229.54 $510.00 ......... $102.00 

15833 ....... Excise excessive skin tissue ........................................................ 3 $1,229.54 $510.00 ......... $102.00 

15834 ....... Excise excessive skin tissue ........................................................ 3 $1,229.54 $510.00 ......... $102.00 

15835 ....... Excise excessive skin tissue ........................................................ 3 $313.49 $313.49 Y ..... $62.70 

15836 ....... Excise excessive skin tissue ........................................................ 3 $920.58 $510.00 ......... $102.00 

15839 ....... Excise excessive skin tissue ........................................................ 3 $920.58 $510.00 ......... $102.00 

15840 ....... Graft for face nerve palsy ............................................................. 4 $1,308.85 $630.00 ......... $126.00 

15841 ....... Graft for face nerve palsy ............................................................. 4 $1,308.85 $630.00 ......... $126.00 

15845 ....... Skin and muscle repair, face ........................................................ 4 $1,308.85 $630.00 ......... $126.00 

15876 ....... Suction assisted lipectomy ........................................................... 3 $1,308.85 $510.00 ......... $102.00 

15877 ....... Suction assisted lipectomy ........................................................... 3 $1,308.85 $510.00 ......... $102.00 

15878 ....... Suction assisted lipectomy ........................................................... 3 $821.29 $510.00 ......... $102.00 

15879 ....... Suction assisted lipectomy ........................................................... 3 $1,308.85 $510.00 ......... $102.00 

15920 ....... Removal of tail bone ulcer ............................................................ 3 $246.96 $246.96 Y ..... $49.39 

15922 ....... Removal of tail bone ulcer ............................................................ 4 $1,308.85 $630.00 ......... $126.00 

15931 ....... Remove sacrum pressure sore .................................................... 3 $1,229.54 $510.00 ......... $102.00

15933 ....... Remove sacrum pressure sore .................................................... 3 $1,229.54 $510.00 ......... $102.00

15934 ....... Remove sacrum pressure sore .................................................... 3 $1,308.85 $510.00 ......... $102.00

15935 ....... Remove sacrum pressure sore .................................................... 4 $1,308.85 $630.00 ......... $126.00

15936 ....... Remove sacrum pressure sore .................................................... 4 $1,308.85 $630.00 ......... $126.00

15937 ....... Remove sacrum pressure sore .................................................... 4 $1,308.85 $630.00 ......... $126.00

15940 ....... Remove hip pressure sore ........................................................... 3 $1,229.54 $510.00 ......... $102.00 

15941 ....... Remove hip pressure sore ........................................................... 3 $1,229.54 $510.00 ......... $102.00 

15944 ....... Remove hip pressure sore ........................................................... 3 $1,308.85 $510.00 ......... $102.00 

15945 ....... Remove hip pressure sore ........................................................... 4 $1,308.85 $630.00 ......... $126.00 

15946 ....... Remove hip pressure sore ........................................................... 4 $1,308.85 $630.00 ......... $126.00 

15950 ....... Remove thigh pressure sore ........................................................ 3 $1,229.54 $510.00 ......... $102.00 

15951 ....... Remove thigh pressure sore ........................................................ 4 $1,229.54 $630.00 ......... $126.00 

15952 ....... Remove thigh pressure sore ........................................................ 3 $1,308.85 $510.00 ......... $102.00 

15953 ....... Remove thigh pressure sore ........................................................ 4 $1,308.85 $630.00 ......... $126.00 


sroberts on PROD1PC70 with PROPOSALS
49720 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

15956 ....... Remove thigh pressure sore ........................................................ 3 $1,308.85 $510.00 ......... $102.00 

15958 ....... Remove thigh pressure sore ........................................................ 4 $1,308.85 $630.00 ......... $126.00 

16025 ....... Dress/debrid p-thick burn, m ........................................................ 2 $66.94 $66.94 Y ..... $13.39 

16030 ....... Dress/debrid p-thick burn, l .......................................................... 2 $98.86 $98.86 Y ..... $19.77 

19020 ....... Incision of breast lesion ................................................................ 2 $1,075.21 $446.00 ......... $89.20 

19100 ....... Bx breast percut w/o image .......................................................... 1 $234.21 $234.21 Y ..... $46.84 

19101 ....... Biopsy of breast, open .................................................................. 2 $1,183.32 $446.00 ......... $89.20 

19102 ....... Bx breast percut w/image ............................................................. 2 $234.21 $234.21 Y ..... $46.84

19103 ....... Bx breast percut w/device ............................................................ 2 $396.89 $396.89 Y ..... $79.38

19110 ....... Nipple exploration ......................................................................... 2 $1,183.32 $446.00 ......... $89.20 

19112 ....... Excise breast duct fistula .............................................................. 3 $1,183.32 $510.00 ......... $102.00 

19120 ....... Removal of breast lesion .............................................................. 3 $1,183.32 $510.00 ......... $102.00 

19125 ....... Excision, breast lesion .................................................................. 3 $1,183.32 $510.00 ......... $102.00 

19126 ....... Excision, addl breast lesion .......................................................... 3 $1,183.32 $510.00 ......... $102.00 

19140 ....... Removal of breast tissue .............................................................. 4 $1,183.32 $630.00 ......... $126.00 

19160 ....... Partial mastectomy ....................................................................... 3 $1,183.32 $510.00 ......... $102.00 

19162 ....... P-mastectomy w/ln removal ......................................................... 7 $2,307.20 $995.00 ......... $199.00 

19180 ....... Removal of breast ........................................................................ 4 $1,732.69 $630.00 ......... $126.00 

19182 ....... Removal of breast ........................................................................ 4 $1,732.69 $630.00 ......... $126.00 

19296 ....... Place po breast cath for rad ......................................................... 9 $2,508.17 $1,339.00 ......... $267.80 

19297 ....... Place breast cath for rad .............................................................. 9 $1,732.69 $1,339.00 ......... $267.80 

19298 ....... Place breast rad tube/caths .......................................................... 9 $3,250.00 $1,339.00 ......... $267.80 

19316 ....... Suspension of breast .................................................................... 4 $1,732.69 $630.00 ......... $126.00 

19318 ....... Reduction of large breast ............................................................. 4 $2,307.20 $630.00 ......... $126.00 

19324 ....... Enlarge breast .............................................................................. 4 $2,307.20 $630.00 ......... $126.00 

19325 ....... Enlarge breast with implant .......................................................... 9 $3,002.43 $1,339.00 ......... $267.80 

19328 ....... Removal of breast implant ............................................................ 1 $1,732.69 $333.00 ......... $66.60 

19330 ....... Removal of implant material ......................................................... 1 $1,732.69 $333.00 ......... $66.60 

19340 ....... Immediate breast prosthesis ........................................................ 2 $2,508.17 $446.00 ......... $89.20 

19342 ....... Delayed breast prosthesis ............................................................ 3 $3,002.43 $510.00 ......... $102.00 

19350 ....... Breast reconstruction .................................................................... 4 $1,183.32 $630.00 ......... $126.00 

19355 ....... Correct inverted nipple(s) ............................................................. 4 $1,732.69 $630.00 ......... $126.00 

19357 ....... Breast reconstruction .................................................................... 5 $3,002.43 $717.00 ......... $143.40 

19366 ....... Breast reconstruction .................................................................... 5 $1,732.69 $717.00 ......... $143.40 

19370 ....... Surgery of breast capsule ............................................................ 4 $1,732.69 $630.00 ......... $126.00 

19371 ....... Removal of breast capsule ........................................................... 4 $1,732.69 $630.00 ......... $126.00 

19380 ....... Revise breast reconstruction ........................................................ 5 $2,508.17 $717.00 ......... $143.40 

20005 ....... Incision of deep abscess .............................................................. 2 $1,281.58 $446.00 ......... $89.20 

20200 ....... Muscle biopsy ............................................................................... 2 $920.58 $446.00 ......... $89.20 

20205 ....... Deep muscle biopsy ..................................................................... 3 $920.58 $510.00 ......... $102.00 

20206 ....... Needle biopsy, muscle ................................................................. 1 $234.21 $234.21 Y ..... $46.84 

20220 ....... Bone biopsy, trocar/needle ........................................................... 1 $246.96 $246.96 Y ..... $49.39

20225 ....... Bone biopsy, trocar/needle ........................................................... 2 $400.87 $400.87 Y ..... $80.17

20240 ....... Bone biopsy, excisional ................................................................ 2 $1,229.54 $446.00 ......... $89.20 

20245 ....... Bone biopsy, excisional ................................................................ 3 $1,229.54 $510.00 ......... $102.00 

20250 ....... Open bone biopsy ........................................................................ 3 $1,281.58 $510.00 ......... $102.00 

20251 ....... Open bone biopsy ........................................................................ 3 $1,281.58 $510.00 ......... $102.00 

20525 ....... Removal of foreign body .............................................................. 3 $1,229.54 $510.00 ......... $102.00 

20650 ....... Insert and remove bone pin ......................................................... 3 $1,281.58 $510.00 ......... $102.00 

20670 ....... Removal of support implant .......................................................... 1 $920.58 $333.00 ......... $66.60 

20680 ....... Removal of support implant .......................................................... 3 $1,229.54 $510.00 ......... $102.00 

20690 ....... Apply bone fixation device ............................................................ 2 $1,542.47 $446.00 ......... $89.20 

20692 ....... Apply bone fixation device ............................................................ 3 $1,542.47 $510.00 ......... $102.00 

20693 ....... Adjust bone fixation device ........................................................... 3 $1,281.58 $510.00 ......... $102.00 

20694 ....... Remove bone fixation device ....................................................... 1 $1,281.58 $333.00 ......... $66.60 

20900 ....... Removal of bone for graft ............................................................. 3 $1,542.47 $510.00 ......... $102.00 

20902 ....... Removal of bone for graft ............................................................. 4 $1,542.47 $630.00 ......... $126.00 

20910 ....... Remove cartilage for graft ............................................................ 3 $1,308.85 $510.00 ......... $102.00 

20912 ....... Remove cartilage for graft ............................................................ 3 $1,308.85 $510.00 ......... $102.00 

20920 ....... Removal of fascia for graft ........................................................... 4 $821.29 $630.00 ......... $126.00 

20922 ....... Removal of fascia for graft ........................................................... 3 $1,308.85 $510.00 ......... $102.00 

20924 ....... Removal of tendon for graft .......................................................... 4 $1,542.47 $630.00 ......... $126.00 

20926 ....... Removal of tissue for graft ........................................................... 4 $821.29 $630.00 ......... $126.00 

20975 ....... Electrical bone stimulation ............................................................ 2 $38.23 $38.23 Y ..... $7.65 

21010 ....... Incision of jaw joint ....................................................................... 2 $1,425.30 $446.00 ......... $89.20 

21015 ....... Resection of facial tumor .............................................................. 3 $1,012.48 $510.00 ......... $102.00 

21025 ....... Excision of bone, lower jaw .......................................................... 2 $2,324.90 $446.00 ......... $89.20 

21026 ....... Excision of facial bone(s) ............................................................. 2 $2,324.90 $446.00 ......... $89.20 

21029 ....... Contour of face bone lesion ......................................................... 2 $2,324.90 $446.00 ......... $89.20 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49721 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

21034 ....... Excise max/zygoma mlg tumor .................................................... 3 $2,324.90 $510.00 ......... $102.00

21040 ....... Excise mandible lesion ................................................................. 2 $1,425.30 $446.00 ......... $89.20 

21044 ....... Removal of jaw bone lesion ......................................................... 2 $2,324.90 $446.00 ......... $89.20 

21046 ....... Remove mandible cyst complex ................................................... 2 $2,324.90 $446.00 ......... $89.20 

21047 ....... Excise lwr jaw cyst w/repair ......................................................... 2 $2,324.90 $446.00 ......... $89.20 

21050 ....... Removal of jaw joint ..................................................................... 3 $2,324.90 $510.00 ......... $102.00 

21060 ....... Remove jaw joint cartilage ........................................................... 2 $2,324.90 $446.00 ......... $89.20 

21070 ....... Remove coronoid process ............................................................ 3 $2,324.90 $510.00 ......... $102.00 

21100 ....... Maxillofacial fixation ...................................................................... 2 $2,324.90 $446.00 ......... $89.20 

21120 ....... Reconstruction of chin .................................................................. 7 $1,425.30 $995.00 ......... $199.00 

21121 ....... Reconstruction of chin .................................................................. 7 $1,425.30 $995.00 ......... $199.00 

21122 ....... Reconstruction of chin .................................................................. 7 $1,425.30 $995.00 ......... $199.00 

21123 ....... Reconstruction of chin .................................................................. 7 $1,425.30 $995.00 ......... $199.00 

21125 ....... Augmentation, lower jaw bone ..................................................... 7 $1,425.30 $995.00 ......... $199.00 

21127 ....... Augmentation, lower jaw bone ..................................................... 9 $2,324.90 $1,339.00 ......... $267.80 

21181 ....... Contour cranial bone lesion .......................................................... 7 $1,425.30 $995.00 ......... $199.00 

21206 ....... Reconstruct upper jaw bone ......................................................... 5 $2,324.90 $717.00 ......... $143.40 

21208 ....... Augmentation of facial bones ....................................................... 7 $2,324.90 $995.00 ......... $199.00 

21209 ....... Reduction of facial bones ............................................................. 5 $2,324.90 $717.00 ......... $143.40 

21210 ....... Face bone graft ............................................................................ 7 $2,324.90 $995.00 ......... $199.00 

21215 ....... Lower jaw bone graft .................................................................... 7 $2,324.90 $995.00 ......... $199.00 

21230 ....... Rib cartilage graft ......................................................................... 7 $2,324.90 $995.00 ......... $199.00 

21235 ....... Ear cartilage graft ......................................................................... 7 $1,425.30 $995.00 ......... $199.00 

21240 ....... Reconstruction of jaw joint ........................................................... 4 $2,324.90 $630.00 ......... $126.00 

21242 ....... Reconstruction of jaw joint ........................................................... 5 $2,324.90 $717.00 ......... $143.40 

21243 ....... Reconstruction of jaw joint ........................................................... 5 $2,324.90 $717.00 ......... $143.40 

21244 ....... Reconstruction of lower jaw ......................................................... 7 $2,324.90 $995.00 ......... $199.00 

21245 ....... Reconstruction of jaw ................................................................... 7 $2,324.90 $995.00 ......... $199.00 

21246 ....... Reconstruction of jaw ................................................................... 7 $2,324.90 $995.00 ......... $199.00 

21248 ....... Reconstruction of jaw ................................................................... 7 $2,324.90 $995.00 ......... $199.00 

21249 ....... Reconstruction of jaw ................................................................... 7 $2,324.90 $995.00 ......... $199.00 

21267 ....... Revise eye sockets ....................................................................... 7 $2,324.90 $995.00 ......... $199.00 

21270 ....... Augmentation, cheek bone ........................................................... 5 $2,324.90 $717.00 ......... $143.40 

21275 ....... Revision, orbitofacial bones .......................................................... 7 $2,324.90 $995.00 ......... $199.00 

21280 ....... Revision of eyelid ......................................................................... 5 $2,324.90 $717.00 ......... $143.40 

21282 ....... Revision of eyelid ......................................................................... 5 $1,012.48 $717.00 ......... $143.40 

21295 ....... Revision of jaw muscle/bone ........................................................ 1 $475.55 $333.00 ......... $66.60 

21296 ....... Revision of jaw muscle/bone ........................................................ 1 $1,425.30 $333.00 ......... $66.60 

21300 ....... Treatment of skull fracture ............................................................ 2 $1,012.48 $446.00 ......... $89.20 

21310 ....... Treatment of nose fracture ........................................................... 2 $146.29 $146.29 Y ..... $29.26

21315 ....... Treatment of nose fracture ........................................................... 2 $146.29 $146.29 Y ..... $29.26

21320 ....... Treatment of nose fracture ........................................................... 2 $475.55 $446.00 ......... $89.20 

21325 ....... Treatment of nose fracture ........................................................... 4 $1,425.30 $630.00 ......... $126.00 

21330 ....... Treatment of nose fracture ........................................................... 5 $1,425.30 $717.00 ......... $143.40 

21335 ....... Treatment of nose fracture ........................................................... 7 $1,425.30 $995.00 ......... $199.00 

21336 ....... Treat nasal septal fracture ............................................................ 4 $2,312.35 $630.00 ......... $126.00 

21337 ....... Treat nasal septal fracture ............................................................ 2 $1,012.48 $446.00 ......... $89.20 

21338 ....... Treat nasoethmoid fracture .......................................................... 4 $1,425.30 $630.00 ......... $126.00 

21339 ....... Treat nasoethmoid fracture .......................................................... 5 $1,425.30 $717.00 ......... $143.40 

21340 ....... Treatment of nose fracture ........................................................... 4 $2,324.90 $630.00 ......... $126.00 

21345 ....... Treat nose/jaw fracture ................................................................. 7 $1,425.30 $995.00 ......... $199.00 

21355 ....... Treat cheek bone fracture ............................................................ 3 $2,324.90 $510.00 ......... $102.00 

21356 ....... Treat cheek bone fracture ............................................................ 3 $1,425.30 $510.00 ......... $102.00 

21400 ....... Treat eye socket fracture .............................................................. 2 $475.55 $446.00 ......... $89.20 

21401 ....... Treat eye socket fracture .............................................................. 3 $1,012.48 $510.00 ......... $102.00 

21421 ....... Treat mouth roof fracture .............................................................. 4 $1,425.30 $630.00 ......... $126.00 

21445 ....... Treat dental ridge fracture ............................................................ 4 $1,425.30 $630.00 ......... $126.00 

21450 ....... Treat lower jaw fracture ................................................................ 3 $146.29 $146.29 Y ..... $29.26 

21451 ....... Treat lower jaw fracture ................................................................ 4 $475.55 $475.55 Y ..... $95.11 

21452 ....... Treat lower jaw fracture ................................................................ 2 $1,012.48 $446.00 ......... $89.20 

21453 ....... Treat lower jaw fracture ................................................................ 3 $2,324.90 $510.00 ......... $102.00 

21454 ....... Treat lower jaw fracture ................................................................ 5 $1,425.30 $717.00 ......... $143.40 

21461 ....... Treat lower jaw fracture ................................................................ 4 $2,324.90 $630.00 ......... $126.00 

21462 ....... Treat lower jaw fracture ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

21465 ....... Treat lower jaw fracture ................................................................ 4 $2,324.90 $630.00 ......... $126.00 

21480 ....... Reset dislocated jaw ..................................................................... 1 $146.29 $146.29 Y ..... $29.26 

21485 ....... Reset dislocated jaw ..................................................................... 2 $1,012.48 $446.00 ......... $89.20 

21490 ....... Repair dislocated jaw ................................................................... 3 $2,324.90 $510.00 ......... $102.00 

21497 ....... Interdental wiring .......................................................................... 2 $1,012.48 $446.00 ......... $89.20 


sroberts on PROD1PC70 with PROPOSALS
49722 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

21501 ....... Drain neck/chest lesion ................................................................ 2 $1,075.21 $446.00 ......... $89.20 

21502 ....... Drain chest lesion ......................................................................... 2 $1,281.58 $446.00 ......... $89.20 

21555 ....... Remove lesion, neck/chest ........................................................... 2 $1,229.54 $446.00 ......... $89.20 

21556 ....... Remove lesion, neck/chest ........................................................... 2 $1,229.54 $446.00 ......... $89.20 

21600 ....... Partial removal of rib .................................................................... 2 $1,542.47 $446.00 ......... $89.20 

21610 ....... Partial removal of rib .................................................................... 2 $1,542.47 $446.00 ......... $89.20 

21700 ....... Revision of neck muscle ............................................................... 2 $1,281.58 $446.00 ......... $89.20 

21720 ....... Revision of neck muscle ............................................................... 3 $1,281.58 $510.00 ......... $102.00 

21725 ....... Revision of neck muscle ............................................................... 3 $91.22 $91.22 Y ..... $18.24 

21800 ....... Treatment of rib fracture ............................................................... 1 $104.11 $104.11 Y ..... $20.82 

21805 ....... Treatment of rib fracture ............................................................... 2 $1,580.03 $446.00 ......... $89.20 

21820 ....... Treat sternum fracture .................................................................. 1 $104.11 $104.11 Y ..... $20.82 

21925 ....... Biopsy soft tissue of back ............................................................. 2 $1,229.54 $446.00 ......... $89.20 

21930 ....... Remove lesion, back or flank ....................................................... 2 $1,229.54 $446.00 ......... $89.20 

21935 ....... Remove tumor, back .................................................................... 3 $1,229.54 $510.00 ......... $102.00 

22305 ....... Treat spine process fracture ......................................................... 1 $104.11 $104.11 Y ..... $20.82

22310 ....... Treat spine fracture ...................................................................... 1 $104.11 $104.11 Y ..... $20.82 

22315 ....... Treat spine fracture ...................................................................... 2 $104.11 $104.11 Y ..... $20.82 

22505 ....... Manipulation of spine .................................................................... 2 $895.58 $446.00 ......... $89.20 

22520 ....... Percutaneous vertebroplasty, ....................................................... 9 $1,542.47 $1339.00 ......... $267.80 

22521 ....... Percutaneous vertebroplasty, ....................................................... 9 $1,542.47 $1339.00 ......... $267.80 

22522 ....... Percutaneous vertebroplasty, ....................................................... 1 $1,542.47 $373.00 ......... $66.00 

22900 ....... Remove abdominal wall lesion ..................................................... 4 $1,229.54 $630.00 ......... $126.00 

23000 ....... Removal of calcium deposits ........................................................ 2 $920.58 $446.00 ......... $89.20 

23020 ....... Release shoulder joint .................................................................. 2 $2,539.24 $446.00 ......... $89.20 

23030 ....... Drain shoulder lesion .................................................................... 1 $1,075.21 $333.00 ......... $66.60 

23031 ....... Drain shoulder bursa .................................................................... 3 $1,075.21 $510.00 ......... $102.00 

23035 ....... Drain shoulder bone lesion ........................................................... 3 $1,281.58 $510.00 ......... $102.00 

23040 ....... Exploratory shoulder surgery ........................................................ 3 $1,542.47 $510.00 ......... $102.00 

23044 ....... Exploratory shoulder surgery ........................................................ 4 $1,542.47 $630.00 ......... $126.00 

23066 ....... Biopsy shoulder tissues ................................................................ 2 $1,229.54 $446.00 ......... $89.20 

23075 ....... Removal of shoulder lesion .......................................................... 2 $920.58 $446.00 ......... $89.20 

23076 ....... Removal of shoulder lesion .......................................................... 2 $1,229.54 $446.00 ......... $89.20 

23077 ....... Remove tumor of shoulder ........................................................... 3 $1,229.54 $510.00 ......... $102.00 

23100 ....... Biopsy of shoulder joint ................................................................ 2 $1,281.58 $446.00 ......... $89.20 

23101 ....... Shoulder joint surgery ................................................................... 7 $1,542.47 $995.00 ......... $199.00 

23105 ....... Remove shoulder joint lining ........................................................ 4 $1,542.47 $630.00 ......... $126.00 

23106 ....... Incision of collarbone joint ............................................................ 4 $1,542.47 $630.00 ......... $126.00 

23107 ....... Explore treat shoulder joint ........................................................... 4 $1,542.47 $630.00 ......... $126.00 

23120 ....... Partial removal, collar bone .......................................................... 5 $2,539.24 $717.00 ......... $143.40 

23125 ....... Removal of collar bone ................................................................. 5 $2,539.24 $717.00 ......... $143.40 

23130 ....... Remove shoulder bone, part ........................................................ 5 $2,539.24 $717.00 ......... $143.40 

23140 ....... Removal of bone lesion ................................................................ 4 $1,281.58 $630.00 ......... $126.00 

23145 ....... Removal of bone lesion ................................................................ 5 $1,542.47 $717.00 ......... $143.40 

23146 ....... Removal of bone lesion ................................................................ 5 $1,542.47 $717.00 ......... $143.40 

23150 ....... Removal of humerus lesion .......................................................... 4 $1,542.47 $630.00 ......... $126.00 

23155 ....... Removal of humerus lesion .......................................................... 5 $1,542.47 $717.00 ......... $143.40 

23156 ....... Removal of humerus lesion .......................................................... 5 $1,542.47 $717.00 ......... $143.40 

23170 ....... Remove collar bone lesion ........................................................... 2 $1,542.47 $446.00 ......... $89.20 

23172 ....... Remove shoulder blade lesion ..................................................... 2 $1,542.47 $446.00 ......... $89.20 

23174 ....... Remove humerus lesion ............................................................... 2 $1,542.47 $446.00 ......... $89.20 

23180 ....... Remove collar bone lesion ........................................................... 4 $1,542.47 $630.00 ......... $126.00 

23182 ....... Remove shoulder blade lesion ..................................................... 4 $1,542.47 $630.00 ......... $126.00 

23184 ....... Remove humerus lesion ............................................................... 4 $1,542.47 $630.00 ......... $126.00 

23190 ....... Partial removal of scapula ............................................................ 4 $1,542.47 $630.00 ......... $126.00 

23195 ....... Removal of head of humerus ....................................................... 5 $1,542.47 $717.00 ......... $143.40 

23330 ....... Remove shoulder foreign body .................................................... 1 $400.87 $333.00 ......... $66.60 

23331 ....... Remove shoulder foreign body .................................................... 1 $1,229.54 $333.00 ......... $66.60

23395 ....... Muscle transfer,shoulder/arm ....................................................... 5 $2,539.24 $717.00 ......... $143.40 

23397 ....... Muscle transfers ........................................................................... 7 $4,055.26 $995.00 ......... $199.00 

23400 ....... Fixation of shoulder blade ............................................................ 7 $1,542.47 $995.00 ......... $199.00 

23405 ....... Incision of tendon & muscle ......................................................... 2 $1,542.47 $446.00 ......... $89.20 

23406 ....... Incise tendon(s) & muscle(s) ........................................................ 2 $1,542.47 $446.00 ......... $89.20 

23410 ....... Repair rotator cuff, acute .............................................................. 5 $2,539.24 $717.00 ......... $143.40 

23412 ....... Repair rotator cuff, chronic ........................................................... 7 $2,539.24 $995.00 ......... $199.00 

23415 ....... Release of shoulder ligament ....................................................... 5 $2,539.24 $717.00 ......... $143.40 

23420 ....... Repair of shoulder ........................................................................ 7 $2,539.24 $995.00 ......... $199.00 

23430 ....... Repair biceps tendon .................................................................... 4 $2,539.24 $630.00 ......... $126.00 

23440 ....... Remove/transplant tendon ............................................................ 4 $2,539.24 $630.00 ......... $126.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49723 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

23450 ....... Repair shoulder capsule ............................................................... 5 $4,055.26 $717.00 ......... $143.40 

23455 ....... Repair shoulder capsule ............................................................... 7 $4,055.26 $995.00 ......... $199.00 

23460 ....... Repair shoulder capsule ............................................................... 5 $4,055.26 $717.00 ......... $143.40 

23462 ....... Repair shoulder capsule ............................................................... 7 $2,539.24 $995.00 ......... $199.00 

23465 ....... Repair shoulder capsule ............................................................... 5 $4,055.26 $717.00 ......... $143.40 

23466 ....... Repair shoulder capsule ............................................................... 7 $2,539.24 $995.00 ......... $199.00 

23480 ....... Revision of collar bone ................................................................. 4 $2,539.24 $630.00 ......... $126.00 

23485 ....... Revision of collar bone ................................................................. 7 $4,055.26 $995.00 ......... $199.00 

23490 ....... Reinforce clavicle .......................................................................... 3 $2,539.24 $510.00 ......... $102.00 

23491 ....... Reinforce shoulder bones ............................................................. 3 $4,055.26 $510.00 ......... $102.00 

23500 ....... Treat clavicle fracture ................................................................... 1 $104.11 $104.11 Y ..... $20.82 

23505 ....... Treat clavicle fracture ................................................................... 1 $104.11 $104.11 Y ..... $20.82 

23515 ....... Treat clavicle fracture ................................................................... 3 $3,472.68 $510.00 ......... $102.00 

23520 ....... Treat clavicle dislocation .............................................................. 1 $104.11 $104.11 Y ..... $20.82 

23525 ....... Treat clavicle dislocation .............................................................. 1 $104.11 $104.11 Y ..... $20.82 

23530 ....... Treat clavicle dislocation .............................................................. 3 $2,312.35 $510.00 ......... $102.00 

23532 ....... Treat clavicle dislocation .............................................................. 4 $1,580.03 $630.00 ......... $126.00 

23540 ....... Treat clavicle dislocation .............................................................. 1 $104.11 $104.11 Y ..... $20.82 

23545 ....... Treat clavicle dislocation .............................................................. 1 $104.11 $104.11 Y ..... $20.82 

23550 ....... Treat clavicle dislocation .............................................................. 3 $2,312.35 $510.00 ......... $102.00 

23552 ....... Treat clavicle dislocation .............................................................. 4 $2,312.35 $630.00 ......... $126.00 

23570 ....... Treat shoulder blade fx ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

23575 ....... Treat shoulder blade fx ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

23585 ....... Treat scapula fracture ................................................................... 3 $3,472.68 $510.00 ......... $102.00 

23605 ....... Treat humerus fracture ................................................................. 2 $104.11 $104.11 Y ..... $20.82 

23615 ....... Treat humerus fracture ................................................................. 4 $3,472.68 $630.00 ......... $126.00 

23616 ....... Treat humerus fracture ................................................................. 4 $3,472.68 $630.00 ......... $126.00 

23625 ....... Treat humerus fracture ................................................................. 2 $104.11 $104.11 Y ..... $20.82 

23630 ....... Treat humerus fracture ................................................................. 5 $3,472.68 $717.00 ......... $143.40 

23650 ....... Treat shoulder dislocation ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

23655 ....... Treat shoulder dislocation ............................................................ 1 $895.58 $333.00 ......... $66.60 

23660 ....... Treat shoulder dislocation ............................................................ 3 $2,312.35 $510.00 ......... $102.00 

23665 ....... Treat dislocation/fracture .............................................................. 2 $104.11 $104.11 Y ..... $20.82 

23670 ....... Treat dislocation/fracture .............................................................. 3 $3,472.68 $510.00 ......... $102.00 

23675 ....... Treat dislocation/fracture .............................................................. 2 $104.11 $104.11 Y ..... $20.82 

23680 ....... Treat dislocation/fracture .............................................................. 3 $2,312.35 $510.00 ......... $102.00 

23700 ....... Fixation of shoulder ...................................................................... 1 $895.58 $333.00 ......... $66.60 

23800 ....... Fusion of shoulder joint ................................................................ 4 $4,055.26 $630.00 ......... $126.00 

23802 ....... Fusion of shoulder joint ................................................................ 7 $2,539.24 $995.00 ......... $199.00 

23921 ....... Amputation follow-up surgery ....................................................... 3 $313.49 $313.49 Y ..... $62.70 

23930 ....... Drainage of arm lesion ................................................................. 1 $1,075.21 $333.00 ......... $66.60 

23931 ....... Drainage of arm bursa .................................................................. 2 $1,075.21 $446.00 ......... $89.20 

23935 ....... Drain arm/elbow bone lesion ........................................................ 2 $1,281.58 $446.00 ......... $89.20 

24000 ....... Exploratory elbow surgery ............................................................ 4 $1,542.47 $630.00 ......... $126.00 

24006 ....... Release elbow joint ...................................................................... 4 $1,542.47 $630.00 ......... $126.00 

24066 ....... Biopsy arm/elbow soft tissue ........................................................ 2 $920.58 $446.00 ......... $89.20 

24075 ....... Remove arm/elbow lesion ............................................................ 2 $920.58 $446.00 ......... $89.20 

24076 ....... Remove arm/elbow lesion ............................................................ 2 $1,229.54 $446.00 ......... $89.20 

24077 ....... Remove tumor of arm/elbow ........................................................ 3 $1,229.54 $510.00 ......... $102.00 

24100 ....... Biopsy elbow joint lining ............................................................... 1 $1,281.58 $333.00 ......... $66.60 

24101 ....... Explore/treat elbow joint ............................................................... 4 $1,542.47 $630.00 ......... $126.00 

24102 ....... Remove elbow joint lining ............................................................. 4 $1,542.47 $630.00 ......... $126.00 

24105 ....... Removal of elbow bursa ............................................................... 3 $1,281.58 $510.00 ......... $102.00 

24110 ....... Remove humerus lesion ............................................................... 2 $1,281.58 $446.00 ......... $89.20 

24115 ....... Remove/graft bone lesion ............................................................. 3 $1,542.47 $510.00 ......... $102.00 

24116 ....... Remove/graft bone lesion ............................................................. 3 $1,542.47 $510.00 ......... $102.00 

24120 ....... Remove elbow lesion ................................................................... 3 $1,281.58 $510.00 ......... $102.00 

24125 ....... Remove/graft bone lesion ............................................................. 3 $1,542.47 $510.00 ......... $102.00 

24126 ....... Remove/graft bone lesion ............................................................. 3 $1,542.47 $510.00 ......... $102.00 

24130 ....... Removal of head of radius ........................................................... 3 $1,542.47 $510.00 ......... $102.00 

24134 ....... Removal of arm bone lesion ........................................................ 2 $1,542.47 $446.00 ......... $89.20 

24136 ....... Remove radius bone lesion .......................................................... 2 $1,542.47 $446.00 ......... $89.20 

24138 ....... Remove elbow bone lesion .......................................................... 2 $1,542.47 $446.00 ......... $89.20 

24140 ....... Partial removal of arm bone ......................................................... 3 $1,542.47 $510.00 ......... $102.00 

24145 ....... Partial removal of radius ............................................................... 3 $1,542.47 $510.00 ......... $102.00 

24147 ....... Partial removal of elbow ............................................................... 2 $1,542.47 $446.00 ......... $89.20 

24155 ....... Removal of elbow joint ................................................................. 3 $2,539.24 $510.00 ......... $102.00 

24160 ....... Remove elbow joint implant ......................................................... 2 $1,542.47 $446.00 ......... $89.20 

24164 ....... Remove radius head implant ........................................................ 3 $1,542.47 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
49724 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

24201 ....... Removal of arm foreign body ....................................................... 2 $920.58 $446.00 ......... $89.20

24301 ....... Muscle/tendon transfer ................................................................. 4 $1,542.47 $630.00 ......... $126.00 

24305 ....... Arm tendon lengthening ............................................................... 4 $1,542.47 $630.00 ......... $126.00 

24310 ....... Revision of arm tendon ................................................................ 3 $1,281.58 $510.00 ......... $102.00 

24320 ....... Repair of arm tendon .................................................................... 3 $2,539.24 $510.00 ......... $102.00 

24330 ....... Revision of arm muscles .............................................................. 3 $4,055.26 $510.00 ......... $102.00 

24331 ....... Revision of arm muscles .............................................................. 3 $2,539.24 $510.00 ......... $102.00 

24340 ....... Repair of biceps tendon ............................................................... 3 $2,539.24 $510.00 ......... $102.00 

24341 ....... Repair arm tendon/muscle ........................................................... 3 $2,539.24 $510.00 ......... $102.00 

24342 ....... Repair of ruptured tendon ............................................................ 3 $2,539.24 $510.00 ......... $102.00 

24345 ....... Repr elbw med ligmnt w/tissu ...................................................... 2 $1,542.47 $446.00 ......... $89.20 

24350 ....... Repair of tennis elbow .................................................................. 3 $1,542.47 $510.00 ......... $102.00 

24351 ....... Repair of tennis elbow .................................................................. 3 $1,542.47 $510.00 ......... $102.00 

24352 ....... Repair of tennis elbow .................................................................. 3 $1,542.47 $510.00 ......... $102.00 

24354 ....... Repair of tennis elbow .................................................................. 3 $1,542.47 $510.00 ......... $102.00 

24356 ....... Revision of tennis elbow ............................................................... 3 $1,542.47 $510.00 ......... $102.00 

24360 ....... Reconstruct elbow joint ................................................................ 5 $2,016.06 $717.00 ......... $143.40 

24361 ....... Reconstruct elbow joint ................................................................ 5 $6,473.11 $717.00 ......... $143.40 

24362 ....... Reconstruct elbow joint ................................................................ 5 $2,903.02 $717.00 ......... $143.40 

24363 ....... Replace elbow joint ...................................................................... 7 $6,473.11 $995.00 ......... $199.00 

24365 ....... Reconstruct head of radius .......................................................... 5 $2,016.06 $717.00 ......... $143.40 

24366 ....... Reconstruct head of radius .......................................................... 5 $6,473.11 $717.00 ......... $143.40 

24400 ....... Revision of humerus ..................................................................... 4 $1,542.47 $630.00 ......... $126.00 

24410 ....... Revision of humerus ..................................................................... 4 $1,542.47 $630.00 ......... $126.00 

24420 ....... Revision of humerus ..................................................................... 3 $2,539.24 $510.00 ......... $102.00 

24430 ....... Repair of humerus ........................................................................ 3 $4,055.26 $510.00 ......... $102.00 

24435 ....... Repair humerus with graft ............................................................ 4 $4,055.26 $630.00 ......... $126.00 

24470 ....... Revision of elbow joint .................................................................. 3 $2,539.24 $510.00 ......... $102.00 

24495 ....... Decompression of forearm ........................................................... 2 $1,542.47 $446.00 ......... $89.20 

24498 ....... Reinforce humerus ....................................................................... 3 $4,055.26 $510.00 ......... $102.00 

24500 ....... Treat humerus fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24505 ....... Treat humerus fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24515 ....... Treat humerus fracture ................................................................. 4 $3,472.68 $630.00 ......... $126.00 

24516 ....... Treat humerus fracture ................................................................. 4 $3,472.68 $630.00 ......... $126.00 

24530 ....... Treat humerus fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24535 ....... Treat humerus fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24538 ....... Treat humerus fracture ................................................................. 2 $1,580.03 $446.00 ......... $89.20 

24545 ....... Treat humerus fracture ................................................................. 4 $3,472.68 $630.00 ......... $126.00 

24546 ....... Treat humerus fracture ................................................................. 5 $3,472.68 $717.00 ......... $143.40 

24560 ....... Treat humerus fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24565 ....... Treat humerus fracture ................................................................. 2 $104.11 $104.11 Y ..... $20.82 

24566 ....... Treat humerus fracture ................................................................. 2 $1,580.03 $446.00 ......... $89.20 

24575 ....... Treat humerus fracture ................................................................. 3 $3,472.68 $510.00 ......... $102.00 

24576 ....... Treat humerus fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24577 ....... Treat humerus fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24579 ....... Treat humerus fracture ................................................................. 3 $3,472.68 $510.00 ......... $102.00 

24582 ....... Treat humerus fracture ................................................................. 2 $1,580.03 $446.00 ......... $89.20 

24586 ....... Treat elbow fracture ...................................................................... 4 $3,472.68 $630.00 ......... $126.00 

24587 ....... Treat elbow fracture ...................................................................... 5 $3,472.68 $717.00 ......... $143.40 

24600 ....... Treat elbow dislocation ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

24605 ....... Treat elbow dislocation ................................................................. 2 $895.58 $446.00 ......... $89.20 

24615 ....... Treat elbow dislocation ................................................................. 3 $3,472.68 $510.00 ......... $102.00 

24620 ....... Treat elbow fracture ...................................................................... 2 $104.11 $104.11 Y ..... $20.82 

24635 ....... Treat elbow fracture ...................................................................... 3 $3,472.68 $510.00 ......... $102.00 

24655 ....... Treat radius fracture ..................................................................... 1 $104.11 $104.11 Y ..... $20.82 

24665 ....... Treat radius fracture ..................................................................... 4 $2,312.35 $630.00 ......... $126.00 

24666 ....... Treat radius fracture ..................................................................... 4 $3,472.68 $630.00 ......... $126.00 

24670 ....... Treat ulnar fracture ....................................................................... 1 $104.11 $104.11 Y ..... $20.82 

24675 ....... Treat ulnar fracture ....................................................................... 1 $104.11 $104.11 Y ..... $20.82 

24685 ....... Treat ulnar fracture ....................................................................... 3 $2,312.35 $510.00 ......... $102.00 

24800 ....... Fusion of elbow joint ..................................................................... 4 $2,539.24 $630.00 ......... $126.00 

24802 ....... Fusion/graft of elbow joint ............................................................ 5 $2,539.24 $717.00 ......... $143.40 

24925 ....... Amputation follow-up surgery ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

25000 ....... Incision of tendon sheath ............................................................. 3 $1,281.58 $510.00 ......... $102.00 

25020 ....... Decompress forearm 1 space ...................................................... 3 $1,281.58 $510.00 ......... $102.00 

25023 ....... Decompress forearm 1 space ...................................................... 3 $1,542.47 $510.00 ......... $102.00 

25024 ....... Decompress forearm 2 spaces .................................................... 3 $1,542.47 $510.00 ......... $102.00

25025 ....... Decompress forearm 2 spaces .................................................... 3 $1,542.47 $510.00 ......... $102.00

25028 ....... Drainage of forearm lesion ........................................................... 1 $1,281.58 $333.00 ......... $66.60 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49725 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

25031 ....... Drainage of forearm bursa ........................................................... 2 $1,281.58 $446.00 ......... $89.20 

25035 ....... Treat forearm bone lesion ............................................................ 2 $1,281.58 $446.00 ......... $89.20 

25040 ....... Explore/treat wrist joint ................................................................. 5 $1,542.47 $717.00 ......... $143.40 

25066 ....... Biopsy forearm soft tissues .......................................................... 2 $1,229.54 $446.00 ......... $89.20 

25075 ....... Removal forearm lesion subcu ..................................................... 2 $920.58 $446.00 ......... $89.20 

25076 ....... Removal forearm lesion deep ...................................................... 3 $1,229.54 $510.00 ......... $102.00 

25077 ....... Remove tumor, forearm/wrist ....................................................... 3 $1,229.54 $510.00 ......... $102.00 

25085 ....... Incision of wrist capsule ............................................................... 3 $1,281.58 $510.00 ......... $102.00 

25100 ....... Biopsy of wrist joint ....................................................................... 2 $1,281.58 $446.00 ......... $89.20 

25101 ....... Explore/treat wrist joint ................................................................. 3 $1,542.47 $510.00 ......... $102.00 

25105 ....... Remove wrist joint lining ............................................................... 4 $1,542.47 $630.00 ......... $126.00 

25107 ....... Remove wrist joint cartilage ......................................................... 3 $1,542.47 $510.00 ......... $102.00 

25110 ....... Remove wrist tendon lesion ......................................................... 3 $1,281.58 $510.00 ......... $102.00 

25111 ....... Remove wrist tendon lesion ......................................................... 3 $986.93 $510.00 ......... $102.00 

25112 ....... Reremove wrist tendon lesion ...................................................... 4 $986.93 $630.00 ......... $126.00 

25115 ....... Remove wrist/forearm lesion ........................................................ 4 $1,281.58 $630.00 ......... $126.00 

25116 ....... Remove wrist/forearm lesion ........................................................ 4 $1,281.58 $630.00 ......... $126.00 

25118 ....... Excise wrist tendon sheath ........................................................... 2 $1,542.47 $446.00 ......... $89.20 

25119 ....... Partial removal of ulna .................................................................. 3 $1,542.47 $510.00 ......... $102.00 

25120 ....... Removal of forearm lesion ........................................................... 3 $1,542.47 $510.00 ......... $102.00 

25125 ....... Remove/graft forearm lesion ........................................................ 3 $1,542.47 $510.00 ......... $102.00 

25126 ....... Remove/graft forearm lesion ........................................................ 3 $1,542.47 $510.00 ......... $102.00 

25130 ....... Removal of wrist lesion ................................................................ 3 $1,542.47 $510.00 ......... $102.00 

25135 ....... Remove & graft wrist lesion ......................................................... 3 $1,542.47 $510.00 ......... $102.00 

25136 ....... Remove & graft wrist lesion ......................................................... 3 $1,542.47 $510.00 ......... $102.00 

25145 ....... Remove forearm bone lesion ....................................................... 2 $1,542.47 $446.00 ......... $89.20 

25150 ....... Partial removal of ulna .................................................................. 2 $1,542.47 $446.00 ......... $89.20 

25151 ....... Partial removal of radius ............................................................... 2 $1,542.47 $446.00 ......... $89.20 

25210 ....... Removal of wrist bone .................................................................. 3 $1,590.63 $510.00 ......... $102.00 

25215 ....... Removal of wrist bones ................................................................ 4 $1,590.63 $630.00 ......... $126.00 

25230 ....... Partial removal of radius ............................................................... 4 $1,542.47 $630.00 ......... $126.00 

25240 ....... Partial removal of ulna .................................................................. 4 $1,542.47 $630.00 ......... $126.00 

25248 ....... Remove forearm foreign body ...................................................... 2 $1,281.58 $446.00 ......... $89.20 

25250 ....... Removal of wrist prosthesis ......................................................... 1 $1,542.47 $333.00 ......... $66.60 

25251 ....... Removal of wrist prosthesis ......................................................... 1 $1,542.47 $333.00 ......... $66.60 

25260 ....... Repair forearm tendon/muscle ..................................................... 4 $1,542.47 $630.00 ......... $126.00 

25263 ....... Repair forearm tendon/muscle ..................................................... 2 $1,542.47 $446.00 ......... $89.20 

25265 ....... Repair forearm tendon/muscle ..................................................... 3 $1,542.47 $510.00 ......... $102.00 

25270 ....... Repair forearm tendon/muscle ..................................................... 4 $1,542.47 $630.00 ......... $126.00 

25272 ....... Repair forearm tendon/muscle ..................................................... 3 $1,542.47 $510.00 ......... $102.00 

25274 ....... Repair forearm tendon/muscle ..................................................... 4 $1,542.47 $630.00 ......... $126.00 

25275 ....... Repair forearm tendon sheath ...................................................... 4 $1,542.47 $630.00 ......... $126.00 

25280 ....... Revise wrist/forearm tendon ......................................................... 4 $1,542.47 $630.00 ......... $126.00 

25290 ....... Incise wrist/forearm tendon .......................................................... 3 $1,542.47 $510.00 ......... $102.00 

25295 ....... Release wrist/forearm tendon ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

25300 ....... Fusion of tendons at wrist ............................................................ 3 $1,542.47 $510.00 ......... $102.00 

25301 ....... Fusion of tendons at wrist ............................................................ 3 $1,542.47 $510.00 ......... $102.00 

25310 ....... Transplant forearm tendon ........................................................... 3 $2,539.24 $510.00 ......... $102.00 

25312 ....... Transplant forearm tendon ........................................................... 4 $2,539.24 $630.00 ......... $126.00 

25315 ....... Revise palsy hand tendon(s) ........................................................ 3 $2,539.24 $510.00 ......... $102.00 

25316 ....... Revise palsy hand tendon(s) ........................................................ 3 $4,055.26 $510.00 ......... $102.00 

25320 ....... Repair/revise wrist joint ................................................................ 3 $2,539.24 $510.00 ......... $102.00 

25332 ....... Revise wrist joint ........................................................................... 5 $2,016.06 $717.00 ......... $143.40 

25335 ....... Realignment of hand .................................................................... 3 $2,539.24 $510.00 ......... $102.00 

25337 ....... Reconstruct ulna/radioulnar .......................................................... 5 $2,539.24 $717.00 ......... $143.40 

25350 ....... Revision of radius ......................................................................... 3 $4,055.26 $510.00 ......... $102.00 

25355 ....... Revision of radius ......................................................................... 3 $2,539.24 $510.00 ......... $102.00 

25360 ....... Revision of ulna ............................................................................ 3 $1,542.47 $510.00 ......... $102.00 

25365 ....... Revise radius & ulna .................................................................... 3 $1,542.47 $510.00 ......... $102.00 

25370 ....... Revise radius or ulna .................................................................... 3 $2,539.24 $510.00 ......... $102.00 

25375 ....... Revise radius & ulna .................................................................... 4 $2,539.24 $630.00 ......... $126.00 

25390 ....... Shorten radius or ulna .................................................................. 3 $1,542.47 $510.00 ......... $102.00 

25391 ....... Lengthen radius or ulna ................................................................ 4 $2,539.24 $630.00 ......... $126.00 

25392 ....... Shorten radius & ulna ................................................................... 3 $1,542.47 $510.00 ......... $102.00 

25393 ....... Lengthen radius & ulna ................................................................ 4 $2,539.24 $630.00 ......... $126.00 

25400 ....... Repair radius or ulna .................................................................... 3 $1,542.47 $510.00 ......... $102.00 

25405 ....... Repair/graft radius or ulna ............................................................ 4 $1,542.47 $630.00 ......... $126.00 

25415 ....... Repair radius & ulna ..................................................................... 3 $1,542.47 $510.00 ......... $102.00 

25420 ....... Repair/graft radius & ulna ............................................................. 4 $4,055.26 $630.00 ......... $126.00 


sroberts on PROD1PC70 with PROPOSALS
49726 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

25425 ....... Repair/graft radius or ulna ............................................................ 3 $2,539.24 $510.00 ......... $102.00 

25426 ....... Repair/graft radius & ulna ............................................................. 4 $2,539.24 $630.00 ......... $126.00 

25440 ....... Repair/graft wrist bone ................................................................. 4 $4,055.26 $630.00 ......... $126.00 

25441 ....... Reconstruct wrist joint .................................................................. 5 $6,473.11 $717.00 ......... $143.40 

25442 ....... Reconstruct wrist joint .................................................................. 5 $6,473.11 $717.00 ......... $143.40 

25443 ....... Reconstruct wrist joint .................................................................. 5 $2,903.02 $717.00 ......... $143.40 

25444 ....... Reconstruct wrist joint .................................................................. 5 $2,903.02 $717.00 ......... $143.40 

25445 ....... Reconstruct wrist joint .................................................................. 5 $2,903.02 $717.00 ......... $143.40 

25446 ....... Wrist replacement ......................................................................... 7 $6,473.11 $995.00 ......... $199.00 

25447 ....... Repair wrist joint(s) ....................................................................... 5 $2,016.06 $717.00 ......... $143.40 

25449 ....... Remove wrist joint implant ........................................................... 5 $2,016.06 $717.00 ......... $143.40 

25450 ....... Revision of wrist joint .................................................................... 3 $2,539.24 $510.00 ......... $102.00 

25455 ....... Revision of wrist joint .................................................................... 3 $2,539.24 $510.00 ......... $102.00 

25490 ....... Reinforce radius ............................................................................ 3 $2,539.24 $510.00 ......... $102.00 

25491 ....... Reinforce ulna ............................................................................... 3 $2,539.24 $510.00 ......... $102.00 

25492 ....... Reinforce radius and ulna ............................................................ 3 $2,539.24 $510.00 ......... $102.00 

25505 ....... Treat fracture of radius ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

25515 ....... Treat fracture of radius ................................................................. 3 $2,312.35 $510.00 ......... $102.00 

25520 ....... Treat fracture of radius ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

25525 ....... Treat fracture of radius ................................................................. 4 $2,312.35 $630.00 ......... $126.00 

25526 ....... Treat fracture of radius ................................................................. 5 $2,312.35 $717.00 ......... $143.40 

25535 ....... Treat fracture of ulna .................................................................... 1 $104.11 $104.11 Y ..... $20.82 

25545 ....... Treat fracture of ulna .................................................................... 3 $2,312.35 $510.00 ......... $102.00 

25565 ....... Treat fracture radius & ulna .......................................................... 2 $104.11 $104.11 Y ..... $20.82 

25574 ....... Treat fracture radius & ulna .......................................................... 3 $3,472.68 $510.00 ......... $102.00 

25575 ....... Treat fracture radius/ulna ............................................................. 3 $3,472.68 $510.00 ......... $102.00 

25605 ....... Treat fracture radius/ulna ............................................................. 3 $104.11 $104.11 Y ..... $20.82 

25611 ....... Treat fracture radius/ulna ............................................................. 3 $1,580.03 $510.00 ......... $102.00 

25620 ....... Treat fracture radius/ulna ............................................................. 5 $3,472.68 $717.00 ......... $143.40 

25624 ....... Treat wrist bone fracture .............................................................. 2 $104.11 $104.11 Y ..... $20.82 

25628 ....... Treat wrist bone fracture .............................................................. 3 $2,312.35 $510.00 ......... $102.00 

25635 ....... Treat wrist bone fracture .............................................................. 1 $104.11 $104.11 Y ..... $20.82 

25645 ....... Treat wrist bone fracture .............................................................. 3 $2,312.35 $510.00 ......... $102.00 

25660 ....... Treat wrist dislocation ................................................................... 1 $104.11 $104.11 Y ..... $20.82 

25670 ....... Treat wrist dislocation ................................................................... 3 $1,580.03 $510.00 ......... $102.00 

25671 ....... Pin radioulnar dislocation ............................................................. 1 $1,580.03 $333.00 ......... $66.60 

25675 ....... Treat wrist dislocation ................................................................... 1 $104.11 $104.11 Y ..... $20.82 

25676 ....... Treat wrist dislocation ................................................................... 2 $1,580.03 $446.00 ......... $89.20 

25680 ....... Treat wrist fracture ........................................................................ 2 $104.11 $104.11 Y ..... $20.82 

25685 ....... Treat wrist fracture ........................................................................ 3 $1,580.03 $510.00 ......... $102.00 

25690 ....... Treat wrist dislocation ................................................................... 1 $104.11 $104.11 Y ..... $20.82 

25695 ....... Treat wrist dislocation ................................................................... 2 $1,580.03 $446.00 ......... $89.20 

25800 ....... Fusion of wrist joint ....................................................................... 4 $4,055.26 $630.00 ......... $126.00 

25805 ....... Fusion/graft of wrist joint .............................................................. 5 $2,539.24 $717.00 ......... $143.40 

25810 ....... Fusion/graft of wrist joint .............................................................. 5 $4,055.26 $717.00 ......... $143.40 

25820 ....... Fusion of hand bones ................................................................... 4 $986.93 $630.00 ......... $126.00 

25825 ....... Fuse hand bones with graft .......................................................... 5 $1,590.63 $717.00 ......... $143.40 

25830 ....... Fusion, radioulnar jnt/ulna ............................................................ 5 $4,055.26 $717.00 ......... $143.40 

25907 ....... Amputation follow-up surgery ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

25922 ....... Amputate hand at wrist ................................................................. 3 $1,281.58 $510.00 ......... $102.00 

25929 ....... Amputation follow-up surgery ....................................................... 3 $821.29 $510.00 ......... $102.00 

26011 ....... Drainage of finger abscess ........................................................... 1 $672.04 $333.00 ......... $66.60 

26020 ....... Drain hand tendon sheath ............................................................ 2 $986.93 $446.00 ......... $89.20 

26025 ....... Drainage of palm bursa ................................................................ 1 $986.93 $333.00 ......... $66.60 

26030 ....... Drainage of palm bursa(s) ............................................................ 2 $986.93 $446.00 ......... $89.20 

26034 ....... Treat hand bone lesion ................................................................. 2 $986.93 $446.00 ......... $89.20 

26040 ....... Release palm contracture ............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26045 ....... Release palm contracture ............................................................. 3 $1,590.63 $510.00 ......... $102.00 

26055 ....... Incise finger tendon sheath .......................................................... 2 $986.93 $446.00 ......... $89.20 

26060 ....... Incision of finger tendon ............................................................... 2 $986.93 $446.00 ......... $89.20 

26070 ....... Explore/treat hand joint ................................................................. 2 $986.93 $446.00 ......... $89.20 

26075 ....... Explore/treat finger joint ................................................................ 4 $986.93 $630.00 ......... $126.00 

26080 ....... Explore/treat finger joint ................................................................ 4 $986.93 $630.00 ......... $126.00 

26100 ....... Biopsy hand joint lining ................................................................. 2 $986.93 $446.00 ......... $89.20 

26105 ....... Biopsy finger joint lining ................................................................ 1 $986.93 $333.00 ......... $66.60 

26110 ....... Biopsy finger joint lining ................................................................ 1 $986.93 $333.00 ......... $66.60 

26115 ....... Removal hand lesion subcut ........................................................ 2 $1,229.54 $446.00 ......... $89.20 

26116 ....... Removal hand lesion, deep .......................................................... 2 $1,229.54 $446.00 ......... $89.20 

26117 ....... Remove tumor, hand/finger .......................................................... 3 $1,229.54 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49727 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

26121 ....... Release palm contracture ............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26123 ....... Release palm contracture ............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26125 ....... Release palm contracture ............................................................. 4 $986.93 $630.00 ......... $126.00 

26130 ....... Remove wrist joint lining ............................................................... 3 $986.93 $510.00 ......... $102.00 

26135 ....... Revise finger joint, each ............................................................... 4 $1,590.63 $630.00 ......... $126.00 

26140 ....... Revise finger joint, each ............................................................... 2 $986.93 $446.00 ......... $89.20 

26145 ....... Tendon excision, palm/finger ........................................................ 3 $986.93 $510.00 ......... $102.00 

26160 ....... Remove tendon sheath lesion ...................................................... 3 $986.93 $510.00 ......... $102.00

26170 ....... Removal of palm tendon, each .................................................... 3 $986.93 $510.00 ......... $102.00 

26180 ....... Removal of finger tendon ............................................................. 3 $986.93 $510.00 ......... $102.00 

26185 ....... Remove finger bone ..................................................................... 4 $986.93 $630.00 ......... $126.00 

26200 ....... Remove hand bone lesion ............................................................ 2 $986.93 $446.00 ......... $89.20 

26205 ....... Remove/graft bone lesion ............................................................. 3 $1,590.63 $510.00 ......... $102.00 

26210 ....... Removal of finger lesion ............................................................... 2 $986.93 $446.00 ......... $89.20 

26215 ....... Remove/graft finger lesion ............................................................ 3 $986.93 $510.00 ......... $102.00 

26230 ....... Partial removal of hand bone ....................................................... 7 $986.93 $986.93 Y ..... $197.39 

26235 ....... Partial removal, finger bone ......................................................... 3 $986.93 $510.00 ......... $102.00 

26236 ....... Partial removal, finger bone ......................................................... 3 $986.93 $510.00 ......... $102.00 

26250 ....... Extensive hand surgery ................................................................ 3 $986.93 $510.00 ......... $102.00 

26255 ....... Extensive hand surgery ................................................................ 3 $1,590.63 $510.00 ......... $102.00 

26260 ....... Extensive finger surgery ............................................................... 3 $986.93 $510.00 ......... $102.00 

26261 ....... Extensive finger surgery ............................................................... 3 $986.93 $510.00 ......... $102.00 

26262 ....... Partial removal of finger ............................................................... 2 $986.93 $446.00 ......... $89.20 

26320 ....... Removal of implant from hand ..................................................... 2 $920.58 $446.00 ......... $89.20 

26350 ....... Repair finger/hand tendon ............................................................ 1 $1,590.63 $333.00 ......... $66.60 

26352 ....... Repair/graft hand tendon .............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26356 ....... Repair finger/hand tendon ............................................................ 4 $1,590.63 $630.00 ......... $126.00 

26357 ....... Repair finger/hand tendon ............................................................ 4 $1,590.63 $630.00 ......... $126.00 

26358 ....... Repair/graft hand tendon .............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26370 ....... Repair finger/hand tendon ............................................................ 4 $1,590.63 $630.00 ......... $126.00 

26372 ....... Repair/graft hand tendon .............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26373 ....... Repair finger/hand tendon ............................................................ 3 $1,590.63 $510.00 ......... $102.00 

26390 ....... Revise hand/finger tendon ............................................................ 4 $1,590.63 $630.00 ......... $126.00 

26392 ....... Repair/graft hand tendon .............................................................. 3 $1,590.63 $510.00 ......... $102.00 

26410 ....... Repair hand tendon ...................................................................... 3 $986.93 $510.00 ......... $102.00 

26412 ....... Repair/graft hand tendon .............................................................. 3 $1,590.63 $510.00 ......... $102.00 

26415 ....... Excision, hand/finger tendon ........................................................ 4 $1,590.63 $630.00 ......... $126.00 

26416 ....... Graft hand or finger tendon .......................................................... 3 $1,590.63 $510.00 ......... $102.00 

26418 ....... Repair finger tendon ..................................................................... 4 $986.93 $630.00 ......... $126.00 

26420 ....... Repair/graft finger tendon ............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26426 ....... Repair finger/hand tendon ............................................................ 3 $1,590.63 $510.00 ......... $102.00 

26428 ....... Repair/graft finger tendon ............................................................. 3 $1,590.63 $510.00 ......... $102.00 

26432 ....... Repair finger tendon ..................................................................... 3 $986.93 $510.00 ......... $102.00 

26433 ....... Repair finger tendon ..................................................................... 3 $986.93 $510.00 ......... $102.00 

26434 ....... Repair/graft finger tendon ............................................................. 3 $1,590.63 $510.00 ......... $102.00 

26437 ....... Realignment of tendons ................................................................ 3 $986.93 $510.00 ......... $102.00 

26440 ....... Release palm/finger tendon .......................................................... 3 $986.93 $510.00 ......... $102.00 

26442 ....... Release palm & finger tendon ...................................................... 3 $1,590.63 $510.00 ......... $102.00 

26445 ....... Release hand/finger tendon ......................................................... 3 $986.93 $510.00 ......... $102.00 

26449 ....... Release forearm/hand tendon ...................................................... 3 $1,590.63 $510.00 ......... $102.00 

26450 ....... Incision of palm tendon ................................................................ 3 $986.93 $510.00 ......... $102.00 

26455 ....... Incision of finger tendon ............................................................... 3 $986.93 $510.00 ......... $102.00 

26460 ....... Incise hand/finger tendon ............................................................. 3 $986.93 $510.00 ......... $102.00 

26471 ....... Fusion of finger tendons ............................................................... 2 $986.93 $446.00 ......... $89.20 

26474 ....... Fusion of finger tendons ............................................................... 2 $986.93 $446.00 ......... $89.20 

26476 ....... Tendon lengthening ...................................................................... 1 $986.93 $333.00 ......... $66.60 

26477 ....... Tendon shortening ........................................................................ 1 $986.93 $333.00 ......... $66.60 

26478 ....... Lengthening of hand tendon ......................................................... 1 $986.93 $333.00 ......... $66.60 

26479 ....... Shortening of hand tendon ........................................................... 1 $986.93 $333.00 ......... $66.60 

26480 ....... Transplant hand tendon ................................................................ 3 $1,590.63 $510.00 ......... $102.00 

26483 ....... Transplant/graft hand tendon ....................................................... 3 $1,590.63 $510.00 ......... $102.00 

26485 ....... Transplant palm tendon ................................................................ 2 $1,590.63 $446.00 ......... $89.20 

26489 ....... Transplant/graft palm tendon ........................................................ 3 $1,590.63 $510.00 ......... $102.00 

26490 ....... Revise thumb tendon .................................................................... 3 $1,590.63 $510.00 ......... $102.00 

26492 ....... Tendon transfer with graft ............................................................ 3 $1,590.63 $510.00 ......... $102.00 

26494 ....... Hand tendon/muscle transfer ....................................................... 3 $1,590.63 $510.00 ......... $102.00 

26496 ....... Revise thumb tendon .................................................................... 3 $1,590.63 $510.00 ......... $102.00 

26497 ....... Finger tendon transfer .................................................................. 3 $1,590.63 $510.00 ......... $102.00 

26498 ....... Finger tendon transfer .................................................................. 4 $1,590.63 $630.00 ......... $126.00 


sroberts on PROD1PC70 with PROPOSALS
49728 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

26499 ....... Revision of finger .......................................................................... 3 $1,590.63 $510.00 ......... $102.00 

26500 ....... Hand tendon reconstruction ......................................................... 4 $986.93 $630.00 ......... $126.00 

26502 ....... Hand tendon reconstruction ......................................................... 4 $1,590.63 $630.00 ......... $126.00 

26504 ....... Hand tendon reconstruction ......................................................... 4 $1,590.63 $630.00 ......... $126.00 

26508 ....... Release thumb contracture .......................................................... 3 $986.93 $510.00 ......... $102.00 

26510 ....... Thumb tendon transfer ................................................................. 3 $1,590.63 $510.00 ......... $102.00 

26516 ....... Fusion of knuckle joint .................................................................. 1 $1,590.63 $333.00 ......... $66.60 

26517 ....... Fusion of knuckle joints ................................................................ 3 $1,590.63 $510.00 ......... $102.00 

26518 ....... Fusion of knuckle joints ................................................................ 3 $1,590.63 $510.00 ......... $102.00 

26520 ....... Release knuckle contracture ........................................................ 3 $986.93 $510.00 ......... $102.00 

26525 ....... Release finger contracture ........................................................... 3 $986.93 $510.00 ......... $102.00 

26530 ....... Revise knuckle joint ...................................................................... 3 $2,016.06 $510.00 ......... $102.00 

26531 ....... Revise knuckle with implant ......................................................... 7 $2,903.02 $995.00 ......... $199.00 

26535 ....... Revise finger joint ......................................................................... 5 $2,016.06 $717.00 ......... $143.40 

26536 ....... Revise/implant finger joint ............................................................ 5 $2,903.02 $717.00 ......... $143.40 

26540 ....... Repair hand joint .......................................................................... 4 $986.93 $630.00 ......... $126.00 

26541 ....... Repair hand joint with graft .......................................................... 7 $1,590.63 $995.00 ......... $199.00 

26542 ....... Repair hand joint with graft .......................................................... 4 $986.93 $630.00 ......... $126.00 

26545 ....... Reconstruct finger joint ................................................................. 4 $1,590.63 $630.00 ......... $126.00 

26546 ....... Repair nonunion hand .................................................................. 4 $1,590.63 $630.00 ......... $126.00 

26548 ....... Reconstruct finger joint ................................................................. 4 $1,590.63 $630.00 ......... $126.00 

26550 ....... Construct thumb replacement ...................................................... 2 $1,590.63 $446.00 ......... $89.20 

26555 ....... Positional change of finger ........................................................... 3 $1,590.63 $510.00 ......... $102.00 

26560 ....... Repair of web finger ..................................................................... 2 $986.93 $446.00 ......... $89.20 

26561 ....... Repair of web finger ..................................................................... 3 $1,590.63 $510.00 ......... $102.00 

26562 ....... Repair of web finger ..................................................................... 4 $1,590.63 $630.00 ......... $126.00 

26565 ....... Correct metacarpal flaw ................................................................ 5 $1,590.63 $717.00 ......... $143.40 

26567 ....... Correct finger deformity ................................................................ 5 $1,590.63 $717.00 ......... $143.40 

26568 ....... Lengthen metacarpal/finger .......................................................... 3 $1,590.63 $510.00 ......... $102.00 

26580 ....... Repair hand deformity .................................................................. 5 $986.93 $717.00 ......... $143.40 

26587 ....... Reconstruct extra finger ............................................................... 5 $986.93 $717.00 ......... $143.40 

26590 ....... Repair finger deformity ................................................................. 5 $986.93 $717.00 ......... $143.40 

26591 ....... Repair muscles of hand ................................................................ 3 $1,590.63 $510.00 ......... $102.00 

26593 ....... Release muscles of hand ............................................................. 3 $986.93 $510.00 ......... $102.00 

26596 ....... Excision constricting tissue ........................................................... 2 $986.93 $446.00 ......... $89.20 

26605 ....... Treat metacarpal fracture ............................................................. 2 $104.11 $104.11 Y ..... $20.82 

26607 ....... Treat metacarpal fracture ............................................................. 2 $104.11 $104.11 Y ..... $20.82 

26608 ....... Treat metacarpal fracture ............................................................. 4 $1,580.03 $630.00 ......... $126.00 

26615 ....... Treat metacarpal fracture ............................................................. 4 $2,312.35 $630.00 ......... $126.00 

26645 ....... Treat thumb fracture ..................................................................... 1 $104.11 $104.11 Y ..... $20.82 

26650 ....... Treat thumb fracture ..................................................................... 2 $1,580.03 $446.00 ......... $89.20 

26665 ....... Treat thumb fracture ..................................................................... 4 $2,312.35 $630.00 ......... $126.00 

26675 ....... Treat hand dislocation .................................................................. 2 $104.11 $104.11 Y ..... $20.82 

26676 ....... Pin hand dislocation ..................................................................... 2 $1,580.03 $446.00 ......... $89.20 

26685 ....... Treat hand dislocation .................................................................. 3 $2,312.35 $510.00 ......... $102.00 

26686 ....... Treat hand dislocation .................................................................. 3 $3,472.68 $510.00 ......... $102.00 

26705 ....... Treat knuckle dislocation .............................................................. 2 $104.11 $104.11 Y ..... $20.82 

26706 ....... Pin knuckle dislocation ................................................................. 2 $104.11 $104.11 Y ..... $20.82 

26715 ....... Treat knuckle dislocation .............................................................. 4 $2,312.35 $630.00 ......... $126.00 

26727 ....... Treat finger fracture, each ............................................................ 7 $1,580.03 $995.00 ......... $199.00 

26735 ....... Treat finger fracture, each ............................................................ 4 $2,312.35 $630.00 ......... $126.00 

26742 ....... Treat finger fracture, each ............................................................ 2 $104.11 $104.11 Y ..... $20.82 

26746 ....... Treat finger fracture, each ............................................................ 5 $2,312.35 $717.00 ......... $143.40 

26756 ....... Pin finger fracture, each ............................................................... 2 $1,580.03 $446.00 ......... $89.20 

26765 ....... Treat finger fracture, each ............................................................ 4 $2,312.35 $630.00 ......... $126.00 

26776 ....... Pin finger dislocation .................................................................... 2 $1,580.03 $446.00 ......... $89.20 

26785 ....... Treat finger dislocation ................................................................. 2 $1,580.03 $446.00 ......... $89.20 

26820 ....... Thumb fusion with graft ................................................................ 5 $1,590.63 $717.00 ......... $143.40 

26841 ....... Fusion of thumb ............................................................................ 4 $1,590.63 $630.00 ......... $126.00 

26842 ....... Thumb fusion with graft ................................................................ 4 $1,590.63 $630.00 ......... $126.00 

26843 ....... Fusion of hand joint ...................................................................... 3 $1,590.63 $510.00 ......... $102.00 

26844 ....... Fusion/graft of hand joint .............................................................. 3 $1,590.63 $510.00 ......... $102.00 

26850 ....... Fusion of knuckle .......................................................................... 4 $1,590.63 $630.00 ......... $126.00 

26852 ....... Fusion of knuckle with graft .......................................................... 4 $1,590.63 $630.00 ......... $126.00 

26860 ....... Fusion of finger joint ..................................................................... 3 $1,590.63 $510.00 ......... $102.00 

26861 ....... Fusion of finger jnt, add-on .......................................................... 2 $1,590.63 $446.00 ......... $89.20 

26862 ....... Fusion/graft of finger joint ............................................................. 4 $1,590.63 $630.00 ......... $126.00 

26863 ....... Fuse/graft added joint ................................................................... 3 $1,590.63 $510.00 ......... $102.00 

26910 ....... Amputate metacarpal bone .......................................................... 3 $1,590.63 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49729 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

26951 ....... Amputation of finger/thumb .......................................................... 2 $986.93 $446.00 ......... $89.20 

26952 ....... Amputation of finger/thumb .......................................................... 4 $986.93 $630.00 ......... $126.00 

26990 ....... Drainage of pelvis lesion .............................................................. 1 $1,281.58 $333.00 ......... $66.60 

26991 ....... Drainage of pelvis bursa ............................................................... 1 $1,281.58 $333.00 ......... $66.60 

27000 ....... Incision of hip tendon ................................................................... 2 $1,281.58 $446.00 ......... $89.20 

27001 ....... Incision of hip tendon ................................................................... 3 $1,542.47 $510.00 ......... $102.00 

27003 ....... Incision of hip tendon ................................................................... 3 $1,542.47 $510.00 ......... $102.00 

27033 ....... Exploration of hip joint .................................................................. 3 $2,539.24 $510.00 ......... $102.00 

27035 ....... Denervation of hip joint ................................................................. 4 $2,539.24 $630.00 ......... $126.00 

27040 ....... Biopsy of soft tissues .................................................................... 1 $400.87 $333.00 ......... $66.60 

27041 ....... Biopsy of soft tissues .................................................................... 2 $400.87 $400.87 Y ..... $80.17 

27047 ....... Remove hip/pelvis lesion .............................................................. 2 $1,229.54 $446.00 ......... $89.20 

27048 ....... Remove hip/pelvis lesion .............................................................. 3 $1,229.54 $510.00 ......... $102.00 

27049 ....... Remove tumor, hip/pelvis ............................................................. 3 $1,229.54 $510.00 ......... $102.00 

27050 ....... Biopsy of sacroiliac joint ............................................................... 3 $1,281.58 $510.00 ......... $102.00 

27052 ....... Biopsy of hip joint ......................................................................... 3 $1,281.58 $510.00 ......... $102.00 

27060 ....... Removal of ischial bursa .............................................................. 5 $1,281.58 $717.00 ......... $143.40 

27062 ....... Remove femur lesion/bursa .......................................................... 5 $1,281.58 $717.00 ......... $143.40 

27065 ....... Removal of hip bone lesion .......................................................... 5 $1,281.58 $717.00 ......... $143.40 

27066 ....... Removal of hip bone lesion .......................................................... 5 $1,542.47 $717.00 ......... $143.40 

27067 ....... Remove/graft hip bone lesion ....................................................... 5 $1,542.47 $717.00 ......... $143.40 

27080 ....... Removal of tail bone ..................................................................... 2 $1,542.47 $446.00 ......... $89.20 

27086 ....... Remove hip foreign body ............................................................. 1 $400.87 $333.00 ......... $66.60 

27087 ....... Remove hip foreign body ............................................................. 3 $1,281.58 $510.00 ......... $102.00 

27097 ....... Revision of hip tendon .................................................................. 3 $1,542.47 $510.00 ......... $102.00 

27098 ....... Transfer tendon to pelvis .............................................................. 3 $1,542.47 $510.00 ......... $102.00 

27100 ....... Transfer of abdominal muscle ...................................................... 4 $2,539.24 $630.00 ......... $126.00 

27105 ....... Transfer of spinal muscle ............................................................. 4 $2,539.24 $630.00 ......... $126.00 

27110 ....... Transfer of iliopsoas muscle ......................................................... 4 $2,539.24 $630.00 ......... $126.00 

27111 ....... Transfer of iliopsoas muscle ......................................................... 4 $2,539.24 $630.00 ......... $126.00 

27193 ....... Treat pelvic ring fracture ............................................................... 1 $104.11 $104.11 Y ..... $20.82 

27194 ....... Treat pelvic ring fracture ............................................................... 2 $895.58 $446.00 ......... $89.20 

27202 ....... Treat tail bone fracture ................................................................. 2 $2,312.35 $446.00 ......... $89.20 

27230 ....... Treat thigh fracture ....................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27238 ....... Treat thigh fracture ....................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27246 ....... Treat thigh fracture ....................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27250 ....... Treat hip dislocation ..................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27252 ....... Treat hip dislocation ..................................................................... 2 $895.58 $446.00 ......... $89.20 

27257 ....... Treat hip dislocation ..................................................................... 3 $895.58 $510.00 ......... $102.00 

27265 ....... Treat hip dislocation ..................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27266 ....... Treat hip dislocation ..................................................................... 2 $895.58 $446.00 ......... $89.20 

27275 ....... Manipulation of hip joint ................................................................ 2 $895.58 $446.00 ......... $89.20 

27301 ....... Drain thigh/knee lesion ................................................................. 3 $1,075.21 $510.00 ......... $102.00 

27305 ....... Incise thigh tendon & fascia ......................................................... 2 $1,281.58 $446.00 ......... $89.20 

27306 ....... Incision of thigh tendon ................................................................ 3 $1,281.58 $510.00 ......... $102.00 

27307 ....... Incision of thigh tendons ............................................................... 3 $1,281.58 $510.00 ......... $102.00 

27310 ....... Exploration of knee joint ............................................................... 4 $1,542.47 $630.00 ......... $126.00 

27315 ....... Partial removal, thigh nerve .......................................................... 2 $1,093.20 $446.00 ......... $89.20 

27320 ....... Partial removal, thigh nerve .......................................................... 2 $1,093.20 $446.00 ......... $89.20 

27323 ....... Biopsy, thigh soft tissues .............................................................. 1 $400.87 $333.00 ......... $66.60 

27324 ....... Biopsy, thigh soft tissues .............................................................. 1 $1,229.54 $333.00 ......... $66.60 

27327 ....... Removal of thigh lesion ................................................................ 2 $1,229.54 $446.00 ......... $89.20 

27328 ....... Removal of thigh lesion ................................................................ 3 $1,229.54 $510.00 ......... $102.00 

27329 ....... Remove tumor, thigh/knee ........................................................... 4 $1,229.54 $630.00 ......... $126.00 

27330 ....... Biopsy, knee joint lining ................................................................ 4 $1,542.47 $630.00 ......... $126.00 

27331 ....... Explore/treat knee joint ................................................................. 4 $1,542.47 $630.00 ......... $126.00 

27332 ....... Removal of knee cartilage ............................................................ 4 $1,542.47 $630.00 ......... $126.00 

27333 ....... Removal of knee cartilage ............................................................ 4 $1,542.47 $630.00 ......... $126.00 

27334 ....... Remove knee joint lining .............................................................. 4 $1,542.47 $630.00 ......... $126.00 

27335 ....... Remove knee joint lining .............................................................. 4 $1,542.47 $630.00 ......... $126.00 

27340 ....... Removal of kneecap bursa ........................................................... 3 $1,281.58 $510.00 ......... $102.00 

27345 ....... Removal of knee cyst ................................................................... 4 $1,281.58 $630.00 ......... $126.00 

27347 ....... Remove knee cyst ........................................................................ 4 $1,281.58 $630.00 ......... $126.00 

27350 ....... Removal of kneecap ..................................................................... 4 $1,542.47 $630.00 ......... $126.00 

27355 ....... Remove femur lesion .................................................................... 3 $1,542.47 $510.00 ......... $102.00 

27356 ....... Remove femur lesion/graft ........................................................... 4 $1,542.47 $630.00 ......... $126.00 

27357 ....... Remove femur lesion/graft ........................................................... 5 $1,542.47 $717.00 ......... $143.40 

27358 ....... Remove femur lesion/fixation ....................................................... 5 $1,542.47 $717.00 ......... $143.40 

27360 ....... Partial removal, leg bone(s) ......................................................... 5 $1,542.47 $717.00 ......... $143.40 


sroberts on PROD1PC70 with PROPOSALS
49730 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

27372 ....... Removal of foreign body .............................................................. 7 $1,229.54 $995.00 ......... $199.00 

27380 ....... Repair of kneecap tendon ............................................................ 1 $1,281.58 $333.00 ......... $66.60 

27381 ....... Repair/graft kneecap tendon ........................................................ 3 $1,281.58 $510.00 ......... $102.00 

27385 ....... Repair of thigh muscle .................................................................. 3 $1,281.58 $510.00 ......... $102.00 

27386 ....... Repair/graft of thigh muscle ......................................................... 3 $1,281.58 $510.00 ......... $102.00 

27390 ....... Incision of thigh tendon ................................................................ 1 $1,281.58 $333.00 ......... $66.60 

27391 ....... Incision of thigh tendons ............................................................... 2 $1,281.58 $446.00 ......... $89.20 

27392 ....... Incision of thigh tendons ............................................................... 3 $1,281.58 $510.00 ......... $102.00 

27393 ....... Lengthening of thigh tendon ......................................................... 2 $1,542.47 $446.00 ......... $89.20 

27394 ....... Lengthening of thigh tendons ....................................................... 3 $1,542.47 $510.00 ......... $102.00 

27395 ....... Lengthening of thigh tendons ....................................................... 3 $2,539.24 $510.00 ......... $102.00 

27396 ....... Transplant of thigh tendon ............................................................ 3 $1,542.47 $510.00 ......... $102.00 

27397 ....... Transplants of thigh tendons ........................................................ 3 $2,539.24 $510.00 ......... $102.00 

27400 ....... Revise thigh muscles/tendons ...................................................... 3 $2,539.24 $510.00 ......... $102.00 

27403 ....... Repair of knee cartilage ............................................................... 4 $1,542.47 $630.00 ......... $126.00 

27405 ....... Repair of knee ligament ............................................................... 4 $2,539.24 $630.00 ......... $126.00 

27407 ....... Repair of knee ligament ............................................................... 4 $4,055.26 $630.00 ......... $126.00 

27409 ....... Repair of knee ligaments .............................................................. 4 $2,539.24 $630.00 ......... $126.00 

27418 ....... Repair degenerated kneecap ....................................................... 3 $2,539.24 $510.00 ......... $102.00 

27420 ....... Revision of unstable kneecap ...................................................... 3 $2,539.24 $510.00 ......... $102.00 

27422 ....... Revision of unstable kneecap ...................................................... 7 $2,539.24 $995.00 ......... $199.00 

27424 ....... Revision/removal of kneecap ....................................................... 3 $2,539.24 $510.00 ......... $102.00 

27425 ....... Lat retinacular release open ......................................................... 7 $1,542.47 $995.00 ......... $199.00 

27427 ....... Reconstruction, knee .................................................................... 3 $2,539.24 $510.00 ......... $102.00 

27428 ....... Reconstruction, knee .................................................................... 4 $4,055.26 $630.00 ......... $126.00 

27429 ....... Reconstruction, knee .................................................................... 4 $4,055.26 $630.00 ......... $126.00 

27430 ....... Revision of thigh muscles ............................................................. 4 $2,539.24 $630.00 ......... $126.00 

27435 ....... Incision of knee joint ..................................................................... 4 $2,539.24 $630.00 ......... $126.00 

27437 ....... Revise kneecap ............................................................................ 4 $2,016.06 $630.00 ......... $126.00 

27438 ....... Revise kneecap with implant ........................................................ 5 $2,903.02 $717.00 ......... $143.40 

27441 ....... Revision of knee joint ................................................................... 5 $2,016.06 $717.00 ......... $143.40 

27442 ....... Revision of knee joint ................................................................... 5 $2,016.06 $717.00 ......... $143.40 

27443 ....... Revision of knee joint ................................................................... 5 $2,016.06 $717.00 ......... $143.40 

27496 ....... Decompression of thigh/knee ....................................................... 5 $1,281.58 $717.00 ......... $143.40 

27497 ....... Decompression of thigh/knee ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

27498 ....... Decompression of thigh/knee ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

27499 ....... Decompression of thigh/knee ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

27500 ....... Treatment of thigh fracture ........................................................... 1 $104.11 $104.11 Y ..... $20.82 

27501 ....... Treatment of thigh fracture ........................................................... 2 $104.11 $104.11 Y ..... $20.82 

27502 ....... Treatment of thigh fracture ........................................................... 2 $104.11 $104.11 Y ..... $20.82 

27503 ....... Treatment of thigh fracture ........................................................... 3 $104.11 $104.11 Y ..... $20.82 

27508 ....... Treatment of thigh fracture ........................................................... 1 $104.11 $104.11 Y ..... $20.82 

27509 ....... Treatment of thigh fracture ........................................................... 3 $1,580.03 $510.00 ......... $102.00 

27510 ....... Treatment of thigh fracture ........................................................... 1 $104.11 $104.11 Y ..... $20.82 

27516 ....... Treat thigh fx growth plate ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

27517 ....... Treat thigh fx growth plate ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

27520 ....... Treat kneecap fracture ................................................................. 1 $104.11 $104.11 Y ..... $20.82 

27530 ....... Treat knee fracture ....................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27532 ....... Treat knee fracture ....................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27538 ....... Treat knee fracture(s) ................................................................... 1 $104.11 $104.11 Y ..... $20.82 

27550 ....... Treat knee dislocation .................................................................. 1 $104.11 $104.11 Y ..... $20.82 

27552 ....... Treat knee dislocation .................................................................. 1 $895.58 $333.00 ......... $66.60 

27560 ....... Treat kneecap dislocation ............................................................. 1 $104.11 $104.11 Y ..... $20.82 

27562 ....... Treat kneecap dislocation ............................................................. 1 $895.58 $333.00 ......... $66.60 

27566 ....... Treat kneecap dislocation ............................................................. 2 $2,312.35 $446.00 ......... $89.20 

27570 ....... Fixation of knee joint .................................................................... 1 $895.58 $333.00 ......... $66.60 

27594 ....... Amputation follow-up surgery ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

27600 ....... Decompression of lower leg ......................................................... 3 $1,281.58 $510.00 ......... $102.00 

27601 ....... Decompression of lower leg ......................................................... 3 $1,281.58 $510.00 ......... $102.00 

27602 ....... Decompression of lower leg ......................................................... 3 $1,281.58 $510.00 ......... $102.00 

27603 ....... Drain lower leg lesion ................................................................... 2 $1,075.21 $446.00 ......... $89.20 

27604 ....... Drain lower leg bursa ................................................................... 2 $1,281.58 $446.00 ......... $89.20 

27605 ....... Incision of achilles tendon ............................................................ 1 $1,244.90 $333.00 ......... $66.60 

27606 ....... Incision of achilles tendon ............................................................ 1 $1,281.58 $333.00 ......... $66.60 

27607 ....... Treat lower leg bone lesion .......................................................... 2 $1,281.58 $446.00 ......... $89.20 

27610 ....... Explore/treat ankle joint ................................................................ 2 $1,542.47 $446.00 ......... $89.20 

27612 ....... Exploration of ankle joint .............................................................. 3 $1,542.47 $510.00 ......... $102.00 

27614 ....... Biopsy lower leg soft tissue .......................................................... 2 $1,229.54 $446.00 ......... $89.20 

27615 ....... Remove tumor, lower leg ............................................................. 3 $1,542.47 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49731 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

27618 ....... Remove lower leg lesion .............................................................. 2 $920.58 $446.00 ......... $89.20 

27619 ....... Remove lower leg lesion .............................................................. 3 $1,229.54 $510.00 ......... $102.00 

27620 ....... Explore/treat ankle joint ................................................................ 4 $1,542.47 $630.00 ......... $126.00 

27625 ....... Remove ankle joint lining ............................................................. 4 $1,542.47 $630.00 ......... $126.00 

27626 ....... Remove ankle joint lining ............................................................. 4 $1,542.47 $630.00 ......... $126.00 

27630 ....... Removal of tendon lesion ............................................................. 3 $1,281.58 $510.00 ......... $102.00 

27635 ....... Remove lower leg bone lesion ..................................................... 3 $1,542.47 $510.00 ......... $102.00 

27637 ....... Remove/graft leg bone lesion ....................................................... 3 $1,542.47 $510.00 ......... $102.00 

27638 ....... Remove/graft leg bone lesion ....................................................... 3 $1,542.47 $510.00 ......... $102.00 

27640 ....... Partial removal of tibia .................................................................. 2 $2,539.24 $446.00 ......... $89.20 

27641 ....... Partial removal of fibula ................................................................ 2 $1,542.47 $446.00 ......... $89.20 

27647 ....... Extensive ankle/heel surgery ........................................................ 3 $2,539.24 $510.00 ......... $102.00 

27650 ....... Repair achilles tendon .................................................................. 3 $2,539.24 $510.00 ......... $102.00 

27652 ....... Repair/graft achilles tendon .......................................................... 3 $4,055.26 $510.00 ......... $102.00 

27654 ....... Repair of achilles tendon .............................................................. 3 $2,539.24 $510.00 ......... $102.00 

27656 ....... Repair leg fascia defect ................................................................ 2 $1,281.58 $446.00 ......... $89.20 

27658 ....... Repair of leg tendon, each ........................................................... 1 $1,281.58 $333.00 ......... $66.60 

27659 ....... Repair of leg tendon, each ........................................................... 2 $1,281.58 $446.00 ......... $89.20 

27664 ....... Repair of leg tendon, each ........................................................... 2 $1,281.58 $446.00 ......... $89.20 

27665 ....... Repair of leg tendon, each ........................................................... 2 $1,542.47 $446.00 ......... $89.20 

27675 ....... Repair lower leg tendons .............................................................. 2 $1,281.58 $446.00 ......... $89.20 

27676 ....... Repair lower leg tendons .............................................................. 3 $1,542.47 $510.00 ......... $102.00 

27680 ....... Release of lower leg tendon ......................................................... 3 $1,542.47 $510.00 ......... $102.00 

27681 ....... Release of lower leg tendons ....................................................... 2 $1,542.47 $446.00 ......... $89.20 

27685 ....... Revision of lower leg tendon ........................................................ 3 $1,542.47 $510.00 ......... $102.00 

27686 ....... Revise lower leg tendons ............................................................. 3 $1,542.47 $510.00 ......... $102.00 

27687 ....... Revision of calf tendon ................................................................. 3 $1,542.47 $510.00 ......... $102.00 

27690 ....... Revise lower leg tendon ............................................................... 4 $2,539.24 $630.00 ......... $126.00 

27691 ....... Revise lower leg tendon ............................................................... 4 $2,539.24 $630.00 ......... $126.00 

27692 ....... Revise additional leg tendon ........................................................ 3 $2,539.24 $510.00 ......... $102.00 

27695 ....... Repair of ankle ligament ............................................................... 2 $1,542.47 $446.00 ......... $89.20 

27696 ....... Repair of ankle ligaments ............................................................. 2 $1,542.47 $446.00 ......... $89.20 

27698 ....... Repair of ankle ligament ............................................................... 2 $1,542.47 $446.00 ......... $89.20 

27700 ....... Revision of ankle joint .................................................................. 5 $2,016.06 $717.00 ......... $143.40 

27704 ....... Removal of ankle implant ............................................................. 2 $1,281.58 $446.00 ......... $89.20 

27705 ....... Incision of tibia .............................................................................. 2 $2,539.24 $446.00 ......... $89.20 

27707 ....... Incision of fibula ............................................................................ 2 $1,281.58 $446.00 ......... $89.20 

27709 ....... Incision of tibia & fibula ................................................................ 2 $1,542.47 $446.00 ......... $89.20 

27730 ....... Repair of tibia epiphysis ............................................................... 2 $1,542.47 $446.00 ......... $89.20 

27732 ....... Repair of fibula epiphysis ............................................................. 2 $1,542.47 $446.00 ......... $89.20 

27734 ....... Repair lower leg epiphyses .......................................................... 2 $1,542.47 $446.00 ......... $89.20 

27740 ....... Repair of leg epiphyses ................................................................ 2 $1,542.47 $446.00 ......... $89.20 

27742 ....... Repair of leg epiphyses ................................................................ 2 $2,539.24 $446.00 ......... $89.20 

27745 ....... Reinforce tibia ............................................................................... 3 $4,055.26 $510.00 ......... $102.00 

27750 ....... Treatment of tibia fracture ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

27752 ....... Treatment of tibia fracture ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

27756 ....... Treatment of tibia fracture ............................................................ 3 $1,580.03 $510.00 ......... $102.00 

27758 ....... Treatment of tibia fracture ............................................................ 4 $2,312.35 $630.00 ......... $126.00 

27759 ....... Treatment of tibia fracture ............................................................ 4 $3,472.68 $630.00 ......... $126.00 

27760 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27762 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27766 ....... Treatment of ankle fracture .......................................................... 3 $2,312.35 $510.00 ......... $102.00 

27780 ....... Treatment of fibula fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82 

27781 ....... Treatment of fibula fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82 

27784 ....... Treatment of fibula fracture .......................................................... 3 $2,312.35 $510.00 ......... $102.00 

27786 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27788 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27792 ....... Treatment of ankle fracture .......................................................... 3 $2,312.35 $510.00 ......... $102.00 

27808 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27810 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27814 ....... Treatment of ankle fracture .......................................................... 3 $2,312.35 $510.00 ......... $102.00 

27816 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27818 ....... Treatment of ankle fracture .......................................................... 1 $104.11 $104.11 Y ..... $20.82

27822 ....... Treatment of ankle fracture .......................................................... 3 $2,312.35 $510.00 ......... $102.00 

27823 ....... Treatment of ankle fracture .......................................................... 3 $3,472.68 $510.00 ......... $102.00 

27824 ....... Treat lower leg fracture ................................................................ 1 $104.11 $104.11 Y ..... $20.82 

27825 ....... Treat lower leg fracture ................................................................ 2 $104.11 $104.11 Y ..... $20.82 

27826 ....... Treat lower leg fracture ................................................................ 3 $2,312.35 $510.00 ......... $102.00 

27827 ....... Treat lower leg fracture ................................................................ 3 $3,472.68 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
49732 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

27828 ....... Treat lower leg fracture ................................................................ 4 $3,472.68 $630.00 ......... $126.00 

27829 ....... Treat lower leg joint ...................................................................... 2 $2,312.35 $446.00 ......... $89.20 

27830 ....... Treat lower leg dislocation ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

27831 ....... Treat lower leg dislocation ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

27832 ....... Treat lower leg dislocation ............................................................ 2 $2,312.35 $446.00 ......... $89.20 

27840 ....... Treat ankle dislocation .................................................................. 1 $104.11 $104.11 Y ..... $20.82 

27842 ....... Treat ankle dislocation .................................................................. 1 $895.58 $333.00 ......... $66.60 

27846 ....... Treat ankle dislocation .................................................................. 3 $2,312.35 $510.00 ......... $102.00 

27848 ....... Treat ankle dislocation .................................................................. 3 $2,312.35 $510.00 ......... $102.00 

27860 ....... Fixation of ankle joint .................................................................... 1 $895.58 $333.00 ......... $66.60 

27870 ....... Fusion of ankle joint, open ........................................................... 4 $4,055.26 $630.00 ......... $126.00 

27871 ....... Fusion of tibiofibular joint .............................................................. 4 $4,055.26 $630.00 ......... $126.00 

27884 ....... Amputation follow-up surgery ....................................................... 3 $1,281.58 $510.00 ......... $102.00 

27889 ....... Amputation of foot at ankle .......................................................... 3 $1,542.47 $510.00 ......... $102.00 

27892 ....... Decompression of leg ................................................................... 3 $1,281.58 $510.00 ......... $102.00 

27893 ....... Decompression of leg ................................................................... 3 $1,281.58 $510.00 ......... $102.00 

27894 ....... Decompression of leg ................................................................... 3 $1,281.58 $510.00 ......... $102.00 

28002 ....... Treatment of foot infection ............................................................ 3 $1,281.58 $510.00 ......... $102.00 

28003 ....... Treatment of foot infection ............................................................ 3 $1,281.58 $510.00 ......... $102.00 

28005 ....... Treat foot bone lesion ................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28008 ....... Incision of foot fascia .................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28011 ....... Incision of toe tendons ................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28020 ....... Exploration of foot joint ................................................................. 2 $1,244.90 $446.00 ......... $89.20 

28022 ....... Exploration of foot joint ................................................................. 2 $1,244.90 $446.00 ......... $89.20 

28024 ....... Exploration of toe joint .................................................................. 2 $1,244.90 $446.00 ......... $89.20 

28030 ....... Removal of foot nerve .................................................................. 4 $1,093.20 $630.00 ......... $126.00 

28035 ....... Decompression of tibia nerve ....................................................... 4 $1,093.20 $630.00 ......... $126.00 

28043 ....... Excision of foot lesion ................................................................... 2 $1,229.54 $446.00 ......... $89.20 

28045 ....... Excision of foot lesion ................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28046 ....... Resection of tumor, foot ............................................................... 3 $1,244.90 $510.00 ......... $102.00 

28050 ....... Biopsy of foot joint lining .............................................................. 2 $1,244.90 $446.00 ......... $89.20 

28052 ....... Biopsy of foot joint lining .............................................................. 2 $1,244.90 $446.00 ......... $89.20 

28054 ....... Biopsy of toe joint lining ............................................................... 2 $1,244.90 $446.00 ......... $89.20 

28060 ....... Partial removal, foot fascia ........................................................... 2 $1,244.90 $446.00 ......... $89.20 

28062 ....... Removal of foot fascia .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28070 ....... Removal of foot joint lining ........................................................... 3 $1,244.90 $510.00 ......... $102.00 

28072 ....... Removal of foot joint lining ........................................................... 3 $1,244.90 $510.00 ......... $102.00 

28080 ....... Removal of foot lesion .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28086 ....... Excise foot tendon sheath ............................................................ 2 $1,244.90 $446.00 ......... $89.20 

28088 ....... Excise foot tendon sheath ............................................................ 2 $1,244.90 $446.00 ......... $89.20 

28090 ....... Removal of foot lesion .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28092 ....... Removal of toe lesions ................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28100 ....... Removal of ankle/heel lesion ....................................................... 2 $1,244.90 $446.00 ......... $89.20 

28102 ....... Remove/graft foot lesion ............................................................... 3 $2,537.37 $510.00 ......... $102.00 

28103 ....... Remove/graft foot lesion ............................................................... 3 $2,537.37 $510.00 ......... $102.00 

28104 ....... Removal of foot lesion .................................................................. 2 $1,244.90 $446.00 ......... $89.20 

28106 ....... Remove/graft foot lesion ............................................................... 3 $2,537.37 $510.00 ......... $102.00 

28107 ....... Remove/graft foot lesion ............................................................... 3 $2,537.37 $510.00 ......... $102.00 

28108 ....... Removal of toe lesions ................................................................. 2 $1,244.90 $446.00 ......... $89.20 

28110 ....... Part removal of metatarsal ........................................................... 3 $1,244.90 $510.00 ......... $102.00 

28111 ....... Part removal of metatarsal ........................................................... 3 $1,244.90 $510.00 ......... $102.00 

28112 ....... Part removal of metatarsal ........................................................... 3 $1,244.90 $510.00 ......... $102.00 

28113 ....... Part removal of metatarsal ........................................................... 3 $1,244.90 $510.00 ......... $102.00 

28114 ....... Removal of metatarsal heads ....................................................... 3 $1,244.90 $510.00 ......... $102.00 

28116 ....... Revision of foot ............................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28118 ....... Removal of heel bone .................................................................. 4 $1,244.90 $630.00 ......... $126.00 

28119 ....... Removal of heel spur ................................................................... 4 $1,244.90 $630.00 ......... $126.00 

28120 ....... Part removal of ankle/heel ............................................................ 7 $1,244.90 $995.00 ......... $199.00 

28122 ....... Partial removal of foot bone ......................................................... 3 $1,244.90 $510.00 ......... $102.00 

28126 ....... Partial removal of toe ................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28130 ....... Removal of ankle bone ................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28140 ....... Removal of metatarsal .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28150 ....... Removal of toe ............................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28153 ....... Partial removal of toe ................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28160 ....... Partial removal of toe ................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28171 ....... Extensive foot surgery .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28173 ....... Extensive foot surgery .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28175 ....... Extensive foot surgery .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28192 ....... Removal of foot foreign body ....................................................... 2 $920.58 $446.00 ......... $89.20 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49733 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

28193 ....... Removal of foot foreign body ....................................................... 4 $400.87 $400.87 Y ..... $80.17 

28200 ....... Repair of foot tendon .................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28202 ....... Repair/graft of foot tendon ............................................................ 3 $1,244.90 $510.00 ......... $102.00 

28208 ....... Repair of foot tendon .................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28210 ....... Repair/graft of foot tendon ............................................................ 3 $2,537.37 $510.00 ......... $102.00 

28222 ....... Release of foot tendons ............................................................... 1 $1,244.90 $333.00 ......... $66.60 

28225 ....... Release of foot tendon ................................................................. 1 $1,244.90 $333.00 ......... $66.60 

28226 ....... Release of foot tendons ............................................................... 1 $1,244.90 $333.00 ......... $66.60 

28234 ....... Incision of foot tendon .................................................................. 2 $1,244.90 $446.00 ......... $89.20 

28238 ....... Revision of foot tendon ................................................................. 3 $2,537.37 $510.00 ......... $102.00 

28240 ....... Release of big toe ........................................................................ 2 $1,244.90 $446.00 ......... $89.20 

28250 ....... Revision of foot fascia .................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28260 ....... Release of midfoot joint ................................................................ 3 $1,244.90 $510.00 ......... $102.00 

28261 ....... Revision of foot tendon ................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28262 ....... Revision of foot and ankle ............................................................ 4 $1,244.90 $630.00 ......... $126.00 

28264 ....... Release of midfoot joint ................................................................ 1 $2,537.37 $333.00 ......... $66.60 

28270 ....... Release of foot contracture .......................................................... 3 $1,244.90 $510.00 ......... $102.00 

28280 ....... Fusion of toes ............................................................................... 2 $1,244.90 $446.00 ......... $89.20 

28285 ....... Repair of hammertoe .................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28286 ....... Repair of hammertoe .................................................................... 4 $1,244.90 $630.00 ......... $126.00 

28288 ....... Partial removal of foot bone ......................................................... 3 $1,244.90 $510.00 ......... $102.00 

28289 ....... Repair hallux rigidus ..................................................................... 3 $1,244.90 $510.00 ......... $102.00 

28290 ....... Correction of bunion ..................................................................... 2 $1,729.40 $446.00 ......... $89.20 

28292 ....... Correction of bunion ..................................................................... 2 $1,729.40 $446.00 ......... $89.20 

28293 ....... Correction of bunion ..................................................................... 3 $1,729.40 $510.00 ......... $102.00 

28294 ....... Correction of bunion ..................................................................... 3 $1,729.40 $510.00 ......... $102.00 

28296 ....... Correction of bunion ..................................................................... 3 $1,729.40 $510.00 ......... $102.00 

28297 ....... Correction of bunion ..................................................................... 3 $1,729.40 $510.00 ......... $102.00 

28298 ....... Correction of bunion ..................................................................... 3 $1,729.40 $510.00 ......... $102.00 

28299 ....... Correction of bunion ..................................................................... 5 $1,729.40 $717.00 ......... $143.40 

28300 ....... Incision of heel bone .................................................................... 2 $2,537.37 $446.00 ......... $89.20 

28302 ....... Incision of ankle bone ................................................................... 2 $1,244.90 $446.00 ......... $89.20 

28304 ....... Incision of midfoot bones .............................................................. 2 $2,537.37 $446.00 ......... $89.20 

28305 ....... Incise/graft midfoot bones ............................................................ 3 $2,537.37 $510.00 ......... $102.00 

28306 ....... Incision of metatarsal .................................................................... 4 $1,244.90 $630.00 ......... $126.00 

28307 ....... Incision of metatarsal .................................................................... 4 $1,244.90 $630.00 ......... $126.00 

28308 ....... Incision of metatarsal .................................................................... 2 $1,244.90 $446.00 ......... $89.20 

28309 ....... Incision of metatarsals .................................................................. 4 $2,537.37 $630.00 ......... $126.00 

28310 ....... Revision of big toe ........................................................................ 3 $1,244.90 $510.00 ......... $102.00 

28312 ....... Revision of toe .............................................................................. 3 $1,244.90 $510.00 ......... $102.00 

28313 ....... Repair deformity of toe ................................................................. 2 $1,244.90 $446.00 ......... $89.20 

28315 ....... Removal of sesamoid bone .......................................................... 4 $1,244.90 $630.00 ......... $126.00 

28320 ....... Repair of foot bones ..................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28322 ....... Repair of metatarsals ................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28340 ....... Resect enlarged toe tissue ........................................................... 4 $1,244.90 $630.00 ......... $126.00 

28341 ....... Resect enlarged toe ..................................................................... 4 $1,244.90 $630.00 ......... $126.00 

28344 ....... Repair extra toe(s) ........................................................................ 4 $1,244.90 $630.00 ......... $126.00 

28345 ....... Repair webbed toe(s) ................................................................... 4 $1,244.90 $630.00 ......... $126.00 

28400 ....... Treatment of heel fracture ............................................................ 1 $104.11 $104.11 Y ..... $20.82 

28405 ....... Treatment of heel fracture ............................................................ 2 $104.11 $104.11 Y ..... $20.82 

28406 ....... Treatment of heel fracture ............................................................ 2 $1,580.03 $446.00 ......... $89.20 

28415 ....... Treat heel fracture ........................................................................ 3 $2,312.35 $510.00 ......... $102.00 

28420 ....... Treat/graft heel fracture ................................................................ 4 $2,312.35 $630.00 ......... $126.00 

28435 ....... Treatment of ankle fracture .......................................................... 2 $104.11 $104.11 Y ..... $20.82

28436 ....... Treatment of ankle fracture .......................................................... 2 $1,580.03 $446.00 ......... $89.20 

28445 ....... Treat ankle fracture ...................................................................... 3 $2,312.35 $510.00 ......... $102.00 

28456 ....... Treat midfoot fracture ................................................................... 2 $1,580.03 $446.00 ......... $89.20 

28465 ....... Treat midfoot fracture, each ......................................................... 3 $2,312.35 $510.00 ......... $102.00 

28476 ....... Treat metatarsal fracture .............................................................. 2 $1,580.03 $446.00 ......... $89.20 

28485 ....... Treat metatarsal fracture .............................................................. 4 $2,312.35 $630.00 ......... $126.00 

28496 ....... Treat big toe fracture .................................................................... 2 $1,580.03 $446.00 ......... $89.20 

28505 ....... Treat big toe fracture .................................................................... 3 $2,312.35 $510.00 ......... $102.00 

28525 ....... Treat toe fracture .......................................................................... 3 $2,312.35 $510.00 ......... $102.00 

28531 ....... Treat sesamoid bone fracture ...................................................... 3 $2,312.35 $510.00 ......... $102.00 

28545 ....... Treat foot dislocation .................................................................... 1 $1,580.03 $333.00 ......... $66.60 

28546 ....... Treat foot dislocation .................................................................... 2 $1,580.03 $446.00 ......... $89.20 

28555 ....... Repair foot dislocation .................................................................. 2 $2,312.35 $446.00 ......... $89.20 

28575 ....... Treat foot dislocation .................................................................... 1 $104.11 $104.11 Y ..... $20.82 

28576 ....... Treat foot dislocation .................................................................... 3 $1,580.03 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
49734 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

28585 ....... Repair foot dislocation .................................................................. 3 $2,312.35 $510.00 ......... $102.00 

28605 ....... Treat foot dislocation .................................................................... 1 $104.11 $104.11 Y ..... $20.82 

28606 ....... Treat foot dislocation .................................................................... 2 $1,580.03 $446.00 ......... $89.20 

28615 ....... Repair foot dislocation .................................................................. 3 $2,312.35 $510.00 ......... $102.00 

28635 ....... Treat toe dislocation ..................................................................... 1 $895.58 $333.00 ......... $66.60 

28636 ....... Treat toe dislocation ..................................................................... 3 $1,580.03 $510.00 ......... $102.00 

28645 ....... Repair toe dislocation ................................................................... 3 $2,312.35 $510.00 ......... $102.00 

28665 ....... Treat toe dislocation ..................................................................... 1 $895.58 $333.00 ......... $66.60 

28666 ....... Treat toe dislocation ..................................................................... 3 $1,580.03 $510.00 ......... $102.00 

28675 ....... Repair of toe dislocation ............................................................... 3 $2,312.35 $510.00 ......... $102.00 

28705 ....... Fusion of foot bones ..................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28715 ....... Fusion of foot bones ..................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28725 ....... Fusion of foot bones ..................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28730 ....... Fusion of foot bones ..................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28735 ....... Fusion of foot bones ..................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28737 ....... Revision of foot bones .................................................................. 5 $2,537.37 $717.00 ......... $143.40 

28740 ....... Fusion of foot bones ..................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28750 ....... Fusion of big toe joint ................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28755 ....... Fusion of big toe joint ................................................................... 4 $1,244.90 $630.00 ......... $126.00 

28760 ....... Fusion of big toe joint ................................................................... 4 $2,537.37 $630.00 ......... $126.00 

28810 ....... Amputation toe & metatarsal ........................................................ 2 $1,244.90 $446.00 ......... $89.20 

28820 ....... Amputation of toe ......................................................................... 2 $1,244.90 $446.00 ......... $89.20 

28825 ....... Partial amputation of toe .............................................................. 2 $1,244.90 $446.00 ......... $89.20 

29800 ....... Jaw arthroscopy/surgery ............................................................... 3 $1,762.08 $510.00 ......... $102.00 

29804 ....... Jaw arthroscopy/surgery ............................................................... 3 $1,762.08 $510.00 ......... $102.00 

29805 ....... Shoulder arthroscopy, dx .............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29806 ....... Shoulder arthroscopy/surgery ....................................................... 3 $2,773.72 $510.00 ......... $102.00 

29807 ....... Shoulder arthroscopy/surgery ....................................................... 3 $2,773.72 $510.00 ......... $102.00 

29819 ....... Shoulder arthroscopy/surgery ....................................................... 3 $1,762.08 $510.00 ......... $102.00 

29820 ....... Shoulder arthroscopy/surgery ....................................................... 3 $1,762.08 $510.00 ......... $102.00 

29821 ....... Shoulder arthroscopy/surgery ....................................................... 3 $1,762.08 $510.00 ......... $102.00 

29822 ....... Shoulder arthroscopy/surgery ....................................................... 3 $1,762.08 $510.00 ......... $102.00 

29823 ....... Shoulder arthroscopy/surgery ....................................................... 3 $1,762.08 $510.00 ......... $102.00 

29824 ....... Shoulder arthroscopy/surgery ....................................................... 5 $1,762.08 $717.00 ......... $143.40 

29825 ....... Shoulder arthroscopy/surgery ....................................................... 3 $1,762.08 $510.00 ......... $102.00 

29826 ....... Shoulder arthroscopy/surgery ....................................................... 3 $2,773.72 $510.00 ......... $102.00 

29827 ....... Arthroscop rotator cuff repr .......................................................... 5 $2,773.72 $717.00 ......... $143.40 

29830 ....... Elbow arthroscopy ........................................................................ 3 $1,762.08 $510.00 ......... $102.00 

29834 ....... Elbow arthroscopy/surgery ........................................................... 3 $1,762.08 $510.00 ......... $102.00 

29835 ....... Elbow arthroscopy/surgery ........................................................... 3 $1,762.08 $510.00 ......... $102.00 

29836 ....... Elbow arthroscopy/surgery ........................................................... 3 $1,762.08 $510.00 ......... $102.00 

29837 ....... Elbow arthroscopy/surgery ........................................................... 3 $1,762.08 $510.00 ......... $102.00 

29838 ....... Elbow arthroscopy/surgery ........................................................... 3 $1,762.08 $510.00 ......... $102.00 

29840 ....... Wrist arthroscopy .......................................................................... 3 $1,762.08 $510.00 ......... $102.00 

29843 ....... Wrist arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29844 ....... Wrist arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29845 ....... Wrist arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29846 ....... Wrist arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29847 ....... Wrist arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29848 ....... Wrist endoscopy/surgery .............................................................. 9 $1,762.08 $1,339.00 ......... $267.80 

29850 ....... Knee arthroscopy/surgery ............................................................. 4 $1,762.08 $630.00 ......... $126.00 

29851 ....... Knee arthroscopy/surgery ............................................................. 4 $2,773.72 $630.00 ......... $126.00 

29855 ....... Tibial arthroscopy/surgery ............................................................ 4 $2,773.72 $630.00 ......... $126.00 

29856 ....... Tibial arthroscopy/surgery ............................................................ 4 $1,762.08 $630.00 ......... $126.00 

29860 ....... Hip arthroscopy, dx ....................................................................... 4 $1,762.08 $630.00 ......... $126.00 

29861 ....... Hip arthroscopy/surgery ................................................................ 4 $1,762.08 $630.00 ......... $126.00 

29862 ....... Hip arthroscopy/surgery ................................................................ 9 $2,773.72 $1,339.00 ......... $267.80 

29863 ....... Hip arthroscopy/surgery ................................................................ 4 $2,773.72 $630.00 ......... $126.00 

29870 ....... Knee arthroscopy, dx .................................................................... 3 $1,762.08 $510.00 ......... $102.00 

29871 ....... Knee arthroscopy/drainage ........................................................... 3 $1,762.08 $510.00 ......... $102.00 

29873 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29874 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29875 ....... Knee arthroscopy/surgery ............................................................. 4 $1,762.08 $630.00 ......... $126.00 

29876 ....... Knee arthroscopy/surgery ............................................................. 4 $1,762.08 $630.00 ......... $126.00 

29877 ....... Knee arthroscopy/surgery ............................................................. 4 $1,762.08 $630.00 ......... $126.00 

29879 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29880 ....... Knee arthroscopy/surgery ............................................................. 4 $1,762.08 $630.00 ......... $126.00 

29881 ....... Knee arthroscopy/surgery ............................................................. 4 $1,762.08 $630.00 ......... $126.00 

29882 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49735 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

29883 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29884 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29885 ....... Knee arthroscopy/surgery ............................................................. 3 $2,773.72 $510.00 ......... $102.00 

29886 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29887 ....... Knee arthroscopy/surgery ............................................................. 3 $1,762.08 $510.00 ......... $102.00 

29888 ....... Knee arthroscopy/surgery ............................................................. 3 $2,773.72 $510.00 ......... $102.00 

29889 ....... Knee arthroscopy/surgery ............................................................. 3 $2,773.72 $510.00 ......... $102.00 

29891 ....... Ankle arthroscopy/surgery ............................................................ 3 $1,762.08 $510.00 ......... $102.00 

29892 ....... Ankle arthroscopy/surgery ............................................................ 3 $1,762.08 $510.00 ......... $102.00 

29893 ....... Scope, plantar fasciotomy ............................................................ 9 $1,244.90 $1,244.90 Y ..... $248.98 

29894 ....... Ankle arthroscopy/surgery ............................................................ 3 $1,762.08 $510.00 ......... $102.00 

29895 ....... Ankle arthroscopy/surgery ............................................................ 3 $1,762.08 $510.00 ......... $102.00 

29897 ....... Ankle arthroscopy/surgery ............................................................ 3 $1,762.08 $510.00 ......... $102.00 

29898 ....... Ankle arthroscopy/surgery ............................................................ 3 $1,762.08 $510.00 ......... $102.00 

29899 ....... Ankle arthroscopy/surgery ............................................................ 3 $2,773.72 $510.00 ......... $102.00 

29900 ....... Mcp joint arthroscopy, dx ............................................................. 3 $986.93 $510.00 ......... $102.00 

29901 ....... Mcp joint arthroscopy, surg .......................................................... 3 $986.93 $510.00 ......... $102.00 

29902 ....... Mcp joint arthroscopy, surg .......................................................... 3 $986.93 $510.00 ......... $102.00 

30115 ....... Removal of nose polyp(s) ............................................................. 2 $1,012.48 $446.00 ......... $89.20 

30117 ....... Removal of intranasal lesion ........................................................ 3 $1,012.48 $510.00 ......... $102.00 

30118 ....... Removal of intranasal lesion ........................................................ 3 $1,425.30 $510.00 ......... $102.00 

30120 ....... Revision of nose ........................................................................... 1 $1,012.48 $333.00 ......... $66.60 

30125 ....... Removal of nose lesion ................................................................ 2 $2,324.90 $446.00 ......... $89.20 

30130 ....... Excise inferior turbinate ................................................................ 3 $1,012.48 $510.00 ......... $102.00 

30140 ....... Resect inferior turbinate ............................................................... 2 $1,425.30 $446.00 ......... $89.20 

30150 ....... Partial removal of nose ................................................................. 3 $2,324.90 $510.00 ......... $102.00 

30160 ....... Removal of nose ........................................................................... 4 $2,324.90 $630.00 ......... $126.00 

30220 ....... Insert nasal septal button ............................................................. 3 $475.55 $475.55 Y ..... $95.11 

30310 ....... Remove nasal foreign body .......................................................... 1 $1,012.48 $333.00 ......... $66.60 

30320 ....... Remove nasal foreign body .......................................................... 2 $1,012.48 $446.00 ......... $89.20 

30400 ....... Reconstruction of nose ................................................................. 4 $2,324.90 $630.00 ......... $126.00 

30410 ....... Reconstruction of nose ................................................................. 5 $2,324.90 $717.00 ......... $143.40 

30420 ....... Reconstruction of nose ................................................................. 5 $2,324.90 $717.00 ......... $143.40 

30430 ....... Revision of nose ........................................................................... 3 $1,425.30 $510.00 ......... $102.00 

30435 ....... Revision of nose ........................................................................... 5 $2,324.90 $717.00 ......... $143.40 

30450 ....... Revision of nose ........................................................................... 7 $2,324.90 $995.00 ......... $199.00 

30460 ....... Revision of nose ........................................................................... 7 $2,324.90 $995.00 ......... $199.00 

30462 ....... Revision of nose ........................................................................... 9 $2,324.90 $1,339.00 ......... $267.80 

30465 ....... Repair nasal stenosis ................................................................... 9 $2,324.90 $1,339.00 ......... $267.80 

30520 ....... Repair of nasal septum ................................................................ 4 $1,425.30 $630.00 ......... $126.00 

30540 ....... Repair nasal defect ....................................................................... 5 $2,324.90 $717.00 ......... $143.40 

30545 ....... Repair nasal defect ....................................................................... 5 $2,324.90 $717.00 ......... $143.40 

30560 ....... Release of nasal adhesions ......................................................... 2 $146.29 $146.29 Y ..... $29.26 

30580 ....... Repair upper jaw fistula ................................................................ 4 $2,324.90 $630.00 ......... $126.00 

30600 ....... Repair mouth/nose fistula ............................................................. 4 $2,324.90 $630.00 ......... $126.00 

30620 ....... Intranasal reconstruction .............................................................. 7 $2,324.90 $995.00 ......... $199.00 

30630 ....... Repair nasal septum defect .......................................................... 7 $1,425.30 $995.00 ......... $199.00 

30801 ....... Ablate inf turbinate, superf ........................................................... 1 $475.55 $333.00 ......... $66.60 

30802 ....... Cauterization, inner nose .............................................................. 1 $475.55 $333.00 ......... $66.60 

30903 ....... Control of nosebleed .................................................................... 1 $73.99 $73.99 Y ..... $14.80 

30905 ....... Control of nosebleed .................................................................... 1 $73.99 $73.99 Y ..... $14.80 

30906 ....... Repeat control of nosebleed ........................................................ 1 $73.99 $73.99 Y ..... $14.80 

30915 ....... Ligation, nasal sinus artery ........................................................... 2 $1,513.03 $446.00 ......... $89.20 

30920 ....... Ligation, upper jaw artery ............................................................. 3 $1,513.03 $510.00 ......... $102.00 

30930 ....... Ther fx, nasal inf turbinate ............................................................ 4 $1,012.48 $630.00 ......... $126.00 

31020 ....... Exploration, maxillary sinus .......................................................... 2 $1,425.30 $446.00 ......... $89.20 

31030 ....... Exploration, maxillary sinus .......................................................... 3 $2,324.90 $510.00 ......... $102.00 

31032 ....... Explore sinus, remove polyps ...................................................... 4 $2,324.90 $630.00 ......... $126.00 

31050 ....... Exploration, sphenoid sinus .......................................................... 2 $2,324.90 $446.00 ......... $89.20 

31051 ....... Sphenoid sinus surgery ................................................................ 4 $2,324.90 $630.00 ......... $126.00 

31070 ....... Exploration of frontal sinus ........................................................... 2 $1,425.30 $446.00 ......... $89.20 

31075 ....... Exploration of frontal sinus ........................................................... 4 $2,324.90 $630.00 ......... $126.00 

31080 ....... Removal of frontal sinus ............................................................... 4 $2,324.90 $630.00 ......... $126.00 

31081 ....... Removal of frontal sinus ............................................................... 4 $2,324.90 $630.00 ......... $126.00 

31084 ....... Removal of frontal sinus ............................................................... 4 $2,324.90 $630.00 ......... $126.00 

31085 ....... Removal of frontal sinus ............................................................... 4 $2,324.90 $630.00 ......... $126.00 

31086 ....... Removal of frontal sinus ............................................................... 4 $2,324.90 $630.00 ......... $126.00 

31087 ....... Removal of frontal sinus ............................................................... 4 $2,324.90 $630.00 ......... $126.00 

31090 ....... Exploration of sinuses .................................................................. 5 $2,324.90 $717.00 ......... $143.40 


sroberts on PROD1PC70 with PROPOSALS
49736 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

31200 ....... Removal of ethmoid sinus ............................................................ 2 $2,324.90 $446.00 ......... $89.20 

31201 ....... Removal of ethmoid sinus ............................................................ 5 $2,324.90 $717.00 ......... $143.40 

31205 ....... Removal of ethmoid sinus ............................................................ 3 $2,324.90 $510.00 ......... $102.00 

31233 ....... Nasal/sinus endoscopy, dx ........................................................... 2 $86.41 $86.41 Y ..... $17.28 

31235 ....... Nasal/sinus endoscopy, dx ........................................................... 1 $931.27 $333.00 ......... $66.60 

31237 ....... Nasal/sinus endoscopy, surg ........................................................ 2 $931.27 $446.00 ......... $89.20 

31238 ....... Nasal/sinus endoscopy, surg ........................................................ 1 $931.27 $333.00 ......... $66.60 

31239 ....... Nasal/sinus endoscopy, surg ........................................................ 4 $1,341.87 $630.00 ......... $126.00 

31240 ....... Nasal/sinus endoscopy, surg ........................................................ 2 $931.27 $446.00 ......... $89.20 

31254 ....... Revision of ethmoid sinus ............................................................ 3 $1,341.87 $510.00 ......... $102.00 

31255 ....... Removal of ethmoid sinus ............................................................ 5 $1,341.87 $717.00 ......... $143.40 

31256 ....... Exploration maxillary sinus ........................................................... 3 $1,341.87 $510.00 ......... $102.00 

31267 ....... Endoscopy, maxillary sinus .......................................................... 3 $1,341.87 $510.00 ......... $102.00 

31276 ....... Sinus endoscopy, surgical ............................................................ 3 $1,341.87 $510.00 ......... $102.00 

31287 ....... Nasal/sinus endoscopy, surg ........................................................ 3 $1,341.87 $510.00 ......... $102.00 

31288 ....... Nasal/sinus endoscopy, surg ........................................................ 3 $1,341.87 $510.00 ......... $102.00 

31300 ....... Removal of larynx lesion .............................................................. 5 $1,425.30 $717.00 ......... $143.40 

31320 ....... Diagnostic incision, larynx ............................................................ 2 $2,324.90 $446.00 ......... $89.20 

31400 ....... Revision of larynx ......................................................................... 2 $2,324.90 $446.00 ......... $89.20 

31420 ....... Removal of epiglottis .................................................................... 2 $2,324.90 $446.00 ......... $89.20 

31510 ....... Laryngoscopy with biopsy ............................................................ 2 $931.27 $446.00 ......... $89.20 

31511 ....... Remove foreign body, larynx ........................................................ 2 $86.41 $86.41 Y ..... $17.28 

31512 ....... Removal of larynx lesion .............................................................. 2 $931.27 $446.00 ......... $89.20 

31513 ....... Injection into vocal cord ................................................................ 2 $86.41 $86.41 Y ..... $17.28 

31515 ....... Laryngoscopy for aspiration ......................................................... 1 $931.27 $333.00 ......... $66.60 

31525 ....... Dx laryngoscopy excl nb .............................................................. 1 $931.27 $333.00 ......... $66.60 

31526 ....... Dx laryngoscopy w/oper scope .................................................... 2 $1,341.87 $446.00 ......... $89.20

31527 ....... Laryngoscopy for treatment .......................................................... 1 $1,341.87 $333.00 ......... $66.60 

31528 ....... Laryngoscopy and dilation ............................................................ 2 $931.27 $446.00 ......... $89.20 

31529 ....... Laryngoscopy and dilation ............................................................ 2 $931.27 $446.00 ......... $89.20 

31530 ....... Laryngoscopy w/fb removal .......................................................... 2 $1,341.87 $446.00 ......... $89.20 

31531 ....... Laryngoscopy w/fb & op scope .................................................... 3 $1,341.87 $510.00 ......... $102.00 

31535 ....... Laryngoscopy w/biopsy ................................................................ 2 $1,341.87 $446.00 ......... $89.20 

31536 ....... Laryngoscopy w/bx & op scope ................................................... 3 $1,341.87 $510.00 ......... $102.00

31540 ....... Laryngoscopy w/exc of tumor ....................................................... 3 $1,341.87 $510.00 ......... $102.00 

31541 ....... Larynscop w/tumr exc + scope .................................................... 4 $1,341.87 $630.00 ......... $126.00 

31545 ....... Remove vc lesion w/scope ........................................................... 4 $1,341.87 $630.00 ......... $126.00 

31546 ....... Remove vc lesion scope/graft ...................................................... 4 $1,341.87 $630.00 ......... $126.00 

31560 ....... Laryngoscop w/arytenoidectom .................................................... 5 $1,341.87 $717.00 ......... $143.40 

31561 ....... Larynscop, remve cart + scop ...................................................... 5 $1,341.87 $717.00 ......... $143.40 

31570 ....... Laryngoscope w/vc inj .................................................................. 2 $931.27 $446.00 ......... $89.20 

31571 ....... Laryngoscop w/vc inj + scope ...................................................... 2 $1,341.87 $446.00 ......... $89.20 

31576 ....... Laryngoscopy with biopsy ............................................................ 2 $1,341.87 $446.00 ......... $89.20 

31577 ....... Remove foreign body, larynx ........................................................ 2 $238.43 $238.43 Y ..... $47.69 

31578 ....... Removal of larynx lesion .............................................................. 2 $1,341.87 $446.00 ......... $89.20 

31580 ....... Revision of larynx ......................................................................... 5 $2,324.90 $717.00 ......... $143.40 

31582 ....... Revision of larynx ......................................................................... 5 $2,324.90 $717.00 ......... $143.40 

31588 ....... Revision of larynx ......................................................................... 5 $2,324.90 $717.00 ......... $143.40 

31590 ....... Reinnervate larynx ........................................................................ 5 $2,324.90 $717.00 ......... $143.40 

31595 ....... Larynx nerve surgery .................................................................... 2 $2,324.90 $446.00 ......... $89.20 

31603 ....... Incision of windpipe ...................................................................... 1 $475.55 $333.00 ......... $66.60 

31611 ....... Surgery/speech prosthesis ........................................................... 3 $1,425.30 $510.00 ......... $102.00 

31612 ....... Puncture/clear windpipe ............................................................... 1 $1,425.30 $333.00 ......... $66.60 

31613 ....... Repair windpipe opening .............................................................. 2 $1,425.30 $446.00 ......... $89.20 

31614 ....... Repair windpipe opening .............................................................. 2 $2,324.90 $446.00 ......... $89.20 

31615 ....... Visualization of windpipe .............................................................. 1 $577.99 $333.00 ......... $66.60 

31622 ....... Dx bronchoscope/wash ................................................................ 1 $577.99 $333.00 ......... $66.60 

31623 ....... Dx bronchoscope/brush ................................................................ 2 $577.99 $446.00 ......... $89.20 

31624 ....... Dx bronchoscope/lavage .............................................................. 2 $577.99 $446.00 ......... $89.20 

31625 ....... Bronchoscopy w/biopsy(s) ............................................................ 2 $577.99 $446.00 ......... $89.20 

31628 ....... Bronchoscopy/lung bx, each ........................................................ 2 $577.99 $446.00 ......... $89.20

31629 ....... Bronchoscopy/needle bx, each .................................................... 2 $577.99 $446.00 ......... $89.20 

31630 ....... Bronchoscopy dilate/fx repr .......................................................... 2 $1,346.75 $446.00 ......... $89.20 

31631 ....... Bronchoscopy, dilate w/stent ........................................................ 2 $1,346.75 $446.00 ......... $89.20 

31635 ....... Bronchoscopy w/fb removal ......................................................... 2 $577.99 $446.00 ......... $89.20

31636 ....... Bronchoscopy, bronch stents ....................................................... 2 $1,346.75 $446.00 ......... $89.20 

31637 ....... Bronchoscopy, stent add-on ......................................................... 1 $577.99 $333.00 ......... $66.60 

31638 ....... Bronchoscopy, revise stent .......................................................... 2 $1,346.75 $446.00 ......... $89.20 

31640 ....... Bronchoscopy w/tumor excise ...................................................... 2 $1,346.75 $446.00 ......... $89.20 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49737 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

31641 ....... Bronchoscopy, treat blockage ...................................................... 2 $1,346.75 $446.00 ......... $89.20 

31643 ....... Diag bronchoscope/catheter ......................................................... 2 $577.99 $446.00 ......... $89.20 

31645 ....... Bronchoscopy, clear airways ........................................................ 1 $577.99 $333.00 ......... $66.60 

31646 ....... Bronchoscopy, reclear airway ...................................................... 1 $577.99 $333.00 ......... $66.60

31656 ....... Bronchoscopy, inj for x-ray ........................................................... 1 $577.99 $333.00 ......... $66.60 

31700 ....... Insertion of airway catheter .......................................................... 1 $86.41 $86.41 Y ..... $17.28 

31717 ....... Bronchial brush biopsy ................................................................. 1 $238.43 $238.43 Y ..... $47.69 

31720 ....... Clearance of airways .................................................................... 1 $46.61 $46.61 Y ..... $9.32

31730 ....... Intro, windpipe wire/tube ............................................................... 1 $238.43 $238.43 Y ..... $47.69 

31750 ....... Repair of windpipe ........................................................................ 5 $2,324.90 $717.00 ......... $143.40 

31755 ....... Repair of windpipe ........................................................................ 2 $2,324.90 $446.00 ......... $89.20 

31820 ....... Closure of windpipe lesion ........................................................... 1 $1,012.48 $333.00 ......... $66.60 

31825 ....... Repair of windpipe defect ............................................................. 2 $1,425.30 $446.00 ......... $89.20 

31830 ....... Revise windpipe scar .................................................................... 2 $1,425.30 $446.00 ......... $89.20 

32000 ....... Drainage of chest ......................................................................... 1 $224.20 $224.20 Y ..... $44.84 

32400 ....... Needle biopsy chest lining ............................................................ 1 $373.79 $333.00 ......... $66.60 

32405 ....... Biopsy, lung or mediastinum ........................................................ 1 $373.79 $333.00 ......... $66.60 

32420 ....... Puncture/clear lung ....................................................................... 1 $224.20 $224.20 Y ..... $44.84 

33010 ....... Drainage of heart sac ................................................................... 2 $224.20 $224.20 Y ..... $44.84 

33011 ....... Repeat drainage of heart sac ....................................................... 2 $224.20 $224.20 Y ..... $44.84 

33212 ....... Insertion of pulse generator .......................................................... 3 $6,021.89 $510.00 ......... $102.00 

33213 ....... Insertion of pulse generator .......................................................... 3 $6,908.16 $510.00 ......... $102.00 

33222 ....... Revise pocket, pacemaker ........................................................... 2 $1,308.85 $446.00 ......... $89.20 

33223 ....... Revise pocket, pacing-defib ......................................................... 2 $1,308.85 $446.00 ......... $89.20 

33233 ....... Removal of pacemaker system .................................................... 2 $1,444.39 $446.00 ......... $89.20 

35188 ....... Repair blood vessel lesion ........................................................... 4 $2,336.80 $630.00 ......... $126.00 

35207 ....... Repair blood vessel lesion ........................................................... 4 $2,336.80 $630.00 ......... $126.00 

35476 ....... Repair venous blockage ............................................................... 9 $2,639.89 $1,339.00 ......... $267.80 

35875 ....... Removal of clot in graft ................................................................ 9 $2,336.80 $1,339.00 ......... $267.80 

35876 ....... Removal of clot in graft ................................................................ 9 $2,336.80 $1,339.00 ......... $267.80 

36260 ....... Insertion of infusion pump ............................................................ 3 $1,752.02 $510.00 ......... $102.00 

36261 ....... Revision of infusion pump ............................................................ 2 $1,752.02 $446.00 ......... $89.20 

36262 ....... Removal of infusion pump ............................................................ 1 $1,397.11 $333.00 ......... $66.60 

36475 ....... Endovenous rf, 1st vein ................................................................ 8 $2,131.38 $973.00 ......... $194.60 

36476 ....... Endovenous rf, vein add-on ......................................................... 8 $2,131.38 $973.00 ......... $194.60 

36478 ....... Endovenous laser, 1st vein .......................................................... 8 $1,513.03 $973.00 ......... $194.60 

36479 ....... Endovenous laser vein addon ...................................................... 8 $1,513.03 $973.00 ......... $194.60 

36555 ....... Insert non-tunnel cv cath .............................................................. 1 $540.67 $333.00 ......... $66.60 

36556 ....... Insert non-tunnel cv cath .............................................................. 1 $540.67 $333.00 ......... $66.60 

36557 ....... Insert tunneled cv cath ................................................................. 2 $1,397.11 $446.00 ......... $89.20 

36558 ....... Insert tunneled cv cath ................................................................. 2 $1,397.11 $446.00 ......... $89.20 

36560 ....... Insert tunneled cv cath ................................................................. 3 $1,752.02 $510.00 ......... $102.00 

36561 ....... Insert tunneled cv cath ................................................................. 3 $1,752.02 $510.00 ......... $102.00 

36563 ....... Insert tunneled cv cath ................................................................. 3 $1,752.02 $510.00 ......... $102.00 

36565 ....... Insert tunneled cv cath ................................................................. 3 $1,752.02 $510.00 ......... $102.00 

36566 ....... Insert tunneled cv cath ................................................................. 3 $1,752.02 $510.00 ......... $102.00 

36568 ....... Insert picc cath ............................................................................. 1 $540.67 $333.00 ......... $66.60 

36569 ....... Insert picc cath ............................................................................. 1 $540.67 $333.00 ......... $66.60 

36570 ....... Insert picvad cath ......................................................................... 3 $1,397.11 $510.00 ......... $102.00 

36571 ....... Insert picvad cath ......................................................................... 3 $1,397.11 $510.00 ......... $102.00 

36575 ....... Repair tunneled cv cath ................................................................ 2 $540.67 $446.00 ......... $89.20 

36576 ....... Repair tunneled cv cath ................................................................ 2 $540.67 $446.00 ......... $89.20 

36578 ....... Replace tunneled cv cath ............................................................. 2 $1,397.11 $446.00 ......... $89.20 

36580 ....... Replace cvad cath ........................................................................ 1 $540.67 $333.00 ......... $66.60 

36581 ....... Replace tunneled cv cath ............................................................. 2 $1,397.11 $446.00 ......... $89.20 

36582 ....... Replace tunneled cv cath ............................................................. 3 $1,752.02 $510.00 ......... $102.00 

36583 ....... Replace tunneled cv cath ............................................................. 3 $1,752.02 $510.00 ......... $102.00 

36584 ....... Replace picc cath ......................................................................... 1 $540.67 $333.00 ......... $66.60 

36585 ....... Replace picvad cath ..................................................................... 3 $1,397.11 $510.00 ......... $102.00 

36589 ....... Removal tunneled cv cath ............................................................ 1 $540.67 $333.00 ......... $66.60 

36590 ....... Removal tunneled cv cath ............................................................ 1 $540.67 $333.00 ......... $66.60 

36640 ....... Insertion catheter, artery ............................................................... 1 $1,752.02 $333.00 ......... $66.60 

36800 ....... Insertion of cannula ...................................................................... 3 $1,814.26 $510.00 ......... $102.00 

36810 ....... Insertion of cannula ...................................................................... 3 $1,814.26 $510.00 ......... $102.00 

36815 ....... Insertion of cannula ...................................................................... 3 $1,814.26 $510.00 ......... $102.00 

36818 ....... AV fuse, upper arm, cephalic ....................................................... 3 $2,336.80 $510.00 ......... $102.00 

36819 ....... Av fuse, uppr arm, basilic ............................................................. 3 $2,336.80 $510.00 ......... $102.00 

36820 ....... Av fusion/forearm vein .................................................................. 3 $2,336.80 $510.00 ......... $102.00 

36821 ....... Av fusion direct any site ............................................................... 3 $2,336.80 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
49738 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

36825 ....... Artery-vein autograft ..................................................................... 4 $2,336.80 $630.00 ......... $126.00 

36830 ....... Artery-vein nonautograft ............................................................... 4 $2,336.80 $630.00 ......... $126.00 

36831 ....... Open thrombect av fistula ............................................................ 9 $2,336.80 $1,339.00 ......... $267.80 

36832 ....... Av fistula revision, open ............................................................... 4 $2,336.80 $630.00 ......... $126.00 

36833 ....... Av fistula revision .......................................................................... 4 $2,336.80 $630.00 ......... $126.00 

36834 ....... Repair a-v aneurysm .................................................................... 3 $2,336.80 $510.00 ......... $102.00 

36835 ....... Artery to vein shunt ...................................................................... 4 $1,814.26 $630.00 ......... $126.00 

36860 ....... External cannula declotting .......................................................... 2 $126.87 $126.87 Y ..... $25.37

36861 ....... Cannula declotting ........................................................................ 3 $1,814.26 $510.00 ......... $102.00 

36870 ....... Percut thrombect av fistula ........................................................... 9 $1,908.11 $1,339.00 ......... $267.80 

37205 ....... Transcath IV stent, percutan ........................................................ 9 $4,067.31 $1,339.00 ......... $267.80 

37206 ....... Transcath IV stent/perc, add ........................................................ 1 $4,067.31 $333.00 ......... $66.60 

37500 ....... Endoscopy ligate perf veins ......................................................... 3 $2,131.38 $510.00 ......... $102.00 

37607 ....... Ligation of a-v fistula .................................................................... 3 $1,513.03 $510.00 ......... $102.00 

37609 ....... Temporal artery procedure ........................................................... 2 $920.58 $446.00 ......... $89.20 

37650 ....... Revision of major vein .................................................................. 2 $1,513.03 $446.00 ......... $89.20 

37700 ....... Revise leg vein ............................................................................. 2 $2,131.38 $446.00 ......... $89.20 

37718 ....... Ligate/strip short leg vein ............................................................. 3 $2,131.38 $510.00 ......... $102.00 

37722 ....... Ligate/strip long leg vein ............................................................... 3 $2,131.38 $510.00 ......... $102.00 

37735 ....... Removal of leg veins/lesion .......................................................... 3 $2,131.38 $510.00 ......... $102.00 

37760 ....... Ligation, leg veins, open ............................................................... 3 $1,513.03 $510.00 ......... $102.00 

37780 ....... Revision of leg vein ...................................................................... 3 $1,513.03 $510.00 ......... $102.00 

37785 ....... Ligate/divide/excise vein ............................................................... 3 $1,513.03 $510.00 ......... $102.00 

37790 ....... Penile venous occlusion ............................................................... 3 $2,031.13 $510.00 ......... $102.00 

38300 ....... Drainage, lymph node lesion ........................................................ 1 $672.04 $333.00 ......... $66.60 

38305 ....... Drainage, lymph node lesion ........................................................ 2 $1,075.21 $446.00 ......... $89.20 

38308 ....... Incision of lymph channels ........................................................... 2 $1,315.18 $446.00 ......... $89.20 

38500 ....... Biopsy/removal, lymph nodes ....................................................... 2 $1,315.18 $446.00 ......... $89.20 

38505 ....... Needle biopsy, lymph nodes ........................................................ 1 $234.21 $234.21 Y ..... $46.84 

38510 ....... Biopsy/removal, lymph nodes ....................................................... 2 $1,315.18 $446.00 ......... $89.20 

38520 ....... Biopsy/removal, lymph nodes ....................................................... 2 $1,315.18 $446.00 ......... $89.20 

38525 ....... Biopsy/removal, lymph nodes ....................................................... 2 $1,315.18 $446.00 ......... $89.20 

38530 ....... Biopsy/removal, lymph nodes ....................................................... 2 $1,315.18 $446.00 ......... $89.20 

38542 ....... Explore deep node(s), neck ......................................................... 2 $2,285.28 $446.00 ......... $89.20 

38550 ....... Removal, neck/armpit lesion ........................................................ 3 $1,315.18 $510.00 ......... $102.00 

38555 ....... Removal, neck/armpit lesion ........................................................ 4 $1,315.18 $630.00 ......... $126.00 

38570 ....... Laparoscopy, lymph node biop .................................................... 9 $2,678.23 $1,339.00 ......... $267.80 

38571 ....... Laparoscopy, lymphadenectomy .................................................. 9 $4,363.07 $1,339.00 ......... $267.80 

38572 ....... Laparoscopy, lymphadenectomy .................................................. 9 $2,678.23 $1,339.00 ......... $267.80 

38740 ....... Remove armpit lymph nodes ........................................................ 2 $2,285.28 $446.00 ......... $89.20 

38745 ....... Remove armpit lymph nodes ........................................................ 4 $2,285.28 $630.00 ......... $126.00 

38760 ....... Remove groin lymph nodes .......................................................... 2 $1,315.18 $446.00 ......... $89.20 

40500 ....... Partial excision of lip ..................................................................... 2 $1,012.48 $446.00 ......... $89.20 

40510 ....... Partial excision of lip ..................................................................... 2 $1,425.30 $446.00 ......... $89.20 

40520 ....... Partial excision of lip ..................................................................... 2 $1,012.48 $446.00 ......... $89.20 

40525 ....... Reconstruct lip with flap ............................................................... 2 $1,425.30 $446.00 ......... $89.20 

40527 ....... Reconstruct lip with flap ............................................................... 2 $1,425.30 $446.00 ......... $89.20 

40530 ....... Partial removal of lip ..................................................................... 2 $1,425.30 $446.00 ......... $89.20 

40650 ....... Repair lip ....................................................................................... 3 $475.55 $475.55 Y ..... $95.11 

40652 ....... Repair lip ....................................................................................... 3 $475.55 $475.55 Y ..... $95.11 

40654 ....... Repair lip ....................................................................................... 3 $475.55 $475.55 Y ..... $95.11 

40700 ....... Repair cleft lip/nasal ..................................................................... 7 $2,324.90 $995.00 ......... $199.00 

40701 ....... Repair cleft lip/nasal ..................................................................... 7 $2,324.90 $995.00 ......... $199.00 

40720 ....... Repair cleft lip/nasal ..................................................................... 7 $2,324.90 $995.00 ......... $199.00 

40761 ....... Repair cleft lip/nasal ..................................................................... 3 $2,324.90 $510.00 ......... $102.00 

40801 ....... Drainage of mouth lesion ............................................................. 2 $475.55 $446.00 ......... $89.20 

40814 ....... Excise/repair mouth lesion ........................................................... 2 $1,012.48 $446.00 ......... $89.20 

40816 ....... Excision of mouth lesion ............................................................... 2 $1,425.30 $446.00 ......... $89.20 

40818 ....... Excise oral mucosa for graft ......................................................... 1 $146.29 $146.29 Y ..... $29.26

40819 ....... Excise lip or cheek fold ................................................................ 1 $475.55 $333.00 ......... $66.60 

40831 ....... Repair mouth laceration ............................................................... 1 $475.55 $333.00 ......... $66.60 

40840 ....... Reconstruction of mouth ............................................................... 2 $1,425.30 $446.00 ......... $89.20 

40842 ....... Reconstruction of mouth ............................................................... 3 $1,425.30 $510.00 ......... $102.00 

40843 ....... Reconstruction of mouth ............................................................... 3 $1,425.30 $510.00 ......... $102.00 

40844 ....... Reconstruction of mouth ............................................................... 5 $2,324.90 $717.00 ......... $143.40 

40845 ....... Reconstruction of mouth ............................................................... 5 $2,324.90 $717.00 ......... $143.40 

41005 ....... Drainage of mouth lesion ............................................................. 1 $146.29 $146.29 Y ..... $29.26

41006 ....... Drainage of mouth lesion ............................................................. 1 $1,425.30 $333.00 ......... $66.60 

41007 ....... Drainage of mouth lesion ............................................................. 1 $1,012.48 $333.00 ......... $66.60 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49739 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

41008 ....... Drainage of mouth lesion ............................................................. 1 $1,012.48 $333.00 ......... $66.60 

41009 ....... Drainage of mouth lesion ............................................................. 1 $146.29 $146.29 Y ..... $29.26

41010 ....... Incision of tongue fold .................................................................. 1 $475.55 $333.00 ......... $66.60 

41015 ....... Drainage of mouth lesion ............................................................. 1 $146.29 $146.29 Y ..... $29.26

41016 ....... Drainage of mouth lesion ............................................................. 1 $475.55 $333.00 ......... $66.60 

41017 ....... Drainage of mouth lesion ............................................................. 1 $475.55 $333.00 ......... $66.60 

41018 ....... Drainage of mouth lesion ............................................................. 1 $475.55 $333.00 ......... $66.60 

41112 ....... Excision of tongue lesion .............................................................. 2 $1,012.48 $446.00 ......... $89.20 

41113 ....... Excision of tongue lesion .............................................................. 2 $1,012.48 $446.00 ......... $89.20 

41114 ....... Excision of tongue lesion .............................................................. 2 $1,425.30 $446.00 ......... $89.20 

41116 ....... Excision of mouth lesion ............................................................... 1 $1,012.48 $333.00 ......... $66.60 

41120 ....... Partial removal of tongue ............................................................. 5 $1,425.30 $717.00 ......... $143.40 

41250 ....... Repair tongue laceration .............................................................. 2 $146.29 $146.29 Y ..... $29.26 

41251 ....... Repair tongue laceration .............................................................. 2 $146.29 $146.29 Y ..... $29.26 

41252 ....... Repair tongue laceration .............................................................. 2 $475.55 $446.00 ......... $89.20 

41500 ....... Fixation of tongue ......................................................................... 1 $1,425.30 $333.00 ......... $66.60 

41510 ....... Tongue to lip surgery .................................................................... 1 $1,012.48 $333.00 ......... $66.60 

41520 ....... Reconstruction, tongue fold .......................................................... 2 $475.55 $446.00 ......... $89.20 

41800 ....... Drainage of gum lesion ................................................................ 1 $91.22 $91.22 Y ..... $18.24 

41827 ....... Excision of gum lesion .................................................................. 2 $1,425.30 $446.00 ......... $89.20 

42000 ....... Drainage mouth roof lesion .......................................................... 2 $146.29 $146.29 Y ..... $29.26 

42107 ....... Excision lesion, mouth roof .......................................................... 2 $1,425.30 $446.00 ......... $89.20 

42120 ....... Remove palate/lesion ................................................................... 4 $2,324.90 $630.00 ......... $126.00 

42140 ....... Excision of uvula ........................................................................... 2 $475.55 $446.00 ......... $89.20 

42145 ....... Repair palate, pharynx/uvula ........................................................ 5 $1,425.30 $717.00 ......... $143.40 

42180 ....... Repair palate ................................................................................ 1 $146.29 $146.29 Y ..... $29.26 

42182 ....... Repair palate ................................................................................ 2 $2,324.90 $446.00 ......... $89.20 

42200 ....... Reconstruct cleft palate ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

42205 ....... Reconstruct cleft palate ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

42210 ....... Reconstruct cleft palate ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

42215 ....... Reconstruct cleft palate ................................................................ 7 $2,324.90 $995.00 ......... $199.00 

42220 ....... Reconstruct cleft palate ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

42226 ....... Lengthening of palate ................................................................... 5 $2,324.90 $717.00 ......... $143.40 

42235 ....... Repair palate ................................................................................ 5 $1,012.48 $717.00 ......... $143.40 

42260 ....... Repair nose to lip fistula ............................................................... 4 $1,425.30 $630.00 ......... $126.00 

42300 ....... Drainage of salivary gland ............................................................ 1 $1,012.48 $333.00 ......... $66.60 

42305 ....... Drainage of salivary gland ............................................................ 2 $1,012.48 $446.00 ......... $89.20 

42310 ....... Drainage of salivary gland ............................................................ 1 $146.29 $146.29 Y ..... $29.26 

42320 ....... Drainage of salivary gland ............................................................ 1 $146.29 $146.29 Y ..... $29.26 

42340 ....... Removal of salivary stone ............................................................ 2 $1,012.48 $446.00 ......... $89.20 

42405 ....... Biopsy of salivary gland ................................................................ 2 $1,012.48 $446.00 ......... $89.20 

42408 ....... Excision of salivary cyst ............................................................... 3 $1,012.48 $510.00 ......... $102.00 

42409 ....... Drainage of salivary cyst .............................................................. 3 $1,012.48 $510.00 ......... $102.00 

42410 ....... Excise parotid gland/lesion ........................................................... 3 $2,324.90 $510.00 ......... $102.00 

42415 ....... Excise parotid gland/lesion ........................................................... 7 $2,324.90 $995.00 ......... $199.00 

42420 ....... Excise parotid gland/lesion ........................................................... 7 $2,324.90 $995.00 ......... $199.00 

42425 ....... Excise parotid gland/lesion ........................................................... 7 $2,324.90 $995.00 ......... $199.00 

42440 ....... Excise submaxillary gland ............................................................ 3 $2,324.90 $510.00 ......... $102.00 

42450 ....... Excise sublingual gland ................................................................ 2 $1,425.30 $446.00 ......... $89.20 

42500 ....... Repair salivary duct ...................................................................... 3 $1,425.30 $510.00 ......... $102.00 

42505 ....... Repair salivary duct ...................................................................... 4 $2,324.90 $630.00 ......... $126.00 

42507 ....... Parotid duct diversion ................................................................... 3 $2,324.90 $510.00 ......... $102.00 

42508 ....... Parotid duct diversion ................................................................... 4 $2,324.90 $630.00 ......... $126.00 

42509 ....... Parotid duct diversion ................................................................... 4 $2,324.90 $630.00 ......... $126.00 

42510 ....... Parotid duct diversion ................................................................... 4 $2,324.90 $630.00 ......... $126.00 

42600 ....... Closure of salivary fistula ............................................................. 1 $1,012.48 $333.00 ......... $66.60 

42665 ....... Ligation of salivary duct ................................................................ 7 $1,425.30 $995.00 ......... $199.00 

42700 ....... Drainage of tonsil abscess ........................................................... 1 $146.29 $146.29 Y ..... $29.26

42720 ....... Drainage of throat abscess .......................................................... 1 $1,012.48 $333.00 ......... $66.60 

42725 ....... Drainage of throat abscess .......................................................... 2 $2,324.90 $446.00 ......... $89.20 

42802 ....... Biopsy of throat ............................................................................. 1 $1,012.48 $333.00 ......... $66.60 

42804 ....... Biopsy of upper nose/throat ......................................................... 1 $1,012.48 $333.00 ......... $66.60 

42806 ....... Biopsy of upper nose/throat ......................................................... 2 $1,425.30 $446.00 ......... $89.20 

42808 ....... Excise pharynx lesion ................................................................... 2 $1,012.48 $446.00 ......... $89.20 

42810 ....... Excision of neck cyst .................................................................... 3 $1,425.30 $510.00 ......... $102.00 

42815 ....... Excision of neck cyst .................................................................... 5 $2,324.90 $717.00 ......... $143.40 

42820 ....... Remove tonsils and adenoids ...................................................... 3 $1,401.87 $510.00 ......... $102.00 

42821 ....... Remove tonsils and adenoids ...................................................... 5 $1,401.87 $717.00 ......... $143.40 

42825 ....... Removal of tonsils ........................................................................ 4 $1,401.87 $630.00 ......... $126.00 


sroberts on PROD1PC70 with PROPOSALS
49740 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

42826 ....... Removal of tonsils ........................................................................ 4 $1,401.87 $630.00 ......... $126.00 

42830 ....... Removal of adenoids .................................................................... 4 $1,401.87 $630.00 ......... $126.00 

42831 ....... Removal of adenoids .................................................................... 4 $1,401.87 $630.00 ......... $126.00 

42835 ....... Removal of adenoids .................................................................... 4 $1,401.87 $630.00 ......... $126.00 

42836 ....... Removal of adenoids .................................................................... 4 $1,401.87 $630.00 ......... $126.00 

42860 ....... Excision of tonsil tags ................................................................... 3 $1,401.87 $510.00 ......... $102.00 

42870 ....... Excision of lingual tonsil ............................................................... 3 $1,401.87 $510.00 ......... $102.00 

42890 ....... Partial removal of pharynx ............................................................ 7 $2,324.90 $995.00 ......... $199.00 

42892 ....... Revision of pharyngeal walls ........................................................ 7 $2,324.90 $995.00 ......... $199.00 

42900 ....... Repair throat wound ..................................................................... 1 $475.55 $333.00 ......... $66.60 

42950 ....... Reconstruction of throat ............................................................... 2 $1,425.30 $446.00 ......... $89.20 

42955 ....... Surgical opening of throat ............................................................ 2 $1,425.30 $446.00 ......... $89.20 

42960 ....... Control throat bleeding ................................................................. 1 $73.99 $73.99 Y ..... $14.80 

42962 ....... Control throat bleeding ................................................................. 2 $2,324.90 $446.00 ......... $89.20 

42972 ....... Control nose/throat bleeding ........................................................ 3 $1,012.48 $510.00 ......... $102.00 

43200 ....... Esophagus endoscopy ................................................................. 1 $511.30 $333.00 ......... $66.60 

43201 ....... Esoph scope w/submucous inj ..................................................... 1 $511.30 $333.00 ......... $66.60 

43202 ....... Esophagus endoscopy, biopsy ..................................................... 1 $511.30 $333.00 ......... $66.60 

43204 ....... Esoph scope w/sclerosis inj ......................................................... 1 $511.30 $333.00 ......... $66.60 

43205 ....... Esophagus endoscopy/ligation ..................................................... 1 $511.30 $333.00 ......... $66.60 

43215 ....... Esophagus endoscopy ................................................................. 1 $511.30 $333.00 ......... $66.60 

43216 ....... Esophagus endoscopy/lesion ....................................................... 1 $511.30 $333.00 ......... $66.60 

43217 ....... Esophagus endoscopy ................................................................. 1 $511.30 $333.00 ......... $66.60 

43219 ....... Esophagus endoscopy ................................................................. 1 $1,395.84 $333.00 ......... $66.60 

43220 ....... Esoph endoscopy, dilation ............................................................ 1 $511.30 $333.00 ......... $66.60 

43226 ....... Esoph endoscopy, dilation ............................................................ 1 $511.30 $333.00 ......... $66.60 

43227 ....... Esoph endoscopy, repair .............................................................. 2 $511.30 $446.00 ......... $89.20 

43228 ....... Esoph endoscopy, ablation .......................................................... 2 $1,695.69 $446.00 ......... $89.20 

43231 ....... Esoph endoscopy w/us exam ....................................................... 2 $511.30 $446.00 ......... $89.20 

43232 ....... Esoph endoscopy w/us fn bx ....................................................... 2 $511.30 $446.00 ......... $89.20 

43234 ....... Upper gi endoscopy, exam ........................................................... 1 $511.30 $333.00 ......... $66.60 

43235 ....... Uppr gi endoscopy, diagnosis ...................................................... 1 $511.30 $333.00 ......... $66.60

43236 ....... Uppr gi scope w/submuc inj ......................................................... 2 $511.30 $446.00 ......... $89.20 

43237 ....... Endoscopic us exam, esoph ........................................................ 2 $511.30 $446.00 ......... $89.20 

43238 ....... Uppr gi endoscopy w/us fn bx ...................................................... 2 $511.30 $446.00 ......... $89.20

43239 ....... Upper gi endoscopy, biopsy ......................................................... 2 $511.30 $446.00 ......... $89.20 

43240 ....... Esoph endoscope w/drain cyst ..................................................... 2 $511.30 $446.00 ......... $89.20 

43241 ....... Upper gi endoscopy with tube ...................................................... 2 $511.30 $446.00 ......... $89.20

43242 ....... Uppr gi endoscopy w/us fn bx ...................................................... 2 $511.30 $446.00 ......... $89.20

43243 ....... Upper gi endoscopy & inject ........................................................ 2 $511.30 $446.00 ......... $89.20 

43244 ....... Upper gi endoscopy/ligation ......................................................... 2 $511.30 $446.00 ......... $89.20 

43245 ....... Uppr gi scope dilate strictr ............................................................ 2 $511.30 $446.00 ......... $89.20 

43246 ....... Place gastrostomy tube ................................................................ 2 $511.30 $446.00 ......... $89.20 

43247 ....... Operative upper gi endoscopy ..................................................... 2 $511.30 $446.00 ......... $89.20 

43248 ....... Uppr gi endoscopy/guide wire ...................................................... 2 $511.30 $446.00 ......... $89.20

43249 ....... Esoph endoscopy, dilation ............................................................ 2 $511.30 $446.00 ......... $89.20 

43250 ....... Upper gi endoscopy/tumor ........................................................... 2 $511.30 $446.00 ......... $89.20 

43251 ....... Operative upper gi endoscopy ..................................................... 2 $511.30 $446.00 ......... $89.20 

43255 ....... Operative upper gi endoscopy ..................................................... 2 $511.30 $446.00 ......... $89.20 

43256 ....... Uppr gi endoscopy w/stent ........................................................... 3 $1,395.84 $510.00 ......... $102.00 

43258 ....... Operative upper gi endoscopy ..................................................... 3 $511.30 $510.00 ......... $102.00

43259 ....... Endoscopic ultrasound exam ....................................................... 3 $511.30 $510.00 ......... $102.00

43260 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43261 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43262 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43263 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43264 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43265 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43267 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43268 ....... Endo cholangiopancreatograph .................................................... 2 $1,395.84 $446.00 ......... $89.20

43269 ....... Endo cholangiopancreatograph .................................................... 2 $1,395.84 $446.00 ......... $89.20

43271 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43272 ....... Endo cholangiopancreatograph .................................................... 2 $1,219.48 $446.00 ......... $89.20

43450 ....... Dilate esophagus .......................................................................... 1 $327.05 $327.05 Y ..... $65.41 

43453 ....... Dilate esophagus .......................................................................... 1 $327.05 $327.05 Y ..... $65.41 

43456 ....... Dilate esophagus .......................................................................... 2 $327.05 $327.05 Y ..... $65.41 

43458 ....... Dilate esophagus .......................................................................... 2 $327.05 $327.05 Y ..... $65.41 

43600 ....... Biopsy of stomach ........................................................................ 1 $511.30 $333.00 ......... $66.60 

43653 ....... Laparoscopy, gastrostomy ............................................................ 9 $2,678.23 $1,339.00 ......... $267.80 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49741 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

43750 ....... Place gastrostomy tube ................................................................ 2 $511.30 $446.00 ......... $89.20 

43760 ....... Change gastrostomy tube ............................................................ 1 $144.22 $144.22 Y ..... $28.84 

43761 ....... Reposition gastrostomy tube ........................................................ 1 $448.45 $333.00 ......... $66.60 

43870 ....... Repair stomach opening ............................................................... 1 $511.30 $333.00 ......... $66.60 

44100 ....... Biopsy of bowel ............................................................................ 1 $511.30 $333.00 ......... $66.60 

44312 ....... Revision of ileostomy .................................................................... 1 $1,308.85 $333.00 ......... $66.60 

44340 ....... Revision of colostomy ................................................................... 3 $1,308.85 $510.00 ......... $102.00 

44360 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44361 ....... Small bowel endoscopy/biopsy .................................................... 2 $577.83 $446.00 ......... $89.20 

44363 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44364 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44365 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44366 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44369 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44370 ....... Small bowel endoscopy/stent ....................................................... 9 $1,395.84 $1,339.00 ......... $267.80 

44372 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44373 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44376 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44377 ....... Small bowel endoscopy/biopsy .................................................... 2 $577.83 $446.00 ......... $89.20 

44378 ....... Small bowel endoscopy ................................................................ 2 $577.83 $446.00 ......... $89.20 

44379 ....... Sbowel endoscope w/stent ........................................................... 9 $1,395.84 $1,339.00 ......... $267.80 

44380 ....... Small bowel endoscopy ................................................................ 1 $577.83 $333.00 ......... $66.60 

44382 ....... Small bowel endoscopy ................................................................ 1 $577.83 $333.00 ......... $66.60 

44383 ....... Ileoscopy w/stent .......................................................................... 9 $1,395.84 $1,339.00 ......... $267.80 

44385 ....... Endoscopy of bowel pouch .......................................................... 1 $542.53 $333.00 ......... $66.60

44386 ....... Endoscopy, bowel pouch/biop ...................................................... 1 $542.53 $333.00 ......... $66.60 

44388 ....... Colonoscopy ................................................................................. 1 $542.53 $333.00 ......... $66.60 

44389 ....... Colonoscopy with biopsy .............................................................. 1 $542.53 $333.00 ......... $66.60 

44390 ....... Colonoscopy for foreign body ....................................................... 1 $542.53 $333.00 ......... $66.60 

44391 ....... Colonoscopy for bleeding ............................................................. 1 $542.53 $333.00 ......... $66.60 

44392 ....... Colonoscopy & polypectomy ........................................................ 1 $542.53 $333.00 ......... $66.60 

44393 ....... Colonoscopy, lesion removal ........................................................ 1 $542.53 $333.00 ......... $66.60 

44394 ....... Colonoscopy w/snare ................................................................... 1 $542.53 $333.00 ......... $66.60 

44397 ....... Colonoscopy w/stent ..................................................................... 1 $1,395.84 $333.00 ......... $66.60 

45000 ....... Drainage of pelvic abscess .......................................................... 1 $301.42 $301.42 Y ..... $60.28 

45005 ....... Drainage of rectal abscess ........................................................... 2 $792.64 $446.00 ......... $89.20 

45020 ....... Drainage of rectal abscess ........................................................... 2 $792.64 $446.00 ......... $89.20 

45100 ....... Biopsy of rectum ........................................................................... 1 $1,368.50 $333.00 ......... $66.60 

45108 ....... Removal of anorectal lesion ......................................................... 2 $1,368.50 $446.00 ......... $89.20 

45150 ....... Excision of rectal stricture ............................................................ 2 $1,368.50 $446.00 ......... $89.20 

45160 ....... Excision of rectal lesion ................................................................ 2 $1,368.50 $446.00 ......... $89.20 

45170 ....... Excision of rectal lesion ................................................................ 2 $1,368.50 $446.00 ......... $89.20 

45190 ....... Destruction, rectal tumor .............................................................. 9 $1,368.50 $1,339.00 ......... $267.80 

45305 ....... Proctosigmoidoscopy w/bx ........................................................... 1 $527.15 $333.00 ......... $66.60 

45307 ....... Proctosigmoidoscopy fb ................................................................ 1 $1,261.19 $333.00 ......... $66.60 

45308 ....... Proctosigmoidoscopy removal ...................................................... 1 $527.15 $333.00 ......... $66.60 

45309 ....... Proctosigmoidoscopy removal ...................................................... 1 $527.15 $333.00 ......... $66.60 

45315 ....... Proctosigmoidoscopy removal ...................................................... 1 $527.15 $333.00 ......... $66.60 

45317 ....... Proctosigmoidoscopy bleed .......................................................... 1 $527.15 $333.00 ......... $66.60 

45320 ....... Proctosigmoidoscopy ablate ......................................................... 1 $1,261.19 $333.00 ......... $66.60 

45321 ....... Proctosigmoidoscopy volvul ......................................................... 1 $1,261.19 $333.00 ......... $66.60 

45327 ....... Proctosigmoidoscopy w/stent ....................................................... 1 $1,395.84 $333.00 ......... $66.60 

45331 ....... Sigmoidoscopy and biopsy ........................................................... 1 $295.48 $295.48 Y ..... $59.10 

45332 ....... Sigmoidoscopy w/fb removal ........................................................ 1 $295.48 $295.48 Y ..... $59.10 

45333 ....... Sigmoidoscopy & polypectomy ..................................................... 1 $527.15 $333.00 ......... $66.60 

45334 ....... Sigmoidoscopy for bleeding ......................................................... 1 $527.15 $333.00 ......... $66.60 

45335 ....... Sigmoidoscopy w/submuc inj ....................................................... 1 $295.48 $295.48 Y ..... $59.10 

45337 ....... Sigmoidoscopy & decompress ..................................................... 1 $295.48 $295.48 Y ..... $59.10 

45338 ....... Sigmoidoscopy w/tumr remove .................................................... 1 $527.15 $333.00 ......... $66.60 

45339 ....... Sigmoidoscopy w/ablate tumr ....................................................... 1 $527.15 $333.00 ......... $66.60

45340 ....... Sig w/balloon dilation .................................................................... 1 $527.15 $333.00 ......... $66.60 

45341 ....... Sigmoidoscopy w/ultrasound ........................................................ 1 $527.15 $333.00 ......... $66.60

45342 ....... Sigmoidoscopy w/us guide bx ...................................................... 1 $527.15 $333.00 ......... $66.60 

45345 ....... Sigmoidoscopy w/stent ................................................................. 1 $1,395.84 $333.00 ......... $66.60 

45355 ....... Surgical colonoscopy .................................................................... 1 $542.53 $333.00 ......... $66.60 

45378 ....... Diagnostic colonoscopy ................................................................ 2 $542.53 $446.00 ......... $89.20 

45379 ....... Colonoscopy w/fb removal ........................................................... 2 $542.53 $446.00 ......... $89.20 

45380 ....... Colonoscopy and biopsy .............................................................. 2 $542.53 $446.00 ......... $89.20 

45381 ....... Colonoscopy, submucous inj ........................................................ 2 $542.53 $446.00 ......... $89.20


sroberts on PROD1PC70 with PROPOSALS
49742 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

45382 ....... Colonoscopy/control bleeding ....................................................... 2 $542.53 $446.00 ......... $89.20 

45383 ....... Lesion removal colonoscopy ........................................................ 2 $542.53 $446.00 ......... $89.20

45384 ....... Lesion remove colonoscopy ......................................................... 2 $542.53 $446.00 ......... $89.20

45385 ....... Lesion removal colonoscopy ........................................................ 2 $542.53 $446.00 ......... $89.20

45386 ....... Colonoscopy dilate stricture ......................................................... 2 $542.53 $446.00 ......... $89.20 

45387 ....... Colonoscopy w/stent ..................................................................... 1 $1,395.84 $333.00 ......... $66.60 

45391 ....... Colonoscopy w/endoscope us ...................................................... 2 $542.53 $446.00 ......... $89.20 

45392 ....... Colonoscopy w/endoscopic fnb .................................................... 2 $542.53 $446.00 ......... $89.20 

45500 ....... Repair of rectum ........................................................................... 2 $1,368.50 $446.00 ......... $89.20 

45505 ....... Repair of rectum ........................................................................... 2 $1,811.98 $446.00 ......... $89.20 

45560 ....... Repair of rectocele ....................................................................... 2 $1,811.98 $446.00 ......... $89.20 

45900 ....... Reduction of rectal prolapse ......................................................... 1 $301.42 $301.42 Y ..... $60.28

45905 ....... Dilation of anal sphincter .............................................................. 1 $1,368.50 $333.00 ......... $66.60 

45910 ....... Dilation of rectal narrowing ........................................................... 1 $1,368.50 $333.00 ......... $66.60 

45915 ....... Remove rectal obstruction ............................................................ 1 $301.42 $301.42 Y ..... $60.28

45990 ....... Surg dx exam, anorcctal ............................................................... 2 $301.42 $301.42 Y ..... $60.28 

46020 ....... Placement of seton ....................................................................... 3 $1,368.50 $510.00 ......... $102.00 

46030 ....... Removal of rectal marker ............................................................. 1 $301.42 $301.42 Y ..... $60.28

46040 ....... Incision of rectal abscess ............................................................. 3 $1,368.50 $510.00 ......... $102.00 

46045 ....... Incision of rectal abscess ............................................................. 2 $1,368.50 $446.00 ......... $89.20 

46050 ....... Incision of anal abscess ............................................................... 1 $301.42 $301.42 Y ..... $60.28 

46060 ....... Incision of rectal abscess ............................................................. 2 $1,368.50 $446.00 ......... $89.20 

46080 ....... Incision of anal sphincter .............................................................. 3 $1,368.50 $510.00 ......... $102.00 

46200 ....... Removal of anal fissure ................................................................ 2 $1,368.50 $446.00 ......... $89.20 

46210 ....... Removal of anal crypt ................................................................... 2 $1,368.50 $446.00 ......... $89.20 

46211 ....... Removal of anal crypts ................................................................. 2 $1,368.50 $446.00 ......... $89.20 

46220 ....... Removal of anal tag ..................................................................... 1 $1,368.50 $333.00 ......... $66.60 

46230 ....... Removal of anal tags .................................................................... 1 $1,368.50 $333.00 ......... $66.60 

46250 ....... Hemorrhoidectomy ........................................................................ 3 $1,368.50 $510.00 ......... $102.00 

46255 ....... Hemorrhoidectomy ........................................................................ 3 $1,368.50 $510.00 ......... $102.00 

46257 ....... Remove hemorrhoids & fissure .................................................... 3 $1,368.50 $510.00 ......... $102.00 

46258 ....... Remove hemorrhoids & fistula ..................................................... 3 $1,368.50 $510.00 ......... $102.00 

46260 ....... Hemorrhoidectomy ........................................................................ 3 $1,368.50 $510.00 ......... $102.00 

46261 ....... Remove hemorrhoids & fissure .................................................... 4 $1,368.50 $630.00 ......... $126.00 

46262 ....... Remove hemorrhoids & fistula ..................................................... 4 $1,368.50 $630.00 ......... $126.00 

46270 ....... Removal of anal fistula ................................................................. 3 $1,368.50 $510.00 ......... $102.00 

46275 ....... Removal of anal fistula ................................................................. 3 $1,368.50 $510.00 ......... $102.00 

46280 ....... Removal of anal fistula ................................................................. 4 $1,368.50 $630.00 ......... $126.00 

46285 ....... Removal of anal fistula ................................................................. 1 $1,368.50 $333.00 ......... $66.60 

46288 ....... Repair anal fistula ......................................................................... 4 $1,368.50 $630.00 ......... $126.00 

46608 ....... Anoscopy, remove for body .......................................................... 1 $527.15 $333.00 ......... $66.60 

46610 ....... Anoscopy, remove lesion ............................................................. 1 $1,261.19 $333.00 ......... $66.60 

46611 ....... Anoscopy ...................................................................................... 1 $527.15 $333.00 ......... $66.60 

46612 ....... Anoscopy, remove lesions ............................................................ 1 $1,261.19 $333.00 ......... $66.60 

46615 ....... Anoscopy ...................................................................................... 2 $1,261.19 $446.00 ......... $89.20 

46700 ....... Repair of anal stricture ................................................................. 3 $1,368.50 $510.00 ......... $102.00 

46706 ....... Repr of anal fistula w/glue ............................................................ 1 $1,811.98 $333.00 ......... $66.60 

46750 ....... Repair of anal sphincter ............................................................... 3 $2,292.31 $510.00 ......... $102.00 

46753 ....... Reconstruction of anus ................................................................. 3 $1,368.50 $510.00 ......... $102.00 

46754 ....... Removal of suture from anus ....................................................... 2 $1,368.50 $446.00 ......... $89.20 

46760 ....... Repair of anal sphincter ............................................................... 2 $2,292.31 $446.00 ......... $89.20 

46761 ....... Repair of anal sphincter ............................................................... 3 $2,292.31 $510.00 ......... $102.00 

46762 ....... Implant artificial sphincter ............................................................. 7 $2,292.31 $995.00 ......... $199.00 

46917 ....... Laser surgery, anal lesions .......................................................... 1 $1,266.73 $333.00 ......... $66.60 

46922 ....... Excision of anal lesion(s) .............................................................. 1 $1,266.73 $333.00 ......... $66.60 

46924 ....... Destruction, anal lesion(s) ............................................................ 1 $1,266.73 $333.00 ......... $66.60 

46937 ....... Cryotherapy of rectal lesion .......................................................... 2 $1,368.50 $446.00 ......... $89.20 

46938 ....... Cryotherapy of rectal lesion .......................................................... 2 $1,811.98 $446.00 ......... $89.20 

46946 ....... Ligation of hemorrhoids ................................................................ 1 $792.64 $333.00 ......... $66.60 

46947 ....... Hemorrhoidopexy by stapling ....................................................... 7 $1,811.98 $995.00 ......... $199.00 

47000 ....... Needle biopsy of liver ................................................................... 1 $373.79 $333.00 ......... $66.60 

47510 ....... Insert catheter, bile duct ............................................................... 2 $1,197.26 $446.00 ......... $89.20 

47511 ....... Insert bile duct drain ..................................................................... 9 $1,197.26 $1,197.26 Y ..... $239.45 

47525 ....... Change bile duct catheter ............................................................ 1 $709.19 $333.00 ......... $66.60 

47530 ....... Revise/reinsert bile tube ............................................................... 1 $709.19 $333.00 ......... $66.60 

47552 ....... Biliary endoscopy thru skin ........................................................... 2 $1,197.26 $446.00 ......... $89.20 

47553 ....... Biliary endoscopy thru skin ........................................................... 3 $1,197.26 $510.00 ......... $102.00 

47554 ....... Biliary endoscopy thru skin ........................................................... 3 $1,197.26 $510.00 ......... $102.00 

47555 ....... Biliary endoscopy thru skin ........................................................... 3 $1,197.26 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49743 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

47556 ....... Biliary endoscopy thru skin ........................................................... 9 $1,197.26 $1,197.26 Y ..... $239.45 

47560 ....... Laparoscopy w/cholangio ............................................................. 3 $1,965.65 $510.00 ......... $102.00 

47561 ....... Laparo w/cholangio/biopsy ........................................................... 3 $1,965.65 $510.00 ......... $102.00 

47630 ....... Remove bile duct stone ................................................................ 3 $1,197.26 $510.00 ......... $102.00 

48102 ....... Needle biopsy, pancreas .............................................................. 1 $373.79 $333.00 ......... $66.60 

49080 ....... Puncture, peritoneal cavity ........................................................... 2 $224.20 $224.20 Y ..... $44.84 

49081 ....... Removal of abdominal fluid .......................................................... 2 $224.20 $224.20 Y ..... $44.84 

49085 ....... Remove abdomen foreign body ................................................... 2 $1,364.94 $446.00 ......... $89.20 

49180 ....... Biopsy, abdominal mass ............................................................... 1 $373.79 $333.00 ......... $66.60 

49250 ....... Excision of umbilicus .................................................................... 4 $1,364.94 $630.00 ......... $126.00 

49320 ....... Diag laparo separate proc ............................................................ 3 $1,965.65 $510.00 ......... $102.00 

49321 ....... Laparoscopy, biopsy ..................................................................... 4 $1,965.65 $630.00 ......... $126.00 

49322 ....... Laparoscopy, aspiration ................................................................ 4 $1,965.65 $630.00 ......... $126.00 

49419 ....... Insrt abdom cath for chemotx ....................................................... 1 $1,814.26 $333.00 ......... $66.60 

49420 ....... Insert abdom drain, temp ............................................................. 1 $1,798.88 $333.00 ......... $66.60 

49421 ....... Insert abdom drain, perm ............................................................. 1 $1,798.88 $333.00 ......... $66.60 

49422 ....... Remove perm cannula/catheter ................................................... 1 $1,444.39 $333.00 ......... $66.60 

49426 ....... Revise abdomen-venous shunt .................................................... 2 $1,364.94 $446.00 ......... $89.20 

49495 ....... Rpr ing hernia baby, reduc ........................................................... 4 $1,794.16 $630.00 ......... $126.00 

49496 ....... Rpr ing hernia baby, blocked ....................................................... 4 $1,794.16 $630.00 ......... $126.00 

49500 ....... Rpr ing hernia, init, reduce ........................................................... 4 $1,794.16 $630.00 ......... $126.00 

49501 ....... Rpr ing hernia, init blocked ........................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49505 ....... Prp i/hern init reduc > 5 yr ........................................................... 4 $1,794.16 $630.00 ......... $126.00 

49507 ....... Prp i/hern init block > 5 yr ............................................................ 9 $1,794.16 $1,339.00 ......... $267.80 

49520 ....... Rerepair ing hernia, reduce .......................................................... 7 $1,794.16 $995.00 ......... $199.00 

49521 ....... Rerepair ing hernia, blocked ........................................................ 9 $1,794.16 $1,339.00 ......... $267.80 

49525 ....... Repair ing hernia, sliding .............................................................. 4 $1,794.16 $630.00 ......... $126.00 

49540 ....... Repair lumbar hernia .................................................................... 2 $1,794.16 $446.00 ......... $89.20 

49550 ....... Rpr rem hernia, init, reduce .......................................................... 5 $1,794.16 $717.00 ......... $143.40 

49553 ....... Rpr fem hernia, init blocked ......................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49555 ....... Rerepair fem hernia, reduce ......................................................... 5 $1,794.16 $717.00 ......... $143.40 

49557 ....... Rerepair fem hernia, blocked ....................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49560 ....... Rpr ventral hern init, reduc ........................................................... 4 $1,794.16 $630.00 ......... $126.00 

49561 ....... Rpr ventral hern init, block ........................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49565 ....... Rerepair ventrl hern, reduce ......................................................... 4 $1,794.16 $630.00 ......... $126.00 

49566 ....... Rerepair ventrl hern, block ........................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49568 ....... Hernia repair w/mesh ................................................................... 7 $1,794.16 $995.00 ......... $199.00 

49570 ....... Rpr epigastric hern, reduce .......................................................... 4 $1,794.16 $630.00 ......... $126.00 

49572 ....... Rpr epigastric hern, blocked ......................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49580 ....... Rpr umbil hern, reduc < 5 yr ........................................................ 4 $1,794.16 $630.00 ......... $126.00 

49582 ....... Rpr umbil hern, block < 5 yr ......................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49585 ....... Rpr umbil hern, reduc > 5 yr ........................................................ 4 $1,794.16 $630.00 ......... $126.00 

49587 ....... Rpr umbil hern, block > 5 yr ......................................................... 9 $1,794.16 $1,339.00 ......... $267.80 

49590 ....... Repair spigelian hernia ................................................................. 3 $1,794.16 $510.00 ......... $102.00 

49600 ....... Repair umbilical lesion .................................................................. 4 $1,794.16 $630.00 ......... $126.00 

49650 ....... Laparo hernia repair initial ............................................................ 4 $2,678.23 $630.00 ......... $126.00 

49651 ....... Laparo hernia repair recur ............................................................ 7 $2,678.23 $995.00 ......... $199.00 

50200 ....... Biopsy of kidney ........................................................................... 1 $373.79 $333.00 ......... $66.60 

50390 ....... Drainage of kidney lesion ............................................................. 1 $373.79 $333.00 ......... $66.60 

50392 ....... Insert kidney drain ........................................................................ 1 $1,186.49 $333.00 ......... $66.60 

50393 ....... Insert ureteral tube ....................................................................... 1 $1,186.49 $333.00 ......... $66.60 

50395 ....... Create passage to kidney ............................................................. 1 $1,186.49 $333.00 ......... $66.60 

50396 ....... Measure kidney pressure ............................................................. 1 $130.24 $130.24 Y ..... $26.05 

50398 ....... Change kidney tube ...................................................................... 1 $448.45 $333.00 ......... $66.60 

50551 ....... Kidney endoscopy ........................................................................ 1 $414.39 $333.00 ......... $66.60 

50553 ....... Kidney endoscopy ........................................................................ 1 $1,186.49 $333.00 ......... $66.60 

50555 ....... Kidney endoscopy & biopsy ......................................................... 1 $414.39 $333.00 ......... $66.60

50557 ....... Kidney endoscopy & treatment .................................................... 1 $1,468.37 $333.00 ......... $66.60

50561 ....... Kidney endoscopy & treatment .................................................... 1 $1,186.49 $333.00 ......... $66.60

50688 ....... Change of ureter tube/stent .......................................................... 1 $448.45 $333.00 ......... $66.60 

50947 ....... Laparo new ureter/bladder ........................................................... 9 $2,678.23 $1,339.00 ......... $267.80 

50948 ....... Laparo new ureter/bladder ........................................................... 9 $2,678.23 $1,339.00 ......... $267.80 

50951 ....... Endoscopy of ureter ..................................................................... 1 $414.39 $333.00 ......... $66.60 

50953 ....... Endoscopy of ureter ..................................................................... 1 $414.39 $333.00 ......... $66.60 

50955 ....... Ureter endoscopy & biopsy .......................................................... 1 $1,186.49 $333.00 ......... $66.60 

50957 ....... Ureter endoscopy & treatment ..................................................... 1 $1,186.49 $333.00 ......... $66.60 

50961 ....... Ureter endoscopy & treatment ..................................................... 1 $1,186.49 $333.00 ......... $66.60 

50970 ....... Ureter endoscopy ......................................................................... 1 $414.39 $333.00 ......... $66.60 

50972 ....... Ureter endoscopy & catheter ........................................................ 1 $414.39 $333.00 ......... $66.60 


sroberts on PROD1PC70 with PROPOSALS
49744 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

50974 ....... Ureter endoscopy & biopsy .......................................................... 1 $1,186.49 $333.00 ......... $66.60 

50976 ....... Ureter endoscopy & treatment ..................................................... 1 $1,186.49 $333.00 ......... $66.60 

50980 ....... Ureter endoscopy & treatment ..................................................... 1 $1,186.49 $333.00 ......... $66.60 

51010 ....... Drainage of bladder ...................................................................... 1 $1,122.28 $333.00 ......... $66.60 

51020 ....... Incise & treat bladder ................................................................... 4 $1,468.37 $630.00 ......... $126.00 

51030 ....... Incise & treat bladder ................................................................... 4 $1,468.37 $630.00 ......... $126.00 

51040 ....... Incise & drain bladder ................................................................... 4 $1,468.37 $630.00 ......... $126.00 

51045 ....... Incise bladder/drain ureter ............................................................ 4 $414.39 $414.39 Y ..... $82.88 

51050 ....... Removal of bladder stone ............................................................ 4 $1,468.37 $630.00 ......... $126.00 

51065 ....... Remove ureter calculus ................................................................ 4 $1,468.37 $630.00 ......... $126.00 

51080 ....... Drainage of bladder abscess ........................................................ 1 $1,075.21 $333.00 ......... $66.60 

51500 ....... Removal of bladder cyst ............................................................... 4 $1,794.16 $630.00 ......... $126.00 

51520 ....... Removal of bladder lesion ............................................................ 4 $1,468.37 $630.00 ......... $126.00 

51710 ....... Change of bladder tube ................................................................ 1 $448.45 $333.00 ......... $66.60 

51715 ....... Endoscopic injection/implant ........................................................ 3 $1,760.18 $510.00 ......... $102.00 

51726 ....... Complex cystometrogram ............................................................. 1 $219.66 $219.66 Y ..... $43.93 

51772 ....... Urethra pressure profile ................................................................ 1 $130.24 $130.24 Y ..... $26.05 

51785 ....... Anal/urinary muscle study ............................................................ 1 $66.75 $66.75 Y ..... $13.35 

51880 ....... Repair of bladder opening ............................................................ 1 $1,468.37 $333.00 ......... $66.60 

51992 ....... Laparo sling operation .................................................................. 5 $2,678.23 $717.00 ......... $143.40 

52000 ....... Cystoscopy ................................................................................... 1 $414.39 $333.00 ......... $66.60 

52001 ....... Cystoscopy, removal of clots ........................................................ 2 $414.39 $414.39 Y ..... $82.88 

52005 ....... Cystoscopy & ureter catheter ....................................................... 2 $1,186.49 $446.00 ......... $89.20 

52007 ....... Cystoscopy and biopsy ................................................................. 2 $1,186.49 $446.00 ......... $89.20 

52010 ....... Cystoscopy & duct catheter .......................................................... 2 $414.39 $414.39 Y ..... $82.88 

52204 ....... Cystoscopy ................................................................................... 2 $1,186.49 $446.00 ......... $89.20 

52214 ....... Cystoscopy and treatment ............................................................ 2 $1,468.37 $446.00 ......... $89.20 

52224 ....... Cystoscopy and treatment ............................................................ 2 $1,468.37 $446.00 ......... $89.20 

52234 ....... Cystoscopy and treatment ............................................................ 2 $1,468.37 $446.00 ......... $89.20 

52235 ....... Cystoscopy and treatment ............................................................ 3 $1,468.37 $510.00 ......... $102.00 

52240 ....... Cystoscopy and treatment ............................................................ 3 $1,468.37 $510.00 ......... $102.00 

52250 ....... Cystoscopy and radiotracer .......................................................... 4 $1,468.37 $630.00 ......... $126.00 

52260 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52270 ....... Cystoscopy & revise urethra ........................................................ 2 $1,186.49 $446.00 ......... $89.20 

52275 ....... Cystoscopy & revise urethra ........................................................ 2 $1,186.49 $446.00 ......... $89.20 

52276 ....... Cystoscopy and treatment ............................................................ 3 $1,186.49 $510.00 ......... $102.00 

52277 ....... Cystoscopy and treatment ............................................................ 2 $1,468.37 $446.00 ......... $89.20 

52281 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52282 ....... Cystoscopy, implant stent ............................................................. 9 $2,160.59 $1,339.00 ......... $267.80 

52283 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52285 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52290 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52300 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52301 ....... Cystoscopy and treatment ............................................................ 3 $1,186.49 $510.00 ......... $102.00 

52305 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52310 ....... Cystoscopy and treatment ............................................................ 2 $414.39 $414.39 Y ..... $82.88 

52315 ....... Cystoscopy and treatment ............................................................ 2 $1,186.49 $446.00 ......... $89.20 

52317 ....... Remove bladder stone ................................................................. 1 $1,468.37 $333.00 ......... $66.60 

52318 ....... Remove bladder stone ................................................................. 2 $1,468.37 $446.00 ......... $89.20 

52320 ....... Cystoscopy and treatment ............................................................ 5 $1,468.37 $717.00 ......... $143.40 

52325 ....... Cystoscopy, stone removal .......................................................... 4 $1,468.37 $630.00 ......... $126.00 

52327 ....... Cystoscopy, inject material ........................................................... 2 $1,468.37 $446.00 ......... $89.20 

52330 ....... Cystoscopy and treatment ............................................................ 2 $1,468.37 $446.00 ......... $89.20 

52332 ....... Cystoscopy and treatment ............................................................ 2 $1,468.37 $446.00 ......... $89.20 

52334 ....... Create passage to kidney ............................................................. 3 $1,468.37 $510.00 ......... $102.00 

52341 ....... Cysto w/ureter stricture tx ............................................................. 3 $1,468.37 $510.00 ......... $102.00 

52342 ....... Cysto w/up stricture tx .................................................................. 3 $1,468.37 $510.00 ......... $102.00 

52343 ....... Cysto w/renal stricture tx .............................................................. 3 $1,468.37 $510.00 ......... $102.00 

52344 ....... Cysto/uretero, stricture tx ............................................................. 3 $1,468.37 $510.00 ......... $102.00 

52345 ....... Cysto/uretero w/up stricture .......................................................... 3 $1,468.37 $510.00 ......... $102.00 

52346 ....... Cystouretero w/renal strict ............................................................ 3 $1,468.37 $510.00 ......... $102.00 

52351 ....... Cystouretero & or pyeloscope ...................................................... 3 $1,186.49 $510.00 ......... $102.00 

52352 ....... Cystouretero w/stone remove ....................................................... 4 $1,468.37 $630.00 ......... $126.00 

52353 ....... Cystouretero w/lithotripsy ............................................................. 4 $2,160.59 $630.00 ......... $126.00 

52354 ....... Cystouretero w/biopsy .................................................................. 4 $1,468.37 $630.00 ......... $126.00 

52355 ....... Cystouretero w/excise tumor ........................................................ 4 $1,468.37 $630.00 ......... $126.00 

52400 ....... Cystouretero w/congen repr ......................................................... 3 $1,468.37 $510.00 ......... $102.00 

52402 ....... Cystourethro cut ejacul duct ......................................................... 3 $1,468.37 $510.00 ......... $102.00 

52450 ....... Incision of prostate ....................................................................... 3 $1,468.37 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49745 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

52500 ....... Revision of bladder neck .............................................................. 3 $1,468.37 $510.00 ......... $102.00 

52510 ....... Dilation prostatic urethra ............................................................... 3 $1,186.49 $510.00 ......... $102.00 

52601 ....... Prostatectomy (turp) ..................................................................... 4 $2,160.59 $630.00 ......... $126.00 

52606 ....... Control postop bleeding ................................................................ 1 $1,468.37 $333.00 ......... $66.60 

52612 ....... Prostatectomy, first stage ............................................................. 2 $2,160.59 $446.00 ......... $89.20 

52614 ....... Prostatectomy, second stage ....................................................... 1 $2,160.59 $333.00 ......... $66.60 

52620 ....... Remove residual prostate ............................................................. 1 $2,160.59 $333.00 ......... $66.60 

52630 ....... Remove prostate regrowth ........................................................... 2 $2,160.59 $446.00 ......... $89.20 

52640 ....... Relieve bladder contracture .......................................................... 2 $1,468.37 $446.00 ......... $89.20 

52647 ....... Laser surgery of prostate ............................................................. 9 $2,642.55 $1,339.00 ......... $267.80 

52648 ....... Laser surgery of prostate ............................................................. 9 $2,642.55 $1,339.00 ......... $267.80 

52700 ....... Drainage of prostate abscess ....................................................... 2 $1,468.37 $446.00 ......... $89.20 

53000 ....... Incision of urethra ......................................................................... 1 $1,139.54 $333.00 ......... $66.60 

53010 ....... Incision of urethra ......................................................................... 1 $1,139.54 $333.00 ......... $66.60 

53020 ....... Incision of urethra ......................................................................... 1 $1,139.54 $333.00 ......... $66.60 

53040 ....... Drainage of urethra abscess ........................................................ 2 $1,139.54 $446.00 ......... $89.20 

53080 ....... Drainage of urinary leakage ......................................................... 3 $1,139.54 $510.00 ......... $102.00 

53200 ....... Biopsy of urethra .......................................................................... 1 $1,139.54 $333.00 ......... $66.60 

53210 ....... Removal of urethra ....................................................................... 5 $1,760.18 $717.00 ......... $143.40 

53215 ....... Removal of urethra ....................................................................... 5 $1,139.54 $717.00 ......... $143.40 

53220 ....... Treatment of urethra lesion .......................................................... 2 $1,760.18 $446.00 ......... $89.20 

53230 ....... Removal of urethra lesion ............................................................ 2 $1,760.18 $446.00 ......... $89.20 

53235 ....... Removal of urethra lesion ............................................................ 3 $1,139.54 $510.00 ......... $102.00 

53240 ....... Surgery for urethra pouch ............................................................ 2 $1,760.18 $446.00 ......... $89.20 

53250 ....... Removal of urethra gland ............................................................. 2 $1,139.54 $446.00 ......... $89.20 

53260 ....... Treatment of urethra lesion .......................................................... 2 $1,139.54 $446.00 ......... $89.20 

53265 ....... Treatment of urethra lesion .......................................................... 2 $1,139.54 $446.00 ......... $89.20 

53270 ....... Removal of urethra gland ............................................................. 2 $1,139.54 $446.00 ......... $89.20 

53275 ....... Repair of urethra defect ................................................................ 2 $1,139.54 $446.00 ......... $89.20 

53400 ....... Revise urethra, stage 1 ................................................................ 3 $1,760.18 $510.00 ......... $102.00 

53405 ....... Revise urethra, stage 2 ................................................................ 2 $1,760.18 $446.00 ......... $89.20 

53410 ....... Reconstruction of urethra ............................................................. 2 $1,760.18 $446.00 ......... $89.20 

53420 ....... Reconstruct urethra, stage 1 ........................................................ 3 $1,760.18 $510.00 ......... $102.00 

53425 ....... Reconstruct urethra, stage 2 ........................................................ 2 $1,760.18 $446.00 ......... $89.20 

53430 ....... Reconstruction of urethra ............................................................. 2 $1,760.18 $446.00 ......... $89.20 

53431 ....... Reconstruct urethra/bladder ......................................................... 2 $1,760.18 $446.00 ......... $89.20 

53440 ....... Male sling procedure .................................................................... 2 $4,885.49 $446.00 ......... $89.20 

53442 ....... Remove/revise male sling ............................................................ 1 $1,760.18 $333.00 ......... $66.60 

53444 ....... Insert tandem cuff ......................................................................... 2 $4,885.49 $446.00 ......... $89.20 

53445 ....... Insert uro/ves nck sphincter ......................................................... 1 $8,354.29 $333.00 ......... $66.60 

53446 ....... Remove uro sphincter .................................................................. 1 $1,760.18 $333.00 ......... $66.60 

53447 ....... Remove/replace ur sphincter ........................................................ 1 $8,354.29 $333.00 ......... $66.60 

53449 ....... Repair uro sphincter ..................................................................... 1 $1,760.18 $333.00 ......... $66.60 

53450 ....... Revision of urethra ....................................................................... 1 $1,760.18 $333.00 ......... $66.60 

53460 ....... Revision of urethra ....................................................................... 1 $1,139.54 $333.00 ......... $66.60 

53502 ....... Repair of urethra injury ................................................................. 2 $1,139.54 $446.00 ......... $89.20 

53505 ....... Repair of urethra injury ................................................................. 2 $1,760.18 $446.00 ......... $89.20 

53510 ....... Repair of urethra injury ................................................................. 2 $1,139.54 $446.00 ......... $89.20 

53515 ....... Repair of urethra injury ................................................................. 2 $1,760.18 $446.00 ......... $89.20 

53520 ....... Repair of urethra defect ................................................................ 2 $1,760.18 $446.00 ......... $89.20 

53605 ....... Dilate urethra stricture .................................................................. 2 $1,186.49 $446.00 ......... $89.20 

53665 ....... Dilation of urethra ......................................................................... 1 $1,139.54 $333.00 ......... $66.60 

54000 ....... Slitting of prepuce ......................................................................... 2 $1,139.54 $446.00 ......... $89.20 

54001 ....... Slitting of prepuce ......................................................................... 2 $1,139.54 $446.00 ......... $89.20 

54015 ....... Drain penis lesion ......................................................................... 4 $1,075.21 $630.00 ......... $126.00 

54057 ....... Laser surg, penis lesion(s) ........................................................... 1 $1,091.87 $333.00 ......... $66.60 

54060 ....... Excision of penis lesion(s) ............................................................ 1 $1,091.87 $333.00 ......... $66.60 

54065 ....... Destruction, penis lesion(s) .......................................................... 1 $1,266.73 $333.00 ......... $66.60 

54100 ....... Biopsy of penis ............................................................................. 1 $920.58 $333.00 ......... $66.60 

54105 ....... Biopsy of penis ............................................................................. 1 $1,229.54 $333.00 ......... $66.60 

54110 ....... Treatment of penis lesion ............................................................. 2 $2,031.13 $446.00 ......... $89.20 

54111 ....... Treat penis lesion, graft ................................................................ 2 $2,031.13 $446.00 ......... $89.20 

54112 ....... Treat penis lesion, graft ................................................................ 2 $2,031.13 $446.00 ......... $89.20 

54115 ....... Treatment of penis lesion ............................................................. 1 $1,075.21 $333.00 ......... $66.60 

54120 ....... Partial removal of penis ................................................................ 2 $2,031.13 $446.00 ......... $89.20 

54150 ....... Circumcision ................................................................................. 1 $1,276.68 $333.00 ......... $66.60 

54152 ....... Circumcision ................................................................................. 1 $1,276.68 $333.00 ......... $66.60 

54160 ....... Circumcision ................................................................................. 2 $1,276.68 $446.00 ......... $89.20 

54161 ....... Circumcision ................................................................................. 2 $1,276.68 $446.00 ......... $89.20 


sroberts on PROD1PC70 with PROPOSALS
49746 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

54162 ....... Lysis penil circumic lesion ............................................................ 2 $1,276.68 $446.00 ......... $89.20 

54163 ....... Repair of circumcision .................................................................. 2 $1,276.68 $446.00 ......... $89.20 

54164 ....... Frenulotomy of penis .................................................................... 2 $1,276.68 $446.00 ......... $89.20 

54205 ....... Treatment of penis lesion ............................................................. 4 $2,031.13 $630.00 ......... $126.00 

54220 ....... Treatment of penis lesion ............................................................. 1 $130.24 $130.24 Y ..... $26.05 

54300 ....... Revision of penis .......................................................................... 3 $2,031.13 $510.00 ......... $102.00 

54304 ....... Revision of penis .......................................................................... 3 $2,031.13 $510.00 ......... $102.00 

54308 ....... Reconstruction of urethra ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54312 ....... Reconstruction of urethra ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54316 ....... Reconstruction of urethra ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54318 ....... Reconstruction of urethra ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54322 ....... Reconstruction of urethra ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54324 ....... Reconstruction of urethra ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54326 ....... Reconstruction of urethra ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54328 ....... Revise penis/urethra ..................................................................... 3 $2,031.13 $510.00 ......... $102.00 

54340 ....... Secondary urethral surgery .......................................................... 3 $2,031.13 $510.00 ......... $102.00 

54344 ....... Secondary urethral surgery .......................................................... 3 $2,031.13 $510.00 ......... $102.00 

54348 ....... Secondary urethral surgery .......................................................... 3 $2,031.13 $510.00 ......... $102.00 

54352 ....... Reconstruct urethra/penis ............................................................. 3 $2,031.13 $510.00 ......... $102.00 

54360 ....... Penis plastic surgery .................................................................... 3 $2,031.13 $510.00 ......... $102.00 

54380 ....... Repair penis .................................................................................. 3 $2,031.13 $510.00 ......... $102.00 

54385 ....... Repair penis .................................................................................. 3 $2,031.13 $510.00 ......... $102.00 

54400 ....... Insert semi-rigid prosthesis ........................................................... 3 $4,885.49 $510.00 ......... $102.00 

54401 ....... Insert self-contd prosthesis ........................................................... 3 $8,354.29 $510.00 ......... $102.00 

54405 ....... Insert multi-comp penis pros ........................................................ 3 $8,354.29 $510.00 ......... $102.00 

54406 ....... Remove muti-comp penis pros ..................................................... 3 $2,031.13 $510.00 ......... $102.00 

54408 ....... Repair multi-comp penis pros ....................................................... 3 $2,031.13 $510.00 ......... $102.00 

54410 ....... Remove/replace penis prosth ....................................................... 3 $8,354.29 $510.00 ......... $102.00 

54415 ....... Remove self-contd penis pros ...................................................... 3 $2,031.13 $510.00 ......... $102.00 

54416 ....... Remv/repl penis contain pros ....................................................... 3 $8,354.29 $510.00 ......... $102.00 

54420 ....... Revision of penis .......................................................................... 4 $2,031.13 $630.00 ......... $126.00 

54435 ....... Revision of penis .......................................................................... 4 $2,031.13 $630.00 ......... $126.00 

54440 ....... Repair of penis ............................................................................. 4 $2,031.13 $630.00 ......... $126.00 

54450 ....... Preputial stretching ....................................................................... 1 $219.66 $219.66 Y ..... $43.93 

54500 ....... Biopsy of testis ............................................................................. 1 $631.61 $333.00 ......... $66.60 

54505 ....... Biopsy of testis ............................................................................. 1 $1,459.20 $333.00 ......... $66.60 

54512 ....... Excise lesion testis ....................................................................... 2 $1,459.20 $446.00 ......... $89.20 

54520 ....... Removal of testis .......................................................................... 3 $1,459.20 $510.00 ......... $102.00 

54522 ....... Orchiectomy, partial ...................................................................... 3 $1,459.20 $510.00 ......... $102.00 

54530 ....... Removal of testis .......................................................................... 4 $1,794.16 $630.00 ......... $126.00 

54550 ....... Exploration for testis ..................................................................... 4 $1,794.16 $630.00 ......... $126.00 

54600 ....... Reduce testis torsion .................................................................... 4 $1,459.20 $630.00 ......... $126.00 

54620 ....... Suspension of testis ..................................................................... 3 $1,459.20 $510.00 ......... $102.00 

54640 ....... Suspension of testis ..................................................................... 4 $1,794.16 $630.00 ......... $126.00 

54660 ....... Revision of testis .......................................................................... 2 $1,459.20 $446.00 ......... $89.20 

54670 ....... Repair testis injury ........................................................................ 3 $1,459.20 $510.00 ......... $102.00 

54680 ....... Relocation of testis(es) ................................................................. 3 $1,459.20 $510.00 ......... $102.00 

54690 ....... Laparoscopy, orchiectomy ............................................................ 9 $2,678.23 $1,339.00 ......... $267.80 

54700 ....... Drainage of scrotum ..................................................................... 2 $1,459.20 $446.00 ......... $89.20 

54800 ....... Biopsy of epididymis ..................................................................... 1 $128.41 $128.41 Y ..... $25.68 

54820 ....... Exploration of epididymis .............................................................. 1 $1,459.20 $333.00 ......... $66.60 

54830 ....... Remove epididymis lesion ............................................................ 3 $1,459.20 $510.00 ......... $102.00 

54840 ....... Remove epididymis lesion ............................................................ 4 $1,459.20 $630.00 ......... $126.00 

54860 ....... Removal of epididymis ................................................................. 3 $1,459.20 $510.00 ......... $102.00 

54861 ....... Removal of epididymis ................................................................. 4 $1,459.20 $630.00 ......... $126.00 

54900 ....... Fusion of spermatic ducts ............................................................ 4 $1,459.20 $630.00 ......... $126.00 

54901 ....... Fusion of spermatic ducts ............................................................ 4 $1,459.20 $630.00 ......... $126.00 

55040 ....... Removal of hydrocele ................................................................... 3 $1,794.16 $510.00 ......... $102.00 

55041 ....... Removal of hydroceles ................................................................. 5 $1,794.16 $717.00 ......... $143.40 

55060 ....... Repair of hydrocele ...................................................................... 4 $1,459.20 $630.00 ......... $126.00 

55100 ....... Drainage of scrotum abscess ....................................................... 1 $672.04 $333.00 ......... $66.60

55110 ....... Explore scrotum ............................................................................ 2 $1,459.20 $446.00 ......... $89.20 

55120 ....... Removal of scrotum lesion ........................................................... 2 $1,459.20 $446.00 ......... $89.20 

55150 ....... Removal of scrotum ...................................................................... 1 $1,459.20 $333.00 ......... $66.60 

55175 ....... Revision of scrotum ...................................................................... 1 $1,459.20 $333.00 ......... $66.60 

55180 ....... Revision of scrotum ...................................................................... 2 $1,459.20 $446.00 ......... $89.20 

55200 ....... Incision of sperm duct .................................................................. 2 $1,459.20 $446.00 ......... $89.20 

55250 ....... Removal of sperm duct(s) ............................................................ 2 $1,459.20 $446.00 ......... $89.20 

55400 ....... Repair of sperm duct .................................................................... 1 $1,459.20 $333.00 ......... $66.60 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49747 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

55500 ....... Removal of hydrocele ................................................................... 3 $1,459.20 $510.00 ......... $102.00 

55520 ....... Removal of sperm cord lesion ...................................................... 4 $1,459.20 $630.00 ......... $126.00 

55530 ....... Revise spermatic cord veins ........................................................ 4 $1,459.20 $630.00 ......... $126.00 

55535 ....... Revise spermatic cord veins ........................................................ 4 $1,794.16 $630.00 ......... $126.00 

55540 ....... Revise hernia & sperm veins ....................................................... 5 $1,794.16 $717.00 ......... $143.40 

55550 ....... Laparo ligate spermatic vein ........................................................ 9 $2,678.23 $1,339.00 ......... $267.80 

55680 ....... Remove sperm pouch lesion ........................................................ 1 $1,459.20 $333.00 ......... $66.60 

55700 ....... Biopsy of prostate ......................................................................... 2 $368.64 $368.64 Y ..... $73.73 

55705 ....... Biopsy of prostate ......................................................................... 2 $368.64 $368.64 Y ..... $73.73 

55720 ....... Drainage of prostate abscess ....................................................... 1 $1,468.37 $333.00 ......... $66.60 

55725 ....... Drainage of prostate abscess ....................................................... 2 $1,468.37 $446.00 ......... $89.20 

55859 ....... Percut/needle insert, pros ............................................................. 9 $2,160.59 $1,339.00 ......... $267.80 

55873 ....... Cryoablate prostate ...................................................................... 9 $6,637.03 $1,339.00 ......... $267.80 

56440 ....... Surgery for vulva lesion ................................................................ 2 $1,262.49 $446.00 ......... $89.20 

56441 ....... Lysis of labial lesion(s) ................................................................. 1 $910.70 $333.00 ......... $66.60 

56515 ....... Destroy vulva lesion/s compl ........................................................ 3 $1,266.73 $510.00 ......... $102.00 

56620 ....... Partial removal of vulva ................................................................ 5 $1,769.04 $717.00 ......... $143.40 

56625 ....... Complete removal of vulva ........................................................... 7 $1,769.04 $995.00 ......... $199.00 

56700 ....... Partial removal of hymen .............................................................. 1 $1,262.49 $333.00 ......... $66.60 

56720 ....... Incision of hymen .......................................................................... 1 $910.70 $333.00 ......... $66.60 

56740 ....... Remove vagina gland lesion ........................................................ 3 $1,262.49 $510.00 ......... $102.00 

56800 ....... Repair of vagina ........................................................................... 3 $1,262.49 $510.00 ......... $102.00 

56810 ....... Repair of perineum ....................................................................... 5 $1,262.49 $717.00 ......... $143.40 

57000 ....... Exploration of vagina .................................................................... 1 $910.70 $333.00 ......... $66.60 

57010 ....... Drainage of pelvic abscess .......................................................... 2 $910.70 $446.00 ......... $89.20 

57020 ....... Drainage of pelvic fluid ................................................................. 2 $426.33 $426.33 Y ..... $85.27 

57023 ....... I& d vag hematoma, non-ob ......................................................... 1 $1,075.21 $333.00 ......... $66.60 

57065 ....... Destroy vag lesions, complex ....................................................... 1 $1,262.49 $333.00 ......... $66.60 

57105 ....... Biopsy of vagina ........................................................................... 2 $1,262.49 $446.00 ......... $89.20 

57130 ....... Remove vagina lesion .................................................................. 2 $1,262.49 $446.00 ......... $89.20 

57135 ....... Remove vagina lesion .................................................................. 2 $1,262.49 $446.00 ......... $89.20 

57155 ....... Insert uteri tandems/ovoids .......................................................... 2 $426.33 $426.33 Y ..... $85.27

57180 ....... Treat vaginal bleeding .................................................................. 1 $184.05 $184.05 Y ..... $36.81 

57200 ....... Repair of vagina ........................................................................... 1 $1,262.49 $333.00 ......... $66.60 

57210 ....... Repair vagina/perineum ................................................................ 2 $1,262.49 $446.00 ......... $89.20 

57220 ....... Revision of urethra ....................................................................... 3 $2,639.04 $510.00 ......... $102.00 

57230 ....... Repair of urethral lesion ............................................................... 3 $1,769.04 $510.00 ......... $102.00 

57240 ....... Repair bladder & vagina ............................................................... 5 $1,769.04 $717.00 ......... $143.40 

57250 ....... Repair rectum & vagina ................................................................ 5 $1,769.04 $717.00 ......... $143.40 

57260 ....... Repair of vagina ........................................................................... 5 $1,769.04 $717.00 ......... $143.40 

57265 ....... Extensive repair of vagina ............................................................ 7 $2,639.04 $995.00 ......... $199.00 

57268 ....... Repair of bowel bulge ................................................................... 3 $1,769.04 $510.00 ......... $102.00 

57288 ....... Repair bladder defect ................................................................... 5 $2,639.04 $717.00 ......... $143.40 

57289 ....... Repair bladder & vagina ............................................................... 5 $1,769.04 $717.00 ......... $143.40 

57291 ....... Construction of vagina .................................................................. 5 $1,769.04 $717.00 ......... $143.40 

57300 ....... Repair rectum-vagina fistula ......................................................... 3 $1,769.04 $510.00 ......... $102.00 

57400 ....... Dilation of vagina .......................................................................... 2 $1,262.49 $446.00 ......... $89.20 

57410 ....... Pelvic examination ........................................................................ 2 $910.70 $446.00 ......... $89.20 

57415 ....... Remove vaginal foreign body ....................................................... 2 $1,262.49 $446.00 ......... $89.20 

57513 ....... Laser surgery of cervix ................................................................. 2 $910.70 $446.00 ......... $89.20 

57520 ....... Conization of cervix ...................................................................... 2 $1,262.49 $446.00 ......... $89.20 

57522 ....... Conization of cervix ...................................................................... 2 $1,769.04 $446.00 ......... $89.20 

57530 ....... Removal of cervix ......................................................................... 3 $1,769.04 $510.00 ......... $102.00 

57550 ....... Removal of residual cervix ........................................................... 3 $1,769.04 $510.00 ......... $102.00 

57556 ....... Remove cervix, repair bowel ........................................................ 5 $2,639.04 $717.00 ......... $143.40 

57700 ....... Revision of cervix ......................................................................... 1 $1,262.49 $333.00 ......... $66.60 

57720 ....... Revision of cervix ......................................................................... 3 $1,262.49 $510.00 ......... $102.00 

57820 ....... D& c of residual cervix ................................................................. 3 $1,093.36 $510.00 ......... $102.00 

58120 ....... Dilation and curettage ................................................................... 2 $1,093.36 $446.00 ......... $89.20 

58145 ....... Myomectomy vag method ............................................................ 5 $1,769.04 $717.00 ......... $143.40 

58346 ....... Insert heyman uteri capsule ......................................................... 2 $910.70 $446.00 ......... $89.20 

58350 ....... Reopen fallopian tube ................................................................... 3 $1,769.04 $510.00 ......... $102.00 

58353 ....... Endometr ablate, thermal ............................................................. 4 $1,769.04 $630.00 ......... $126.00 

58545 ....... Laparoscopic myomectomy .......................................................... 9 $1,965.65 $1,339.00 ......... $267.80 

58546 ....... Laparo-myomectomy, complex ..................................................... 9 $2,678.23 $1,339.00 ......... $267.80 

58550 ....... Laparo-asst vag hysterectomy ..................................................... 9 $4,363.07 $1,339.00 ......... $267.80 

58555 ....... Hysteroscopy, dx, sep proc .......................................................... 1 $1,318.42 $333.00 ......... $66.60 

58558 ....... Hysteroscopy, biopsy .................................................................... 3 $1,318.42 $510.00 ......... $102.00 

58559 ....... Hysteroscopy, lysis ....................................................................... 2 $1,318.42 $446.00 ......... $89.20 


sroberts on PROD1PC70 with PROPOSALS
49748 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

58560 ....... Hysteroscopy, resect septum ....................................................... 3 $2,049.83 $510.00 ......... $102.00 

58561 ....... Hysteroscopy, remove myoma ..................................................... 3 $2,049.83 $510.00 ......... $102.00

58562 ....... Hysteroscopy, remove fb .............................................................. 3 $1,318.42 $510.00 ......... $102.00 

58563 ....... Hysteroscopy, ablation ................................................................. 4 $2,049.83 $630.00 ......... $126.00 

58565 ....... Hysteroscopy, sterilization ............................................................ 9 $2,639.04 $1,339.00 ......... $267.80 

58660 ....... Laparoscopy, lysis ........................................................................ 5 $2,678.23 $717.00 ......... $143.40 

58661 ....... Laparoscopy, remove adnexa ...................................................... 5 $2,678.23 $717.00 ......... $143.40 

58662 ....... Laparoscopy, excise lesions ......................................................... 5 $2,678.23 $717.00 ......... $143.40 

58670 ....... Laparoscopy, tubal cautery .......................................................... 3 $2,678.23 $510.00 ......... $102.00 

58671 ....... Laparoscopy, tubal block .............................................................. 3 $2,678.23 $510.00 ......... $102.00 

58672 ....... Laparoscopy, fimbrioplasty ........................................................... 5 $2,678.23 $717.00 ......... $143.40 

58673 ....... Laparoscopy, salpingostomy ........................................................ 5 $2,678.23 $717.00 ......... $143.40 

58800 ....... Drainage of ovarian cyst(s) .......................................................... 3 $910.70 $510.00 ......... $102.00 

58820 ....... Drain ovary abscess, open ........................................................... 3 $1,769.04 $510.00 ......... $102.00 

58900 ....... Biopsy of ovary(s) ......................................................................... 3 $910.70 $510.00 ......... $102.00 

58970 ....... Retrieval of oocyte ........................................................................ 1 $271.49 $271.49 Y ..... $54.30 

58974 ....... Transfer of embryo ....................................................................... 1 $271.49 $271.49 Y ..... $54.30 

58976 ....... Transfer of embryo ....................................................................... 1 $271.49 $271.49 Y ..... $54.30 

59160 ....... D& c after delivery ........................................................................ 3 $1,093.36 $510.00 ......... $102.00 

59320 ....... Revision of cervix ......................................................................... 1 $1,262.49 $333.00 ......... $66.60 

59812 ....... Treatment of miscarriage .............................................................. 5 $1,140.24 $717.00 ......... $143.40 

59820 ....... Care of miscarriage ...................................................................... 5 $1,140.24 $717.00 ......... $143.40 

59821 ....... Treatment of miscarriage .............................................................. 5 $1,140.24 $717.00 ......... $143.40 

59840 ....... Abortion ......................................................................................... 5 $1,062.41 $717.00 ......... $143.40 

59841 ....... Abortion ......................................................................................... 5 $1,062.41 $717.00 ......... $143.40 

59870 ....... Evacuate mole of uterus ............................................................... 5 $1,140.24 $717.00 ......... $143.40 

59871 ....... Remove cerclage suture ............................................................... 5 $1,262.49 $717.00 ......... $143.40 

60000 ....... Drain thyroid/tongue cyst .............................................................. 1 $475.55 $333.00 ......... $66.60 

60200 ....... Remove thyroid lesion .................................................................. 2 $2,285.28 $446.00 ......... $89.20 

60280 ....... Remove thyroid duct lesion .......................................................... 4 $2,285.28 $630.00 ......... $126.00 

60281 ....... Remove thyroid duct lesion .......................................................... 4 $2,285.28 $630.00 ......... $126.00 

61020 ....... Remove brain cavity fluid ............................................................. 1 $187.01 $187.01 Y ..... $37.40 

61026 ....... Injection into brain canal ............................................................... 1 $187.01 $187.01 Y ..... $37.40 

61050 ....... Remove brain canal fluid .............................................................. 1 $187.01 $187.01 Y ..... $37.40 

61055 ....... Injection into brain canal ............................................................... 1 $187.01 $187.01 Y ..... $37.40 

61070 ....... Brain canal shunt procedure ........................................................ 1 $187.01 $187.01 Y ..... $37.40 

61215 ....... Insert brain-fluid device ................................................................ 3 $2,811.11 $510.00 ......... $102.00 

61790 ....... Treat trigeminal nerve ................................................................... 3 $1,093.20 $510.00 ......... $102.00 

61791 ....... Treat trigeminal tract ..................................................................... 3 $341.23 $341.23 Y ..... $68.25 

61885 ....... Insrt/redo neurostim 1 array ......................................................... 2 $10,828.84 $446.00 ......... $89.20 

61886 ....... Implant neurostim arrays .............................................................. 3 $14,500.02 $510.00 ......... $102.00 

61888 ....... Revise/remove neuroreceiver ....................................................... 1 $2,089.79 $333.00 ......... $66.60 

62194 ....... Replace/irrigate catheter ............................................................... 1 $709.19 $333.00 ......... $66.60 

62225 ....... Replace/irrigate catheter ............................................................... 1 $709.19 $333.00 ......... $66.60 

62230 ....... Replace/revise brain shunt ........................................................... 2 $2,811.11 $446.00 ......... $89.20 

62263 ....... Epidural lysis mult sessions ......................................................... 1 $765.89 $333.00 ......... $66.60 

62264 ....... Epidural lysis on single day .......................................................... 1 $765.89 $333.00 ......... $66.60 

62268 ....... Drain spinal cord cyst ................................................................... 1 $187.01 $187.01 Y ..... $37.40 

62269 ....... Needle biopsy, spinal cord ........................................................... 1 $373.79 $333.00 ......... $66.60 

62270 ....... Spinal fluid tap, diagnostic ............................................................ 1 $138.43 $138.43 Y ..... $27.69 

62272 ....... Drain cerebro spinal fluid .............................................................. 1 $138.43 $138.43 Y ..... $27.69 

62273 ....... Inject epidural patch ..................................................................... 1 $341.23 $333.00 ......... $66.60 

62280 ....... Treat spinal cord lesion ................................................................ 1 $392.62 $333.00 ......... $66.60 

62281 ....... Treat spinal cord lesion ................................................................ 1 $392.62 $333.00 ......... $66.60 

62282 ....... Treat spinal canal lesion ............................................................... 1 $392.62 $333.00 ......... $66.60 

62287 ....... Percutaneous diskectomy ............................................................. 9 $2,049.86 $1,339.00 ......... $267.80 

62294 ....... Injection into spinal artery ............................................................. 3 $187.01 $187.01 Y ..... $37.40 

62310 ....... Inject spine c/t ............................................................................... 1 $392.62 $333.00 ......... $66.60 

62311 ....... Inject spine l/s (cd) ....................................................................... 1 $392.62 $333.00 ......... $66.60 

62318 ....... Inject spine w/cath, c/t .................................................................. 1 $392.62 $333.00 ......... $66.60 

62319 ....... Inject spine w/cath l/s (cd) ............................................................ 1 $392.62 $333.00 ......... $66.60 

62350 ....... Implant spinal canal cath .............................................................. 2 $1,803.02 $446.00 ......... $89.20 

62355 ....... Remove spinal canal catheter ...................................................... 2 $765.89 $446.00 ......... $89.20

62360 ....... Insert spine infusion device .......................................................... 2 $6,894.62 $446.00 ......... $89.20 

62361 ....... Implant spine infusion pump ......................................................... 2 $11,275.98 $446.00 ......... $89.20 

62362 ....... Implant spine infusion pump ......................................................... 2 $11,275.98 $446.00 ......... $89.20 

62365 ....... Remove spine infusion device ...................................................... 2 $2,049.86 $446.00 ......... $89.20 

63600 ....... Remove spinal cord lesion ........................................................... 2 $1,093.20 $446.00 ......... $89.20 

63610 ....... Stimulation of spinal cord ............................................................. 1 $1,093.20 $333.00 ......... $66.60 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49749 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

63650 ....... Implant neuroelectrodes ............................................................... 2 $3,470.58 $446.00 ......... $89.20 

63660 ....... Revise/remove neuroelectrode ..................................................... 1 $1,057.63 $333.00 ......... $66.60 

63685 ....... Insrt/redo spine n generator ......................................................... 2 $10,964.12 $446.00 ......... $89.20 

63688 ....... Revise/remove neuroreceiver ....................................................... 1 $2,089.79 $333.00 ......... $66.60 

63744 ....... Revision of spinal shunt ............................................................... 3 $2,225.70 $510.00 ......... $102.00 

63746 ....... Removal of spinal shunt ............................................................... 2 $674.24 $446.00 ......... $89.20 

64410 ....... Nblock inj, phrenic ........................................................................ 1 $341.23 $333.00 ......... $66.60 

64415 ....... Nblock inj, brachial plexus ............................................................ 1 $138.43 $138.43 Y ..... $27.69 

64417 ....... Nblock inj, axillary ......................................................................... 1 $138.43 $138.43 Y ..... $27.69 

64420 ....... Nblock inj, intercost, sng .............................................................. 1 $138.43 $138.43 Y ..... $27.69 

64421 ....... Nblock inj, intercost, mlt ............................................................... 1 $341.23 $333.00 ......... $66.60 

64430 ....... Nblock inj, pudendal ..................................................................... 1 $138.43 $138.43 Y ..... $27.69 

64470 ....... Inj paravertebral c/t ....................................................................... 1 $392.62 $333.00 ......... $66.60 

64472 ....... Inj paravertebral c/t add-on .......................................................... 1 $341.23 $333.00 ......... $66.60 

64475 ....... Inj paravertebral l/s ....................................................................... 1 $392.62 $333.00 ......... $66.60 

64476 ....... Inj paravertebral l/s add-on ........................................................... 1 $341.23 $333.00 ......... $66.60 

64479 ....... Inj foramen epidural c/t ................................................................. 1 $392.62 $333.00 ......... $66.60 

64480 ....... Inj foramen epidural add-on ......................................................... 1 $392.62 $333.00 ......... $66.60 

64483 ....... Inj foramen epidural l/s ................................................................. 1 $392.62 $333.00 ......... $66.60 

64484 ....... Inj foramen epidural add-on ......................................................... 1 $392.62 $333.00 ......... $66.60 

64510 ....... Nblock, stellate ganglion ............................................................... 1 $392.62 $333.00 ......... $66.60 

64517 ....... Nblock inj, hypogas plxs ............................................................... 2 $138.43 $138.43 Y ..... $27.69 

64520 ....... Nblock, lumbar/thoracic ................................................................ 1 $392.62 $333.00 ......... $66.60 

64530 ....... Nblock inj, celiac pelus ................................................................. 1 $392.62 $333.00 ......... $66.60 

64553 ....... Implant neuroelectrodes ............................................................... 1 $14,412.95 $333.00 ......... $66.60 

64561 ....... Implant neuroelectrodes ............................................................... 3 $3,470.58 $510.00 ......... $102.00 

64573 ....... Implant neuroelectrodes ............................................................... 1 $14,412.95 $333.00 ......... $66.60 

64575 ....... Implant neuroelectrodes ............................................................... 1 $5,184.89 $333.00 ......... $66.60 

64577 ....... Implant neuroelectrodes ............................................................... 1 $5,184.89 $333.00 ......... $66.60 

64580 ....... Implant neuroelectrodes ............................................................... 1 $5,184.89 $333.00 ......... $66.60 

64581 ....... Implant neuroelectrodes ............................................................... 3 $5,184.89 $510.00 ......... $102.00 

64585 ....... Revise/remove neuroelectrode ..................................................... 1 $1,057.63 $333.00 ......... $66.60 

64590 ....... Insrt/redo perph n generator ......................................................... 2 $10,964.12 $446.00 ......... $89.20 

64595 ....... Revise/remove neuroreceiver ....................................................... 1 $2,089.79 $333.00 ......... $66.60 

64600 ....... Injection treatment of nerve .......................................................... 1 $765.89 $333.00 ......... $66.60 

64605 ....... Injection treatment of nerve .......................................................... 1 $765.89 $333.00 ......... $66.60 

64610 ....... Injection treatment of nerve .......................................................... 1 $765.89 $333.00 ......... $66.60 

64620 ....... Injection treatment of nerve .......................................................... 1 $765.89 $333.00 ......... $66.60 

64622 ....... Destr paravertebrl nerve l/s .......................................................... 1 $765.89 $333.00 ......... $66.60 

64623 ....... Destr paravertebral n add-on ....................................................... 1 $392.62 $333.00 ......... $66.60 

64626 ....... Destr paravertebrl nerve c/t .......................................................... 1 $765.89 $333.00 ......... $66.60 

64627 ....... Destr paravertebral n add-on ....................................................... 1 $392.62 $333.00 ......... $66.60 

64630 ....... Injection treatment of nerve .......................................................... 2 $341.23 $341.23 Y ..... $68.25 

64680 ....... Injection treatment of nerve .......................................................... 2 $392.62 $392.62 Y ..... $78.52 

64681 ....... Injection treatment of nerve .......................................................... 2 $765.89 $446.00 ......... $89.20 

64702 ....... Revise finger/toe nerve ................................................................. 1 $1,093.20 $333.00 ......... $66.60 

64704 ....... Revise hand/foot nerve ................................................................. 1 $1,093.20 $333.00 ......... $66.60 

64708 ....... Revise arm/leg nerve .................................................................... 2 $1,093.20 $446.00 ......... $89.20 

64712 ....... Revision of sciatic nerve ............................................................... 2 $1,093.20 $446.00 ......... $89.20 

64713 ....... Revision of arm nerve(s) .............................................................. 2 $1,093.20 $446.00 ......... $89.20 

64714 ....... Revise low back nerve(s) ............................................................. 2 $1,093.20 $446.00 ......... $89.20 

64716 ....... Revision of cranial nerve .............................................................. 3 $1,093.20 $510.00 ......... $102.00 

64718 ....... Revise ulnar nerve at elbow ......................................................... 2 $1,093.20 $446.00 ......... $89.20 

64719 ....... Revise ulnar nerve at wrist ........................................................... 2 $1,093.20 $446.00 ......... $89.20 

64721 ....... Carpal tunnel surgery ................................................................... 2 $1,093.20 $446.00 ......... $89.20 

64722 ....... Relieve pressure on nerve(s) ....................................................... 1 $1,093.20 $333.00 ......... $66.60 

64726 ....... Release foot/toe nerve ................................................................. 1 $1,093.20 $333.00 ......... $66.60 

64727 ....... Internal nerve revision .................................................................. 1 $1,093.20 $333.00 ......... $66.60 

64732 ....... Incision of brow nerve .................................................................. 2 $1,093.20 $446.00 ......... $89.20 

64734 ....... Incision of cheek nerve ................................................................. 2 $1,093.20 $446.00 ......... $89.20 

64736 ....... Incision of chin nerve .................................................................... 2 $1,093.20 $446.00 ......... $89.20 

64738 ....... Incision of jaw nerve ..................................................................... 2 $1,093.20 $446.00 ......... $89.20 

64740 ....... Incision of tongue nerve ............................................................... 2 $1,093.20 $446.00 ......... $89.20 

64742 ....... Incision of facial nerve .................................................................. 2 $1,093.20 $446.00 ......... $89.20 

64744 ....... Incise nerve, back of head ........................................................... 2 $1,093.20 $446.00 ......... $89.20 

64746 ....... Incise diaphragm nerve ................................................................ 2 $1,093.20 $446.00 ......... $89.20 

64771 ....... Sever cranial nerve ....................................................................... 2 $1,093.20 $446.00 ......... $89.20 

64772 ....... Incision of spinal nerve ................................................................. 2 $1,093.20 $446.00 ......... $89.20 

64774 ....... Remove skin nerve lesion ............................................................ 2 $1,093.20 $446.00 ......... $89.20 


sroberts on PROD1PC70 with PROPOSALS
49750 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

64776 ....... Remove digit nerve lesion ............................................................ 3 $1,093.20 $510.00 ......... $102.00 

64778 ....... Digit nerve surgery add-on ........................................................... 2 $1,093.20 $446.00 ......... $89.20 

64782 ....... Remove limb nerve lesion ............................................................ 3 $1,093.20 $510.00 ......... $102.00 

64783 ....... Limb nerve surgery add-on .......................................................... 2 $1,093.20 $446.00 ......... $89.20 

64784 ....... Remove nerve lesion .................................................................... 3 $1,093.20 $510.00 ......... $102.00 

64786 ....... Remove sciatic nerve lesion ......................................................... 3 $2,049.86 $510.00 ......... $102.00 

64787 ....... Implant nerve end ......................................................................... 2 $1,093.20 $446.00 ......... $89.20 

64788 ....... Remove skin nerve lesion ............................................................ 3 $1,093.20 $510.00 ......... $102.00 

64790 ....... Removal of nerve lesion ............................................................... 3 $1,093.20 $510.00 ......... $102.00 

64792 ....... Removal of nerve lesion ............................................................... 3 $2,049.86 $510.00 ......... $102.00 

64795 ....... Biopsy of nerve ............................................................................. 2 $1,093.20 $446.00 ......... $89.20 

64802 ....... Remove sympathetic nerves ........................................................ 2 $1,093.20 $446.00 ......... $89.20 

64821 ....... Remove sympathetic nerves ........................................................ 4 $1,590.63 $630.00 ......... $126.00 

64831 ....... Repair of digit nerve ..................................................................... 4 $2,049.86 $630.00 ......... $126.00 

64832 ....... Repair nerve add-on ..................................................................... 1 $2,049.86 $333.00 ......... $66.60 

64834 ....... Repair of hand or foot nerve ........................................................ 2 $2,049.86 $446.00 ......... $89.20 

64835 ....... Repair of hand or foot nerve ........................................................ 3 $2,049.86 $510.00 ......... $102.00 

64836 ....... Repair of hand or foot nerve ........................................................ 3 $2,049.86 $510.00 ......... $102.00 

64837 ....... Repair nerve add-on ..................................................................... 1 $2,049.86 $333.00 ......... $66.60 

64840 ....... Repair of leg nerve ....................................................................... 2 $2,049.86 $446.00 ......... $89.20 

64856 ....... Repair/transpose nerve ................................................................ 2 $2,049.86 $446.00 ......... $89.20 

64857 ....... Repair arm/leg nerve .................................................................... 2 $2,049.86 $446.00 ......... $89.20 

64858 ....... Repair sciatic nerve ...................................................................... 2 $2,049.86 $446.00 ......... $89.20 

64859 ....... Nerve surgery ............................................................................... 1 $2,049.86 $333.00 ......... $66.60 

64861 ....... Repair of arm nerves .................................................................... 3 $2,049.86 $510.00 ......... $102.00 

64862 ....... Repair of low back nerves ............................................................ 3 $2,049.86 $510.00 ......... $102.00 

64864 ....... Repair of facial nerve ................................................................... 3 $2,049.86 $510.00 ......... $102.00 

64865 ....... Repair of facial nerve ................................................................... 4 $2,049.86 $630.00 ......... $126.00 

64870 ....... Fusion of facial/other nerve .......................................................... 4 $2,049.86 $630.00 ......... $126.00 

64872 ....... Subsequent repair of nerve .......................................................... 2 $2,049.86 $446.00 ......... $89.20 

64874 ....... Repair & revise nerve add-on ...................................................... 3 $2,049.86 $510.00 ......... $102.00 

64876 ....... Repair nerve/shorten bone ........................................................... 3 $2,049.86 $510.00 ......... $102.00 

64885 ....... Nerve graft, head or neck ............................................................. 2 $2,049.86 $446.00 ......... $89.20 

64886 ....... Nerve graft, head or neck ............................................................. 2 $2,049.86 $446.00 ......... $89.20 

64890 ....... Nerve graft, hand or foot .............................................................. 2 $2,049.86 $446.00 ......... $89.20 

64891 ....... Nerve graft, hand or foot .............................................................. 2 $2,049.86 $446.00 ......... $89.20 

64892 ....... Nerve graft, arm or leg ................................................................. 2 $2,049.86 $446.00 ......... $89.20 

64893 ....... Nerve graft, arm or leg ................................................................. 2 $2,049.86 $446.00 ......... $89.20 

64895 ....... Nerve graft, hand or foot .............................................................. 3 $2,049.86 $510.00 ......... $102.00 

64896 ....... Nerve graft, hand or foot .............................................................. 3 $2,049.86 $510.00 ......... $102.00 

64897 ....... Nerve graft, arm or leg ................................................................. 3 $2,049.86 $510.00 ......... $102.00 

64898 ....... Nerve graft, arm or leg ................................................................. 3 $2,049.86 $510.00 ......... $102.00 

64901 ....... Nerve graft add-on ........................................................................ 2 $2,049.86 $446.00 ......... $89.20 

64902 ....... Nerve graft add-on ........................................................................ 2 $2,049.86 $446.00 ......... $89.20 

64905 ....... Nerve pedicle transfer .................................................................. 2 $2,049.86 $446.00 ......... $89.20 

64907 ....... Nerve pedicle transfer .................................................................. 1 $2,049.86 $333.00 ......... $66.60 

65091 ....... Revise eye .................................................................................... 3 $2,186.40 $510.00 ......... $102.00 

65093 ....... Revise eye with implant ................................................................ 3 $2,186.40 $510.00 ......... $102.00 

65101 ....... Removal of eye ............................................................................. 3 $2,186.40 $510.00 ......... $102.00 

65103 ....... Remove eye/insert implant ........................................................... 3 $2,186.40 $510.00 ......... $102.00 

65105 ....... Remove eye/attach implant .......................................................... 4 $2,186.40 $630.00 ......... $126.00 

65110 ....... Removal of eye ............................................................................. 5 $2,186.40 $717.00 ......... $143.40 

65112 ....... Remove eye/revise socket ........................................................... 7 $2,186.40 $995.00 ......... $199.00 

65114 ....... Remove eye/revise socket ........................................................... 7 $2,186.40 $995.00 ......... $199.00 

65130 ....... Insert ocular implant ..................................................................... 3 $1,529.55 $510.00 ......... $102.00 

65135 ....... Insert ocular implant ..................................................................... 2 $1,529.55 $446.00 ......... $89.20 

65140 ....... Attach ocular implant .................................................................... 3 $2,186.40 $510.00 ......... $102.00 

65150 ....... Revise ocular implant ................................................................... 2 $1,529.55 $446.00 ......... $89.20 

65155 ....... Reinsert ocular implant ................................................................. 3 $2,186.40 $510.00 ......... $102.00 

65175 ....... Removal of ocular implant ............................................................ 1 $1,047.14 $333.00 ......... $66.60 

65235 ....... Remove foreign body from eye .................................................... 2 $923.07 $446.00 ......... $89.20 

65260 ....... Remove foreign body from eye .................................................... 3 $1,005.95 $510.00 ......... $102.00 

65265 ....... Remove foreign body from eye .................................................... 4 $1,657.60 $630.00 ......... $126.00 

65270 ....... Repair of eye wound .................................................................... 2 $1,047.14 $446.00 ......... $89.20 

65272 ....... Repair of eye wound .................................................................... 2 $1,412.47 $446.00 ......... $89.20 

65275 ....... Repair of eye wound .................................................................... 4 $1,412.47 $630.00 ......... $126.00 

65280 ....... Repair of eye wound .................................................................... 4 $1,005.95 $630.00 ......... $126.00 

65285 ....... Repair of eye wound .................................................................... 4 $2,270.12 $630.00 ......... $126.00 

65290 ....... Repair of eye socket wound ......................................................... 3 $1,310.33 $510.00 ......... $102.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49751 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

65400 ....... Removal of eye lesion .................................................................. 1 $923.07 $333.00 ......... $66.60 

65410 ....... Biopsy of cornea ........................................................................... 2 $923.07 $446.00 ......... $89.20 

65420 ....... Removal of eye lesion .................................................................. 2 $923.07 $446.00 ......... $89.20 

65426 ....... Removal of eye lesion .................................................................. 5 $1,412.47 $717.00 ......... $143.40 

65710 ....... Corneal transplant ........................................................................ 7 $2,335.53 $995.00 ......... $199.00 

65730 ....... Corneal transplant ........................................................................ 7 $2,335.53 $995.00 ......... $199.00 

65750 ....... Corneal transplant ........................................................................ 7 $2,335.53 $995.00 ......... $199.00 

65755 ....... Corneal transplant ........................................................................ 7 $2,335.53 $995.00 ......... $199.00 

65770 ....... Revise cornea with implant .......................................................... 7 $3,116.62 $995.00 ......... $199.00 

65772 ....... Correction of astigmatism ............................................................. 4 $923.07 $630.00 ......... $126.00 

65775 ....... Correction of astigmatism ............................................................. 4 $923.07 $630.00 ......... $126.00 

65780 ....... Ocular reconst, transplant ............................................................ 5 $2,335.53 $717.00 ......... $143.40 

65781 ....... Ocular reconst, transplant ............................................................ 5 $2,335.53 $717.00 ......... $143.40 

65782 ....... Ocular reconst, transplant ............................................................ 5 $2,335.53 $717.00 ......... $143.40 

65800 ....... Drainage of eye ............................................................................ 1 $923.07 $333.00 ......... $66.60 

65805 ....... Drainage of eye ............................................................................ 1 $923.07 $333.00 ......... $66.60 

65810 ....... Drainage of eye ............................................................................ 3 $1,412.47 $510.00 ......... $102.00 

65815 ....... Drainage of eye ............................................................................ 2 $1,412.47 $446.00 ......... $89.20 

65820 ....... Relieve inner eye pressure ........................................................... 1 $368.07 $333.00 ......... $66.60 

65850 ....... Incision of eye ............................................................................... 4 $1,412.47 $630.00 ......... $126.00 

65865 ....... Incise inner eye adhesions ........................................................... 1 $923.07 $333.00 ......... $66.60 

65870 ....... Incise inner eye adhesions ........................................................... 4 $1,412.47 $630.00 ......... $126.00 

65875 ....... Incise inner eye adhesions ........................................................... 4 $1,412.47 $630.00 ......... $126.00 

65880 ....... Incise inner eye adhesions ........................................................... 4 $923.07 $630.00 ......... $126.00 

65900 ....... Remove eye lesion ....................................................................... 5 $923.07 $717.00 ......... $143.40 

65920 ....... Remove implant of eye ................................................................. 7 $1,412.47 $995.00 ......... $199.00 

65930 ....... Remove blood clot from eye ........................................................ 5 $1,412.47 $717.00 ......... $143.40 

66020 ....... Injection treatment of eye ............................................................. 1 $923.07 $333.00 ......... $66.60 

66030 ....... Injection treatment of eye ............................................................. 1 $368.07 $333.00 ......... $66.60 

66130 ....... Remove eye lesion ....................................................................... 7 $1,412.47 $995.00 ......... $199.00 

66150 ....... Glaucoma surgery ........................................................................ 4 $1,412.47 $630.00 ......... $126.00 

66155 ....... Glaucoma surgery ........................................................................ 4 $1,412.47 $630.00 ......... $126.00 

66160 ....... Glaucoma surgery ........................................................................ 2 $1,412.47 $446.00 ......... $89.20 

66165 ....... Glaucoma surgery ........................................................................ 4 $1,412.47 $630.00 ......... $126.00 

66170 ....... Glaucoma surgery ........................................................................ 4 $1,412.47 $630.00 ......... $126.00 

66172 ....... Incision of eye ............................................................................... 4 $1,412.47 $630.00 ......... $126.00 

66180 ....... Implant eye shunt ......................................................................... 5 $2,296.20 $717.00 ......... $143.40 

66185 ....... Revise eye shunt .......................................................................... 2 $2,296.20 $446.00 ......... $89.20 

66220 ....... Repair eye lesion .......................................................................... 3 $2,270.12 $510.00 ......... $102.00 

66225 ....... Repair/graft eye lesion .................................................................. 4 $2,296.20 $630.00 ......... $126.00 

66250 ....... Follow-up surgery of eye .............................................................. 2 $923.07 $446.00 ......... $89.20 

66500 ....... Incision of iris ................................................................................ 1 $368.07 $333.00 ......... $66.60 

66505 ....... Incision of iris ................................................................................ 1 $368.07 $333.00 ......... $66.60 

66600 ....... Remove iris and lesion ................................................................. 3 $1,412.47 $510.00 ......... $102.00 

66605 ....... Removal of iris .............................................................................. 3 $1,412.47 $510.00 ......... $102.00 

66625 ....... Removal of iris .............................................................................. 3 $368.07 $368.07 Y ..... $73.61 

66630 ....... Removal of iris .............................................................................. 3 $1,412.47 $510.00 ......... $102.00 

66635 ....... Removal of iris .............................................................................. 3 $1,412.47 $510.00 ......... $102.00 

66680 ....... Repair iris & ciliary body ............................................................... 3 $1,412.47 $510.00 ......... $102.00 

66682 ....... Repair iris & ciliary body ............................................................... 2 $1,412.47 $446.00 ......... $89.20 

66700 ....... Destruction, ciliary body ............................................................... 2 $923.07 $446.00 ......... $89.20 

66710 ....... Ciliary transsleral therapy ............................................................. 2 $923.07 $446.00 ......... $89.20 

66711 ....... Ciliary endoscopic ablation ........................................................... 2 $923.07 $446.00 ......... $89.20 

66720 ....... Destruction, ciliary body ............................................................... 2 $923.07 $446.00 ......... $89.20 

66740 ....... Destruction, ciliary body ............................................................... 2 $1,412.47 $446.00 ......... $89.20 

66821 ....... After cataract laser surgery .......................................................... 2 $315.55 $315.55 Y ..... $63.11 

66825 ....... Reposition intraocular lens ........................................................... 4 $1,412.47 $630.00 ......... $126.00 

66830 ....... Removal of lens lesion ................................................................. 4 $368.07 $368.07 Y ..... $73.61 

66840 ....... Removal of lens material .............................................................. 4 $895.12 $630.00 ......... $126.00 

66850 ....... Removal of lens material .............................................................. 7 $1,754.47 $995.00 ......... $199.00 

66852 ....... Removal of lens material .............................................................. 4 $1,754.47 $630.00 ......... $126.00 

66920 ....... Extraction of lens .......................................................................... 4 $1,754.47 $630.00 ......... $126.00 

66930 ....... Extraction of lens .......................................................................... 5 $1,754.47 $717.00 ......... $143.40 

66940 ....... Extraction of lens .......................................................................... 5 $895.12 $717.00 ......... $143.40 

66982 ....... Cataract surgery, complex ............................................................ 8 $1,450.54 $973.00 ......... $194.60 

66983 ....... Cataract surg w/iol, 1 stage .......................................................... 8 $1,450.54 $973.00 ......... $194.60 

66984 ....... Cataract surg w/iol, 1 stage .......................................................... 8 $1,450.54 $973.00 ......... $194.60 

66985 ....... Insert lens prosthesis .................................................................... 6 $1,450.54 $826.00 ......... $165.20 

66986 ....... Exchange lens prosthesis ............................................................. 6 $1,450.54 $826.00 ......... $165.20 


sroberts on PROD1PC70 with PROPOSALS
49752 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

67005 ....... Partial removal of eye fluid ........................................................... 4 $1,657.60 $630.00 ......... $126.00 

67010 ....... Partial removal of eye fluid ........................................................... 4 $1,657.60 $630.00 ......... $126.00 

67015 ....... Release of eye fluid ...................................................................... 1 $1,657.60 $333.00 ......... $66.60 

67025 ....... Replace eye fluid .......................................................................... 1 $1,657.60 $333.00 ......... $66.60 

67027 ....... Implant eye drug system .............................................................. 4 $2,270.12 $630.00 ......... $126.00 

67030 ....... Incise inner eye strands ............................................................... 1 $1,005.95 $333.00 ......... $66.60 

67031 ....... Laser surgery, eye strands ........................................................... 2 $315.55 $315.55 Y ..... $63.11

67036 ....... Removal of inner eye fluid ............................................................ 4 $2,270.12 $630.00 ......... $126.00 

67038 ....... Strip retinal membrane ................................................................. 5 $2,270.12 $717.00 ......... $143.40 

67039 ....... Laser treatment of retina .............................................................. 7 $2,270.12 $995.00 ......... $199.00 

67040 ....... Laser treatment of retina .............................................................. 7 $2,270.12 $995.00 ......... $199.00 

67107 ....... Repair detached retina ................................................................. 5 $2,270.12 $717.00 ......... $143.40 

67108 ....... Repair detached retina ................................................................. 7 $2,270.12 $995.00 ......... $199.00 

67112 ....... Rerepair detached retina .............................................................. 7 $2,270.12 $995.00 ......... $199.00 

67115 ....... Release encircling material .......................................................... 2 $1,005.95 $446.00 ......... $89.20 

67120 ....... Remove eye implant material ....................................................... 2 $1,005.95 $446.00 ......... $89.20 

67121 ....... Remove eye implant material ....................................................... 2 $1,657.60 $446.00 ......... $89.20 

67141 ....... Treatment of retina ....................................................................... 2 $250.82 $250.82 Y ..... $50.16 

67218 ....... Treatment of retinal lesion ............................................................ 5 $1,005.95 $717.00 ......... $143.40 

67227 ....... Treatment of retinal lesion ............................................................ 1 $1,657.60 $333.00 ......... $66.60 

67250 ....... Reinforce eye wall ........................................................................ 3 $1,047.14 $510.00 ......... $102.00 

67255 ....... Reinforce/graft eye wall ................................................................ 3 $1,657.60 $510.00 ......... $102.00 

67311 ....... Revise eye muscle ....................................................................... 3 $1,310.33 $510.00 ......... $102.00 

67312 ....... Revise two eye muscles ............................................................... 4 $1,310.33 $630.00 ......... $126.00 

67314 ....... Revise eye muscle ....................................................................... 4 $1,310.33 $630.00 ......... $126.00 

67316 ....... Revise two eye muscles ............................................................... 4 $1,310.33 $630.00 ......... $126.00 

67318 ....... Revise eye muscle(s) ................................................................... 4 $1,310.33 $630.00 ......... $126.00 

67320 ....... Revise eye muscle(s) add-on ....................................................... 4 $1,310.33 $630.00 ......... $126.00 

67331 ....... Eye surgery follow-up add-on ....................................................... 4 $1,310.33 $630.00 ......... $126.00 

67332 ....... Rerevise eye muscles add-on ...................................................... 4 $1,310.33 $630.00 ......... $126.00 

67334 ....... Revise eye muscle w/suture ......................................................... 4 $1,310.33 $630.00 ......... $126.00 

67335 ....... Eye suture during surgery ............................................................ 4 $1,310.33 $630.00 ......... $126.00 

67340 ....... Revise eye muscle add-on ........................................................... 4 $1,310.33 $630.00 ......... $126.00 

67343 ....... Release eye tissue ....................................................................... 7 $1,310.33 $995.00 ......... $199.00 

67350 ....... Biopsy eye muscle ........................................................................ 1 $858.69 $333.00 ......... $66.60 

67400 ....... Explore/biopsy eye socket ............................................................ 3 $1,529.55 $510.00 ......... $102.00 

67405 ....... Explore/drain eye socket .............................................................. 4 $1,529.55 $630.00 ......... $126.00 

67412 ....... Explore/treat eye socket ............................................................... 5 $1,529.55 $717.00 ......... $143.40 

67413 ....... Explore/treat eye socket ............................................................... 5 $1,529.55 $717.00 ......... $143.40 

67415 ....... Aspiration, orbital contents ........................................................... 1 $1,047.14 $333.00 ......... $66.60 

67420 ....... Explore/treat eye socket ............................................................... 5 $2,186.40 $717.00 ......... $143.40 

67430 ....... Explore/treat eye socket ............................................................... 5 $2,186.40 $717.00 ......... $143.40 

67440 ....... Explore/drain eye socket .............................................................. 5 $2,186.40 $717.00 ......... $143.40 

67445 ....... Explr/decompress eye socket ....................................................... 5 $2,186.40 $717.00 ......... $143.40 

67450 ....... Explore/biopsy eye socket ............................................................ 5 $2,186.40 $717.00 ......... $143.40 

67550 ....... Insert eye socket implant .............................................................. 4 $2,186.40 $630.00 ......... $126.00 

67560 ....... Revise eye socket implant ............................................................ 2 $1,529.55 $446.00 ......... $89.20 

67570 ....... Decompress optic nerve ............................................................... 4 $2,186.40 $630.00 ......... $126.00 

67715 ....... Incision of eyelid fold .................................................................... 1 $1,047.14 $333.00 ......... $66.60 

67808 ....... Remove eyelid lesion(s) ............................................................... 2 $1,047.14 $446.00 ......... $89.20 

67830 ....... Revise eyelashes .......................................................................... 2 $426.88 $426.88 Y ..... $85.38 

67835 ....... Revise eyelashes .......................................................................... 2 $1,047.14 $446.00 ......... $89.20 

67880 ....... Revision of eyelid ......................................................................... 3 $923.07 $510.00 ......... $102.00 

67882 ....... Revision of eyelid ......................................................................... 3 $1,047.14 $510.00 ......... $102.00 

67900 ....... Repair brow defect ....................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67901 ....... Repair eyelid defect ...................................................................... 5 $1,047.14 $717.00 ......... $143.40 

67902 ....... Repair eyelid defect ...................................................................... 5 $1,047.14 $717.00 ......... $143.40 

67903 ....... Repair eyelid defect ...................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67904 ....... Repair eyelid defect ...................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67906 ....... Repair eyelid defect ...................................................................... 5 $1,047.14 $717.00 ......... $143.40 

67908 ....... Repair eyelid defect ...................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67909 ....... Revise eyelid defect ..................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67911 ....... Revise eyelid defect ..................................................................... 3 $1,047.14 $510.00 ......... $102.00 

67912 ....... Correction eyelid w/implant .......................................................... 3 $1,047.14 $510.00 ......... $102.00 

67914 ....... Repair eyelid defect ...................................................................... 3 $1,047.14 $510.00 ......... $102.00 

67916 ....... Repair eyelid defect ...................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67917 ....... Repair eyelid defect ...................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67921 ....... Repair eyelid defect ...................................................................... 3 $1,047.14 $510.00 ......... $102.00 

67923 ....... Repair eyelid defect ...................................................................... 4 $1,047.14 $630.00 ......... $126.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49753 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

67924 ....... Repair eyelid defect ...................................................................... 4 $1,047.14 $630.00 ......... $126.00 

67935 ....... Repair eyelid wound ..................................................................... 2 $1,047.14 $446.00 ......... $89.20 

67950 ....... Revision of eyelid ......................................................................... 2 $1,047.14 $446.00 ......... $89.20 

67961 ....... Revision of eyelid ......................................................................... 3 $1,047.14 $510.00 ......... $102.00 

67966 ....... Revision of eyelid ......................................................................... 3 $1,047.14 $510.00 ......... $102.00 

67971 ....... Reconstruction of eyelid ............................................................... 3 $1,529.55 $510.00 ......... $102.00 

67973 ....... Reconstruction of eyelid ............................................................... 3 $1,529.55 $510.00 ......... $102.00 

67974 ....... Reconstruction of eyelid ............................................................... 3 $1,529.55 $510.00 ......... $102.00 

67975 ....... Reconstruction of eyelid ............................................................... 3 $1,047.14 $510.00 ......... $102.00 

68115 ....... Remove eyelid lining lesion .......................................................... 2 $1,047.14 $446.00 ......... $89.20 

68130 ....... Remove eyelid lining lesion .......................................................... 2 $923.07 $446.00 ......... $89.20 

68320 ....... Revise/graft eyelid lining ............................................................... 4 $1,047.14 $630.00 ......... $126.00 

68325 ....... Revise/graft eyelid lining ............................................................... 4 $1,529.55 $630.00 ......... $126.00 

68326 ....... Revise/graft eyelid lining ............................................................... 4 $1,529.55 $630.00 ......... $126.00 

68328 ....... Revise/graft eyelid lining ............................................................... 4 $1,529.55 $630.00 ......... $126.00 

68330 ....... Revise eyelid lining ....................................................................... 4 $1,412.47 $630.00 ......... $126.00 

68335 ....... Revise/graft eyelid lining ............................................................... 4 $1,529.55 $630.00 ......... $126.00 

68340 ....... Separate eyelid adhesions ........................................................... 4 $1,047.14 $630.00 ......... $126.00 

68360 ....... Revise eyelid lining ....................................................................... 2 $1,412.47 $446.00 ......... $89.20 

68362 ....... Revise eyelid lining ....................................................................... 2 $1,412.47 $446.00 ......... $89.20 

68371 ....... Harvest eye tissue, alograft .......................................................... 2 $923.07 $446.00 ......... $89.20 

68500 ....... Removal of tear gland .................................................................. 3 $1,529.55 $510.00 ......... $102.00 

68505 ....... Partial removal, tear gland ........................................................... 3 $1,529.55 $510.00 ......... $102.00 

68510 ....... Biopsy of tear gland ...................................................................... 1 $1,047.14 $333.00 ......... $66.60 

68520 ....... Removal of tear sac ..................................................................... 3 $1,529.55 $510.00 ......... $102.00 

68525 ....... Biopsy of tear sac ......................................................................... 1 $1,047.14 $333.00 ......... $66.60 

68540 ....... Remove tear gland lesion ............................................................. 3 $1,529.55 $510.00 ......... $102.00 

68550 ....... Remove tear gland lesion ............................................................. 3 $1,529.55 $510.00 ......... $102.00 

68700 ....... Repair tear ducts .......................................................................... 2 $1,529.55 $446.00 ......... $89.20 

68720 ....... Create tear sac drain .................................................................... 4 $1,529.55 $630.00 ......... $126.00 

68745 ....... Create tear duct drain ................................................................... 4 $1,529.55 $630.00 ......... $126.00 

68750 ....... Create tear duct drain ................................................................... 4 $1,529.55 $630.00 ......... $126.00 

68770 ....... Close tear system fistula .............................................................. 4 $1,047.14 $630.00 ......... $126.00 

68810 ....... Probe nasolacrimal duct ............................................................... 1 $135.01 $135.01 Y ..... $27.00 

68811 ....... Probe nasolacrimal duct ............................................................... 2 $1,047.14 $446.00 ......... $89.20 

68815 ....... Probe nasolacrimal duct ............................................................... 2 $1,047.14 $446.00 ......... $89.20 

69110 ....... Remove external ear, partial ........................................................ 1 $920.58 $333.00 ......... $66.60 

69120 ....... Removal of external ear ............................................................... 2 $1,425.30 $446.00 ......... $89.20 

69140 ....... Remove ear canal lesion(s) .......................................................... 2 $1,425.30 $446.00 ......... $89.20 

69145 ....... Remove ear canal lesion(s) .......................................................... 2 $920.58 $446.00 ......... $89.20 

69150 ....... Extensive ear canal surgery ......................................................... 3 $475.55 $475.55 Y ..... $95.11 

69205 ....... Clear outer ear canal .................................................................... 1 $1,229.54 $333.00 ......... $66.60 

69300 ....... Revise external ear ....................................................................... 3 $1,425.30 $510.00 ......... $102.00 

69310 ....... Rebuild outer ear canal ................................................................ 3 $2,324.90 $510.00 ......... $102.00 

69320 ....... Rebuild outer ear canal ................................................................ 7 $2,324.90 $995.00 ......... $199.00 

69421 ....... Incision of eardrum ....................................................................... 3 $1,012.48 $510.00 ......... $102.00 

69436 ....... Create eardrum opening ............................................................... 3 $1,012.48 $510.00 ......... $102.00 

69440 ....... Exploration of middle ear .............................................................. 3 $1,425.30 $510.00 ......... $102.00 

69450 ....... Eardrum revision ........................................................................... 1 $2,324.90 $333.00 ......... $66.60 

69501 ....... Mastoidectomy .............................................................................. 7 $2,324.90 $995.00 ......... $199.00 

69502 ....... Mastoidectomy .............................................................................. 7 $1,425.30 $995.00 ......... $199.00 

69505 ....... Remove mastoid structures .......................................................... 7 $2,324.90 $995.00 ......... $199.00 

69511 ....... Extensive mastoid surgery ........................................................... 7 $2,324.90 $995.00 ......... $199.00 

69530 ....... Extensive mastoid surgery ........................................................... 7 $2,324.90 $995.00 ......... $199.00 

69550 ....... Remove ear lesion ........................................................................ 5 $2,324.90 $717.00 ......... $143.40 

69552 ....... Remove ear lesion ........................................................................ 7 $2,324.90 $995.00 ......... $199.00 

69601 ....... Mastoid surgery revision ............................................................... 7 $2,324.90 $995.00 ......... $199.00 

69602 ....... Mastoid surgery revision ............................................................... 7 $2,324.90 $995.00 ......... $199.00 

69603 ....... Mastoid surgery revision ............................................................... 7 $2,324.90 $995.00 ......... $199.00 

69604 ....... Mastoid surgery revision ............................................................... 7 $2,324.90 $995.00 ......... $199.00 

69605 ....... Mastoid surgery revision ............................................................... 7 $2,324.90 $995.00 ......... $199.00 

69620 ....... Repair of eardrum ......................................................................... 2 $1,425.30 $446.00 ......... $89.20 

69631 ....... Repair eardrum structures ............................................................ 5 $2,324.90 $717.00 ......... $143.40 

69632 ....... Rebuild eardrum structures .......................................................... 5 $2,324.90 $717.00 ......... $143.40 

69633 ....... Rebuild eardrum structures .......................................................... 5 $2,324.90 $717.00 ......... $143.40 

69635 ....... Repair eardrum structures ............................................................ 7 $2,324.90 $995.00 ......... $199.00 

69636 ....... Rebuild eardrum structures .......................................................... 7 $2,324.90 $995.00 ......... $199.00 

69637 ....... Rebuild eardrum structures .......................................................... 7 $2,324.90 $995.00 ......... $199.00 

69641 ....... Revise middle ear & mastoid ....................................................... 7 $2,324.90 $995.00 ......... $199.00 


sroberts on PROD1PC70 with PROPOSALS
49754 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM AA.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND

PAYMENT RATES; INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DRA—Continued 

HCPCS Short Descriptor ASC Payment Group 

OPPS Payment Rate ASC Payment Rate DRA 

Cap 

ASC Copayment 

Amount 

69642 ....... Revise middle ear & mastoid ....................................................... 7 $2,324.90 $995.00 ......... $199.00 

69643 ....... Revise middle ear & mastoid ....................................................... 7 $2,324.90 $995.00 ......... $199.00 

69644 ....... Revise middle ear & mastoid ....................................................... 7 $2,324.90 $995.00 ......... $199.00 

69645 ....... Revise middle ear & mastoid ....................................................... 7 $2,324.90 $995.00 ......... $199.00 

69646 ....... Revise middle ear & mastoid ....................................................... 7 $2,324.90 $995.00 ......... $199.00 

69650 ....... Release middle ear bone ............................................................. 7 $1,425.30 $995.00 ......... $199.00 

69660 ....... Revise middle ear bone ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

69661 ....... Revise middle ear bone ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

69662 ....... Revise middle ear bone ................................................................ 5 $2,324.90 $717.00 ......... $143.40 

69666 ....... Repair middle ear structures ........................................................ 4 $2,324.90 $630.00 ......... $126.00 

69667 ....... Repair middle ear structures ........................................................ 4 $2,324.90 $630.00 ......... $126.00 

69670 ....... Remove mastoid air cells ............................................................. 3 $2,324.90 $510.00 ......... $102.00 

69676 ....... Remove middle ear nerve ............................................................ 3 $2,324.90 $510.00 ......... $102.00 

69700 ....... Close mastoid fistula .................................................................... 3 $2,324.90 $510.00 ......... $102.00 

69711 ....... Remove/repair hearing aid ........................................................... 1 $2,324.90 $333.00 ......... $66.60 

69714 ....... Implant temple bone w/stimul ....................................................... 9 $2,324.90 $1,339.00 ......... $267.80 

69715 ....... Temple bne implnt w/stimulat ....................................................... 9 $2,324.90 $1,339.00 ......... $267.80 

69717 ....... Temple bone implant revision ...................................................... 9 $2,324.90 $1,339.00 ......... $267.80 

69718 ....... Revise temple bone implant ......................................................... 9 $2,324.90 $1,339.00 ......... $267.80 

69720 ....... Release facial nerve ..................................................................... 5 $2,324.90 $717.00 ......... $143.40 

69740 ....... Repair facial nerve ........................................................................ 5 $2,324.90 $717.00 ......... $143.40 

69745 ....... Repair facial nerve ........................................................................ 5 $2,324.90 $717.00 ......... $143.40 

69801 ....... Incise inner ear ............................................................................. 5 $2,324.90 $717.00 ......... $143.40 

69802 ....... Incise inner ear ............................................................................. 7 $2,324.90 $995.00 ......... $199.00 

69805 ....... Explore inner ear .......................................................................... 7 $2,324.90 $995.00 ......... $199.00 

69806 ....... Explore inner ear .......................................................................... 7 $2,324.90 $995.00 ......... $199.00 

69820 ....... Establish inner ear window ........................................................... 5 $2,324.90 $717.00 ......... $143.40 

69840 ....... Revise inner ear window .............................................................. 5 $2,324.90 $717.00 ......... $143.40 

69905 ....... Remove inner ear ......................................................................... 7 $2,324.90 $995.00 ......... $199.00 

69910 ....... Remove inner ear & mastoid ........................................................ 7 $2,324.90 $995.00 ......... $199.00 

69915 ....... Incise inner ear nerve ................................................................... 7 $2,324.90 $995.00 ......... $199.00 

69930 ....... Implant cochlear device ................................................................ 7 $25,040.37 $995.00 ......... $199.00 

G0105 ...... Colorectal scrn; hi risk ind ............................................................ 2 $480.92 $446.00 ......... $89.20 

G0121 ...... Colon ca scrn; not high rsk .......................................................... 2 $480.92 $446.00 ......... $89.20 

G0260 ...... Inj for sacroiliac jt anesth .............................................................. 1 $341.23 $333.00 ......... $66.60 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

00100 ....... Anesth, salivary gland .................................... ........... N ....... .......... .................... .................... .................... ....................

00102 ....... Anesth, repair of cleft lip ................................ ........... N ....... .......... .................... .................... .................... ....................

00103 ....... Anesth, blepharoplasty ................................... ........... N ....... .......... .................... .................... .................... ....................

00104 ....... Anesth, electroshock ...................................... ........... N ....... .......... .................... .................... .................... ....................

00120 ....... Anesth, ear surgery ........................................ ........... N ....... .......... .................... .................... .................... ....................

00124 ....... Anesth, ear exam ........................................... ........... N ....... .......... .................... .................... .................... ....................

00126 ....... Anesth, tympanotomy .................................... ........... N ....... .......... .................... .................... .................... ....................

00140 ....... Anesth, procedures on eye ............................ ........... N ....... .......... .................... .................... .................... ....................

00142 ....... Anesth, lens surgery ...................................... ........... N ....... .......... .................... .................... .................... ....................

00144 ....... Anesth, corneal transplant ............................. ........... N ....... .......... .................... .................... .................... ....................

00145 ....... Anesth, vitreoretinal surg ............................... ........... N ....... .......... .................... .................... .................... ....................

00147 ....... Anesth, iridectomy .......................................... ........... N ....... .......... .................... .................... .................... ....................

00148 ....... Anesth, eye exam .......................................... ........... N ....... .......... .................... .................... .................... ....................

00160 ....... Anesth, nose/sinus surgery ............................ ........... N ....... .......... .................... .................... .................... ....................

00162 ....... Anesth, nose/sinus surgery ............................ ........... N ....... .......... .................... .................... .................... ....................

00164 ....... Anesth, biopsy of nose .................................. ........... N ....... .......... .................... .................... .................... ....................

00170 ....... Anesth, procedure on mouth ......................... ........... N ....... .......... .................... .................... .................... ....................

00172 ....... Anesth, cleft palate repair .............................. ........... N ....... .......... .................... .................... .................... ....................

00174 ....... Anesth, pharyngeal surgery ........................... ........... N ....... .......... .................... .................... .................... ....................

00190 ....... Anesth, face/skull bone surg .......................... ........... N ....... .......... .................... .................... .................... ....................

00210 ....... Anesth, open head surgery ............................ ........... N ....... .......... .................... .................... .................... ....................

00212 ....... Anesth, skull drainage .................................... ........... N ....... .......... .................... .................... .................... ....................

00216 ....... Anesth, head vessel surgery ......................... ........... N ....... .......... .................... .................... .................... ....................

00218 ....... Anesth, special head surgery ........................ ........... N ....... .......... .................... .................... .................... ....................

00220 ....... Anesth, intrcrn nerve ...................................... ........... N ....... .......... .................... .................... .................... ....................

00222 ....... Anesth, head nerve surgery ........................... ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49755 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

00300 ....... Anesth, head/neck/ptrunk .............................. ........... N ....... .......... .................... .................... .................... ....................

00320 ....... Anesth, neck organ, 1 & over ........................ ........... N ....... .......... .................... .................... .................... ....................

00322 ....... Anesth, biopsy of thyroid ............................... ........... N ....... .......... .................... .................... .................... ....................

00326 ....... Anesth, larynx/trach, < 1 yr ............................ ........... N ....... .......... .................... .................... .................... ....................

00350 ....... Anesth, neck vessel surgery .......................... ........... N ....... .......... .................... .................... .................... ....................

00352 ....... Anesth, neck vessel surgery .......................... ........... N ....... .......... .................... .................... .................... ....................

00400 ....... Anesth, skin, ext/per/atrunk ........................... ........... N ....... .......... .................... .................... .................... ....................

00402 ....... Anesth, surgery of breast ............................... ........... N ....... .......... .................... .................... .................... ....................

00410 ....... Anesth, correct heart rhythm ......................... ........... N ....... .......... .................... .................... .................... ....................

00450 ....... Anesth, surgery of shoulder ........................... ........... N ....... .......... .................... .................... .................... ....................

00454 ....... Anesth, collar bone biopsy ............................. ........... N ....... .......... .................... .................... .................... ....................

00470 ....... Anesth, removal of rib .................................... ........... N ....... .......... .................... .................... .................... ....................

00472 ....... Anesth, chest wall repair ................................ ........... N ....... .......... .................... .................... .................... ....................

00500 ....... Anesth, esophageal surgery .......................... ........... N ....... .......... .................... .................... .................... ....................

00520 ....... Anesth, chest procedure ................................ ........... N ....... .......... .................... .................... .................... ....................

00522 ....... Anesth, chest lining biopsy ............................ ........... N ....... .......... .................... .................... .................... ....................

00528 ....... Anesth, chest partition view ........................... ........... N ....... .......... .................... .................... .................... ....................

00529 ....... Anesth, chest partition view ........................... ........... N ....... .......... .................... .................... .................... ....................

00530 ....... Anesth, pacemaker insertion ......................... ........... N ....... .......... .................... .................... .................... ....................

00532 ....... Anesth, vascular access ................................ ........... N ....... .......... .................... .................... .................... ....................

00534 ....... Anesth, cardioverter/defib .............................. ........... N ....... .......... .................... .................... .................... ....................

00537 ....... Anesth, cardiac electrophys ........................... ........... N ....... .......... .................... .................... .................... ....................

00539 ....... Anesth, trach-bronch reconst ......................... ........... N ....... .......... .................... .................... .................... ....................

00541 ....... Anesth, one lung ventilation ........................... ........... N ....... .......... .................... .................... .................... ....................

00548 ....... Anesth, trachea,bronchi surg ......................... ........... N ....... .......... .................... .................... .................... ....................

00550 ....... Anesth, sternal debridement .......................... ........... N ....... .......... .................... .................... .................... ....................

00563 ....... Anesth, heart surg w/arrest ............................ ........... N ....... .......... .................... .................... .................... ....................

00566 ....... Anesth, cabg w/o pump ................................. ........... N ....... .......... .................... .................... .................... ....................

00600 ....... Anesth, spine, cord surgery ........................... ........... N ....... .......... .................... .................... .................... ....................

00620 ....... Anesth, spine, cord surgery ........................... ........... N ....... .......... .................... .................... .................... ....................

00630 ....... Anesth, spine, cord surgery ........................... ........... N ....... .......... .................... .................... .................... ....................

00634 ....... Anesth for chemonucleolysis ......................... ........... N ....... .......... .................... .................... .................... ....................

00635 ....... Anesth, lumbar puncture ................................ ........... N ....... .......... .................... .................... .................... ....................

00640 ....... Anesth, spine manipulation ............................ ........... N ....... .......... .................... .................... .................... ....................

00700 ....... Anesth, abdominal wall surg .......................... ........... N ....... .......... .................... .................... .................... ....................

00702 ....... Anesth, for liver biopsy .................................. ........... N ....... .......... .................... .................... .................... ....................

00730 ....... Anesth, abdominal wall surg .......................... ........... N ....... .......... .................... .................... .................... ....................

00740 ....... Anesth, upper gi visualize .............................. ........... N ....... .......... .................... .................... .................... ....................

00750 ....... Anesth, repair of hernia ................................. ........... N ....... .......... .................... .................... .................... ....................

00752 ....... Anesth, repair of hernia ................................. ........... N ....... .......... .................... .................... .................... ....................

00754 ....... Anesth, repair of hernia ................................. ........... N ....... .......... .................... .................... .................... ....................

00756 ....... Anesth, repair of hernia ................................. ........... N ....... .......... .................... .................... .................... ....................

00770 ....... Anesth, blood vessel repair ........................... ........... N ....... .......... .................... .................... .................... ....................

00790 ....... Anesth, surg upper abdomen ........................ ........... N ....... .......... .................... .................... .................... ....................

00797 ....... Anesth, surgery for obesity ............................ ........... N ....... .......... .................... .................... .................... ....................

00800 ....... Anesth, abdominal wall surg .......................... ........... N ....... .......... .................... .................... .................... ....................

00810 ....... Anesth, low intestine scope ........................... ........... N ....... .......... .................... .................... .................... ....................

00820 ....... Anesth, abdominal wall surg .......................... ........... N ....... .......... .................... .................... .................... ....................

00830 ....... Anesth, repair of hernia ................................. ........... N ....... .......... .................... .................... .................... ....................

00832 ....... Anesth, repair of hernia ................................. ........... N ....... .......... .................... .................... .................... ....................

00834 ....... Anesth, hernia repair < 1 yr ........................... ........... N ....... .......... .................... .................... .................... ....................

00836 ....... Anesth hernia repair preemie ........................ ........... N ....... .......... .................... .................... .................... ....................

00840 ....... Anesth, surg lower abdomen ......................... ........... N ....... .......... .................... .................... .................... ....................

00842 ....... Anesth, amniocentesis ................................... ........... N ....... .......... .................... .................... .................... ....................

00851 ....... Anesth, tubal ligation ...................................... ........... N ....... .......... .................... .................... .................... ....................

00860 ....... Anesth, surgery of abdomen .......................... ........... N ....... .......... .................... .................... .................... ....................

00862 ....... Anesth, kidney/ureter surg ............................. ........... N ....... .......... .................... .................... .................... ....................

00870 ....... Anesth, bladder stone surg ............................ ........... N ....... .......... .................... .................... .................... ....................

00872 ....... Anesth kidney stone destruct ......................... ........... N ....... .......... .................... .................... .................... ....................

00873 ....... Anesth kidney stone destruct ......................... ........... N ....... .......... .................... .................... .................... ....................

00880 ....... Anesth, abdomen vessel surg ....................... ........... N ....... .......... .................... .................... .................... ....................

00902 ....... Anesth, anorectal surgery .............................. ........... N ....... .......... .................... .................... .................... ....................

00906 ....... Anesth, removal of vulva ............................... ........... N ....... .......... .................... .................... .................... ....................

00910 ....... Anesth, bladder surgery ................................. ........... N ....... .......... .................... .................... .................... ....................

00912 ....... Anesth, bladder tumor surg ........................... ........... N ....... .......... .................... .................... .................... ....................

00914 ....... Anesth, removal of prostate ........................... ........... N ....... .......... .................... .................... .................... ....................

00916 ....... Anesth, bleeding control ................................ ........... N ....... .......... .................... .................... .................... ....................

00918 ....... Anesth, stone removal ................................... ........... N ....... .......... .................... .................... .................... ....................

00920 ....... Anesth, genitalia surgery ............................... ........... N ....... .......... .................... .................... .................... ....................

00921 ....... Anesth, vasectomy ......................................... ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
49756 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

00922 ....... Anesth, sperm duct surgery ........................... ........... N ....... .......... .................... .................... .................... ....................

00924 ....... Anesth, testis exploration ............................... ........... N ....... .......... .................... .................... .................... ....................

00926 ....... Anesth, removal of testis ............................... ........... N ....... .......... .................... .................... .................... ....................

00928 ....... Anesth, removal of testis ............................... ........... N ....... .......... .................... .................... .................... ....................

00930 ....... Anesth, testis suspension .............................. ........... N ....... .......... .................... .................... .................... ....................

00938 ....... Anesth, insert penis device ............................ ........... N ....... .......... .................... .................... .................... ....................

00940 ....... Anesth, vaginal procedures ........................... ........... N ....... .......... .................... .................... .................... ....................

00942 ....... Anesth, surg on vag/urethral .......................... ........... N ....... .......... .................... .................... .................... ....................

00948 ....... Anesth, repair of cervix .................................. ........... N ....... .......... .................... .................... .................... ....................

00950 ....... Anesth, vaginal endoscopy ............................ ........... N ....... .......... .................... .................... .................... ....................

00952 ....... Anesth, hysteroscope/graph .......................... ........... N ....... .......... .................... .................... .................... ....................

01112 ....... Anesth, bone aspirate/bx ............................... ........... N ....... .......... .................... .................... .................... ....................

01120 ....... Anesth, pelvis surgery .................................... ........... N ....... .......... .................... .................... .................... ....................

01130 ....... Anesth, body cast procedure ......................... ........... N ....... .......... .................... .................... .................... ....................

01160 ....... Anesth, pelvis procedure ............................... ........... N ....... .......... .................... .................... .................... ....................

01170 ....... Anesth, pelvis surgery .................................... ........... N ....... .......... .................... .................... .................... ....................

01173 ....... Anesth, fx repair, pelvis ................................. ........... N ....... .......... .................... .................... .................... ....................

01180 ....... Anesth, pelvis nerve removal ......................... ........... N ....... .......... .................... .................... .................... ....................

01190 ....... Anesth, pelvis nerve removal ......................... ........... N ....... .......... .................... .................... .................... ....................

01200 ....... Anesth, hip joint procedure ............................ ........... N ....... .......... .................... .................... .................... ....................

01202 ....... Anesth, arthroscopy of hip ............................. ........... N ....... .......... .................... .................... .................... ....................

01210 ....... Anesth, hip joint surgery ................................ ........... N ....... .......... .................... .................... .................... ....................

01215 ....... Anesth, revise hip repair ................................ ........... N ....... .......... .................... .................... .................... ....................

01220 ....... Anesth, procedure on femur .......................... ........... N ....... .......... .................... .................... .................... ....................

01230 ....... Anesth, surgery of femur ............................... ........... N ....... .......... .................... .................... .................... ....................

01250 ....... Anesth, upper leg surgery .............................. ........... N ....... .......... .................... .................... .................... ....................

01260 ....... Anesth, upper leg veins surg ......................... ........... N ....... .......... .................... .................... .................... ....................

01270 ....... Anesth, thigh arteries surg ............................. ........... N ....... .......... .................... .................... .................... ....................

01320 ....... Anesth, knee area surgery ............................. ........... N ....... .......... .................... .................... .................... ....................

01340 ....... Anesth, knee area procedure ........................ ........... N ....... .......... .................... .................... .................... ....................

01360 ....... Anesth, knee area surgery ............................. ........... N ....... .......... .................... .................... .................... ....................

01380 ....... Anesth, knee joint procedure ......................... ........... N ....... .......... .................... .................... .................... ....................

01382 ....... Anesth, dx knee arthroscopy ......................... ........... N ....... .......... .................... .................... .................... ....................

01390 ....... Anesth, knee area procedure ........................ ........... N ....... .......... .................... .................... .................... ....................

01392 ....... Anesth, knee area surgery ............................. ........... N ....... .......... .................... .................... .................... ....................

01400 ....... Anesth, knee joint surgery ............................. ........... N ....... .......... .................... .................... .................... ....................

01420 ....... Anesth, knee joint casting .............................. ........... N ....... .......... .................... .................... .................... ....................

01430 ....... Anesth, knee veins surgery ........................... ........... N ....... .......... .................... .................... .................... ....................

01432 ....... Anesth, knee vessel surg ............................... ........... N ....... .......... .................... .................... .................... ....................

01440 ....... Anesth, knee arteries surg ............................. ........... N ....... .......... .................... .................... .................... ....................

01462 ....... Anesth, lower leg procedure .......................... ........... N ....... .......... .................... .................... .................... ....................

01464 ....... Anesth, ankle/ft arthroscopy .......................... ........... N ....... .......... .................... .................... .................... ....................

01470 ....... Anesth, lower leg surgery .............................. ........... N ....... .......... .................... .................... .................... ....................

01472 ....... Anesth, achilles tendon surg .......................... ........... N ....... .......... .................... .................... .................... ....................

01474 ....... Anesth, lower leg surgery .............................. ........... N ....... .......... .................... .................... .................... ....................

01480 ....... Anesth, lower leg bone surg .......................... ........... N ....... .......... .................... .................... .................... ....................

01482 ....... Anesth, radical leg surgery ............................ ........... N ....... .......... .................... .................... .................... ....................

01484 ....... Anesth, lower leg revision .............................. ........... N ....... .......... .................... .................... .................... ....................

01490 ....... Anesth, lower leg casting ............................... ........... N ....... .......... .................... .................... .................... ....................

01500 ....... Anesth, leg arteries surg ................................ ........... N ....... .......... .................... .................... .................... ....................

01520 ....... Anesth, lower leg vein surg ........................... ........... N ....... .......... .................... .................... .................... ....................

01522 ....... Anesth, lower leg vein surg ........................... ........... N ....... .......... .................... .................... .................... ....................

01610 ....... Anesth, surgery of shoulder ........................... ........... N ....... .......... .................... .................... .................... ....................

01620 ....... Anesth, shoulder procedure ........................... ........... N ....... .......... .................... .................... .................... ....................

01622 ....... Anes dx shoulder arthroscopy ....................... ........... N ....... .......... .................... .................... .................... ....................

01630 ....... Anesth, surgery of shoulder ........................... ........... N ....... .......... .................... .................... .................... ....................

01650 ....... Anesth, shoulder artery surg .......................... ........... N ....... .......... .................... .................... .................... ....................

01670 ....... Anesth, shoulder vein surg ............................ ........... N ....... .......... .................... .................... .................... ....................

01680 ....... Anesth, shoulder casting ................................ ........... N ....... .......... .................... .................... .................... ....................

01682 ....... Anesth, airplane cast ..................................... ........... N ....... .......... .................... .................... .................... ....................

01710 ....... Anesth, elbow area surgery ........................... ........... N ....... .......... .................... .................... .................... ....................

01712 ....... Anesth, uppr arm tendon surg ....................... ........... N ....... .......... .................... .................... .................... ....................

01714 ....... Anesth, uppr arm tendon surg ....................... ........... N ....... .......... .................... .................... .................... ....................

01716 ....... Anesth, biceps tendon repair ......................... ........... N ....... .......... .................... .................... .................... ....................

01730 ....... Anesth, uppr arm procedure .......................... ........... N ....... .......... .................... .................... .................... ....................

01732 ....... Anesth, dx elbow arthroscopy ........................ ........... N ....... .......... .................... .................... .................... ....................

01740 ....... Anesth, upper arm surgery ............................ ........... N ....... .......... .................... .................... .................... ....................

01742 ....... Anesth, humerus surgery ............................... ........... N ....... .......... .................... .................... .................... ....................

01744 ....... Anesth, humerus repair .................................. ........... N ....... .......... .................... .................... .................... ....................

01758 ....... Anesth, humeral lesion surg .......................... ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49757 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

01760 ....... Anesth, elbow replacement ............................ ........... N ....... .......... .................... .................... .................... ....................

01770 ....... Anesth, uppr arm artery surg ......................... ........... N ....... .......... .................... .................... .................... ....................

01772 ....... Anesth, uppr arm embolectomy ..................... ........... N ....... .......... .................... .................... .................... ....................

01780 ....... Anesth, upper arm vein surg ......................... ........... N ....... .......... .................... .................... .................... ....................

01782 ....... Anesth, uppr arm vein repair ......................... ........... N ....... .......... .................... .................... .................... ....................

01810 ....... Anesth, lower arm surgery ............................. ........... N ....... .......... .................... .................... .................... ....................

01820 ....... Anesth, lower arm procedure ......................... ........... N ....... .......... .................... .................... .................... ....................

01829 ....... Anesth, dx wrist arthroscopy .......................... ........... N ....... .......... .................... .................... .................... ....................

01830 ....... Anesth, lower arm surgery ............................. ........... N ....... .......... .................... .................... .................... ....................

01832 ....... Anesth, wrist replacement .............................. ........... N ....... .......... .................... .................... .................... ....................

01840 ....... Anesth, lwr arm artery surg ........................... ........... N ....... .......... .................... .................... .................... ....................

01842 ....... Anesth, lwr arm embolectomy ....................... ........... N ....... .......... .................... .................... .................... ....................

01844 ....... Anesth, vascular shunt surg .......................... ........... N ....... .......... .................... .................... .................... ....................

01850 ....... Anesth, lower arm vein surg .......................... ........... N ....... .......... .................... .................... .................... ....................

01852 ....... Anesth, lwr arm vein repair ............................ ........... N ....... .......... .................... .................... .................... ....................

01860 ....... Anesth, lower arm casting ............................. ........... N ....... .......... .................... .................... .................... ....................

01905 ....... Anes, spine inject, x-ray/re ............................ ........... N ....... .......... .................... .................... .................... ....................

01916 ....... Anesth, dx arteriography ................................ ........... N ....... .......... .................... .................... .................... ....................

01920 ....... Anesth, catheterize heart ............................... ........... N ....... .......... .................... .................... .................... ....................

01922 ....... Anesth, cat or MRI scan ................................ ........... N ....... .......... .................... .................... .................... ....................

01924 ....... Anes, ther interven rad, art ............................ ........... N ....... .......... .................... .................... .................... ....................

01925 ....... Anes, ther interven rad, car ........................... ........... N ....... .......... .................... .................... .................... ....................

01926 ....... Anes, tx interv rad hrt/cran ............................ ........... N ....... .......... .................... .................... .................... ....................

01930 ....... Anes, ther interven rad, vei ............................ ........... N ....... .......... .................... .................... .................... ....................

01931 ....... Anes, ther interven rad, tip ............................ ........... N ....... .......... .................... .................... .................... ....................

01932 ....... Anes, tx interv rad, th vein ............................. ........... N ....... .......... .................... .................... .................... ....................

01933 ....... Anes, tx interv rad, cran v .............................. ........... N ....... .......... .................... .................... .................... ....................

01951 ....... Anesth, burn, less 4 percent .......................... ........... N ....... .......... .................... .................... .................... ....................

01952 ....... Anesth, burn, 4–9 percent ............................. ........... N ....... .......... .................... .................... .................... ....................

01953 ....... Anesth, burn, each 9 percent ........................ ........... N ....... .......... .................... .................... .................... ....................

01958 ....... Anesth, antepartum manipul .......................... ........... N ....... .......... .................... .................... .................... ....................

01960 ....... Anesth, vaginal delivery ................................. ........... N ....... .......... .................... .................... .................... ....................

01961 ....... Anesth, cs delivery ......................................... ........... N ....... .......... .................... .................... .................... ....................

01962 ....... Anesth, emer hysterectomy ........................... ........... N ....... .......... .................... .................... .................... ....................

01963 ....... Anesth, cs hysterectomy ................................ ........... N ....... .......... .................... .................... .................... ....................

01965 ....... Anesth, inc/missed ab proc ............................ ........... N ....... .......... .................... .................... .................... ....................

01966 ....... Anesth, induced ab procedure ....................... ........... N ....... .......... .................... .................... .................... ....................

01967 ....... Anesth/analg, vag delivery ............................. ........... N ....... .......... .................... .................... .................... ....................

01968 ....... Anes/analg cs deliver add-on ........................ ........... N ....... .......... .................... .................... .................... ....................

01969 ....... Anesth/analg cs hyst add-on ......................... ........... N ....... .......... .................... .................... .................... ....................

01991 ....... Anesth, nerve block/inj ................................... ........... N ....... .......... .................... .................... .................... ....................

01992 ....... Anesth, n block/inj, prone .............................. ........... N ....... .......... .................... .................... .................... ....................

01995 ....... Regional anesthesia limb ............................... ........... N ....... .......... .................... .................... .................... ....................

01996 ....... Hosp manage cont drug admin ..................... ........... N ....... .......... .................... .................... .................... ....................

01999 ....... Unlisted anesth procedure ............................. ........... N ....... .......... .................... .................... .................... ....................

10021 ....... Fna w/o image ............................................... ........... T ....... 0002 1.0948 67.39 .................... 13.48 

10022 ....... Fna w/image ................................................... ........... T ....... 0036 2.0147 124.01 .................... 24.80 

10040 ....... Acne surgery .................................................. ........... T ....... 0010 0.4829 29.72 8.14 5.94 

10060 ....... Drainage of skin abscess ............................... ........... T ....... 0006 1.4821 91.22 21.76 18.24 

10061 ....... Drainage of skin abscess ............................... ........... T ....... 0006 1.4821 91.22 21.76 18.24 

10080 ....... Drainage of pilonidal cyst ............................... ........... T ....... 0006 1.4821 91.22 21.76 18.24 

10081 ....... Drainage of pilonidal cyst ............................... ........... T ....... 0007 10.9184 672.04 .................... 134.41 

10120 ....... Remove foreign body ..................................... ........... T ....... 0006 1.4821 91.22 21.76 18.24 

10121 ....... Remove foreign body ..................................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

10140 ....... Drainage of hematoma/fluid ........................... ........... T ....... 0007 10.9184 672.04 .................... 134.41 

10160 ....... Puncture drainage of lesion ........................... ........... T ....... 0018 1.0534 64.84 15.87 12.97 

10180 ....... Complex drainage, wound ............................. ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

11000 ....... Debride infected skin ..................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11001 ....... Debride infected skin add-on ......................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11010 ....... Debride skin, fx .............................................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11011 ....... Debride skin/muscle, fx .................................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11012 ....... Debride skin/muscle/bone, fx ......................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11040 ....... Debride skin, partial ....................................... ........... T ....... 0015 1.6062 98.86 20.13 19.77 

11041 ....... Debride skin, full ............................................ ........... T ....... 0015 1.6062 98.86 20.13 19.77 

11042 ....... Debride skin/tissue ......................................... ........... T ....... 0016 2.6253 161.59 32.68 32.32 

11043 ....... Debride tissue/muscle .................................... ........... T ....... 0016 2.6253 161.59 32.68 32.32 

11044 ....... Debride tissue/muscle/bone ........................... ........... T ....... 0682 6.7529 415.65 158.65 83.13 

11055 ....... Trim skin lesion .............................................. ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11056 ....... Trim skin lesions, 2 to 4 ................................. ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11057 ....... Trim skin lesions, over 4 ................................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 


sroberts on PROD1PC70 with PROPOSALS
49758 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

11100 ....... Biopsy, skin lesion ......................................... ........... T ....... 0018 1.0534 64.84 15.87 12.97 

11101 ....... Biopsy, skin add-on ........................................ ........... T ....... 0018 1.0534 64.84 15.87 12.97 

11200 ....... Removal of skin tags ..................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11201 ....... Remove skin tags add-on .............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

11300 ....... Shave skin lesion ........................................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11301 ....... Shave skin lesion ........................................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11302 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11303 ....... Shave skin lesion ........................................... ........... T ....... 0015 1.6062 98.86 20.13 19.77 

11305 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11306 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11307 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11308 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11310 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11311 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11312 ....... Shave skin lesion ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11313 ....... Shave skin lesion ........................................... ........... T ....... 0016 2.6253 161.59 32.68 32.32 

11400 ....... Exc tr-ext b9+marg 0.5 < cm ......................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11401 ....... Exc tr-ext b9+marg 0.6–1 cm ........................ ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11402 ....... Exc tr-ext b9+marg 1.1–2 cm ........................ ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11403 ....... Exc tr-ext b9+marg 2.1–3 cm ........................ ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11404 ....... Exc tr-ext b9+marg 3.1–4 cm ........................ ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11406 ....... Exc tr-ext b9+marg > 4.0 cm ......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11420 ....... Exc h-f-nk-sp b9+marg 0.5 < ......................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11421 ....... Exc h-f-nk-sp b9+marg 0.6–1 ........................ ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11422 ....... Exc h-f-nk-sp b9+marg 1.1–2 ........................ ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11423 ....... Exc h-f-nk-sp b9+marg 2.1–3 ........................ ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11424 ....... Exc h-f-nk-sp b9+marg 3.1–4 ........................ ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11426 ....... Exc h-f-nk-sp b9+marg > 4 cm ...................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11440 ....... Exc face-mm b9+marg 0.5 < cm ................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11441 ....... Exc face-mm b9+marg 0.6–1 cm .................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11442 ....... Exc face-mm b9+marg 1.1–2 cm .................. ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11443 ....... Exc face-mm b9+marg 2.1–3 cm .................. ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11444 ....... Exc face-mm b9+marg 3.1–4 cm .................. ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11446 ....... Exc face-mm b9+marg > 4 cm ...................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11450 ....... Removal, sweat gland lesion ......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11451 ....... Removal, sweat gland lesion ......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11462 ....... Removal, sweat gland lesion ......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11463 ....... Removal, sweat gland lesion ......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11470 ....... Removal, sweat gland lesion ......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11471 ....... Removal, sweat gland lesion ......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11600 ....... Exc tr-ext mlg+marg 0.5 < cm ....................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11601 ....... Exc tr-ext mlg+marg 0.6–1 cm ...................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11602 ....... Exc tr-ext mlg+marg 1.1–2 cm ...................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11603 ....... Exc tr-ext mlg+marg 2.1–3 cm ...................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11604 ....... Exc tr-ext mlg+marg 3.1–4 cm ...................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11606 ....... Exc tr-ext mlg+marg > 4 cm .......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11620 ....... Exc h-f-nk-sp mlg+marg 0.5 < ....................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11621 ....... Exc h-f-nk-sp mlg+marg 0.6–1 ...................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11622 ....... Exc h-f-nk-sp mlg+marg 1.1–2 ...................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11623 ....... Exc h-f-nk-sp mlg+marg 2.1–3 ...................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11624 ....... Exc h-f-nk-sp mlg+marg 3.1–4 ...................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11626 ....... Exc h-f-nk-sp mlg+mar > 4 cm ...................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11640 ....... Exc face-mm malig+marg 0.5 < ..................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11641 ....... Exc face-mm malig+marg 0.6–1 .................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11642 ....... Exc face-mm malig+marg 1.1–2 .................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11643 ....... Exc face-mm malig+marg 2.1–3 .................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

11644 ....... Exc face-mm malig+marg 3.1–4 .................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

11646 ....... Exc face-mm mlg+marg > 4 cm .................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11719 ....... Trim nail(s) ..................................................... ........... T ....... 0009 0.6803 41.87 .................... 8.37 

11720 ....... Debride nail, 1–5 ............................................ ........... T ....... 0009 0.6803 41.87 .................... 8.37 

11721 ....... Debride nail, 6 or more .................................. ........... T ....... 0009 0.6803 41.87 .................... 8.37 

11730 ....... Removal of nail plate ..................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

11732 ....... Remove nail plate, add-on ............................. ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11740 ....... Drain blood from under nail ........................... ........... T ....... 0009 0.6803 41.87 .................... 8.37

11750 ....... Removal of nail bed ....................................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11752 ....... Remove nail bed/finger tip ............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11755 ....... Biopsy, nail unit .............................................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11760 ....... Repair of nail bed ........................................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11762 ....... Reconstruction of nail bed ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11765 ....... Excision of nail fold, toe ................................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49759 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

11770 ....... Removal of pilonidal lesion ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11771 ....... Removal of pilonidal lesion ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11772 ....... Removal of pilonidal lesion ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11900 ....... Injection into skin lesions ............................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11901 ....... Added skin lesions injection ........................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 

11920 ....... Correct skin color defects .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11921 ....... Correct skin color defects .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11922 ....... Correct skin color defects .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11950 ....... Therapy for contour defects ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11951 ....... Therapy for contour defects ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11952 ....... Therapy for contour defects ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11954 ....... Therapy for contour defects ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

11960 ....... Insert tissue expander(s) ............................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

11970 ....... Replace tissue expander ............................... CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

11971 ....... Remove tissue expander(s) ........................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

11976 ....... Removal of contraceptive cap ....................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

11980 ....... Implant hormone pellet(s) .............................. ........... X ....... 0340 0.6211 38.23 .................... 7.65 

11981 ....... Insert drug implant device .............................. ........... X ....... 0340 0.6211 38.23 .................... 7.65 

11982 ....... Remove drug implant device ......................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

11983 ....... Remove/insert drug implant ........................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

12001 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12002 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12004 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12005 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12006 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12007 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12011 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12013 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12014 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12015 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12016 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12017 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12018 ....... Repair superficial wound(s) ........................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12020 ....... Closure of split wound ................................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12021 ....... Closure of split wound ................................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12031 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12032 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12034 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12035 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12036 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12037 ....... Layer closure of wound(s) ............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

12041 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12042 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12044 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12045 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12046 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12047 ....... Layer closure of wound(s) ............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

12051 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12052 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12053 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12054 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12055 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12056 ....... Layer closure of wound(s) ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

12057 ....... Layer closure of wound(s) ............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

13100 ....... Repair of wound or lesion .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

13101 ....... Repair of wound or lesion .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

13102 ....... Repair wound/lesion add-on .......................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13120 ....... Repair of wound or lesion .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13121 ....... Repair of wound or lesion .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13122 ....... Repair wound/lesion add-on .......................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13131 ....... Repair of wound or lesion .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13132 ....... Repair of wound or lesion .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13133 ....... Repair wound/lesion add-on .......................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13150 ....... Repair of wound or lesion .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

13151 ....... Repair of wound or lesion .............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13152 ....... Repair of wound or lesion .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

13153 ....... Repair wound/lesion add-on .......................... ........... T ....... 0024 1.4924 91.86 30.08 18.37 

13160 ....... Late closure of wound .................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

14000 ....... Skin tissue rearrangement ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

14001 ....... Skin tissue rearrangement ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 


sroberts on PROD1PC70 with PROPOSALS
49760 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

14020 ....... Skin tissue rearrangement ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

14021 ....... Skin tissue rearrangement ............................. CH .... T ....... 0686 13.3433 821.29 .................... 164.26 

14040 ....... Skin tissue rearrangement ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

14041 ....... Skin tissue rearrangement ............................. CH .... T ....... 0686 13.3433 821.29 .................... 164.26 

14060 ....... Skin tissue rearrangement ............................. CH .... T ....... 0686 13.3433 821.29 .................... 164.26 

14061 ....... Skin tissue rearrangement ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

14300 ....... Skin tissue rearrangement ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

14350 ....... Skin tissue rearrangement ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15000 ....... Wound prep, 1st 100 sq cm .......................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15001 ....... Wound prep, addl 100 sq cm ........................ ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15040 ....... Harvest cultured skin graft ............................. ........... T ....... 0024 1.4924 91.86 30.08 18.37 

15050 ....... Skin pinch graft .............................................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15100 ....... Skin splt grft, trnk/arm/leg .............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15101 ....... Skin splt grft t/a/l, add-on ............................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15110 ....... Epidrm autogrft trnk/arm/leg .......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15111 ....... Epidrm autogrft t/a/l add-on ........................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15115 ....... Epidrm a-grft face/nck/hf/g ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15116 ....... Epidrm a-grft f/n/hf/g addl .............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15120 ....... Skn splt a-grft fac/nck/hf/g ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15121 ....... Skn splt a-grft f/n/hf/g add ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15130 ....... Derm autograft, trnk/arm/leg .......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15131 ....... Derm autograft t/a/l add-on ............................ ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15135 ....... Derm autograft face/nck/hf/g .......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15136 ....... Derm autograft, f/n/hf/g add ........................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15150 ....... Cult epiderm grft t/arm/leg ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15151 ....... Cult epiderm grft t/a/l addl ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15152 ....... Cult epiderm graft t/a/l +% ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15155 ....... Cult epiderm graft, f/n/hf/g ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15156 ....... Cult epidrm grft f/n/hfg add ............................ ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15157 ....... Cult epiderm grft f/n/hfg +% ........................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15170 ....... Acell graft trunk/arms/legs ............................. CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15171 ....... Acell graft t/arm/leg add-on ............................ CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15175 ....... Acellular graft, f/n/hf/g .................................... CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15176 ....... Acell graft, f/n/hf/g add-on .............................. CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15200 ....... Skin full graft, trunk ........................................ CH .... T ....... 0686 13.3433 821.29 .................... 164.26 

15201 ....... Skin full graft trunk add-on ............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15220 ....... Skin full graft sclp/arm/leg .............................. CH .... T ....... 0686 13.3433 821.29 .................... 164.26 

15221 ....... Skin full graft add-on ...................................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15240 ....... Skin full grft face/genit/hf ............................... ........... T ....... 0686 13.3433 821.29 .................... 164.26 

15241 ....... Skin full graft add-on ...................................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15260 ....... Skin full graft een&lips ................................... ........... T ....... 0686 13.3433 821.29 .................... 164.26 

15261 ....... Skin full graft add-on ...................................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15300 ....... Apply skinallogrft, t/arm/lg .............................. CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15301 ....... Apply sknallogrft t/a/l addl .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15320 ....... Apply skin allogrft f/n/hf/g ............................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15321 ....... Aply sknallogrft f/n/hfg add ............................ ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15330 ....... Aply acell alogrft t/arm/leg ............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15331 ....... Aply acell grft t/a/l add-on .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15335 ....... Apply acell graft, f/n/hf/g ................................ ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15336 ....... Aply acell grft f/n/hf/g add .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15340 ....... Apply cult skin substitute ............................... CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15341 ....... Apply cult skin sub add-on ............................. CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15360 ....... Apply cult derm sub, t/a/l ............................... CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15361 ....... Aply cult derm sub t/a/l add ........................... CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15365 ....... Apply cult derm sub f/n/hf/g ........................... CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15366 ....... Apply cult derm f/hf/g add .............................. CH .... T ....... 0025 5.0931 313.49 95.46 62.70 

15400 ....... Apply skin xenograft, t/a/l ............................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15401 ....... Apply skn xenogrft t/a/l add ........................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15420 ....... Apply skin xgraft, f/n/hf/g ............................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15421 ....... Apply skn xgrft f/n/hf/g add ............................ ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15430 ....... Apply acellular xenograft ................................ ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15431 ....... Apply acellular xgraft add .............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15570 ....... Form skin pedicle flap .................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15572 ....... Form skin pedicle flap .................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15574 ....... Form skin pedicle flap .................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15576 ....... Form skin pedicle flap .................................... ........... T ....... 0686 13.3433 821.29 .................... 164.26 

15600 ....... Skin graft ........................................................ ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15610 ....... Skin graft ........................................................ ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15620 ....... Skin graft ........................................................ ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15630 ....... Skin graft ........................................................ ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49761 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

15650 ....... Transfer skin pedicle flap ............................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15732 ....... Muscle-skin graft, head/neck ......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15734 ....... Muscle-skin graft, trunk .................................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15736 ....... Muscle-skin graft, arm .................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15738 ....... Muscle-skin graft, leg ..................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15740 ....... Island pedicle flap graft .................................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

15750 ....... Neurovascular pedicle graft ........................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15760 ....... Composite skin graft ...................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15770 ....... Derma-fat-fascia graft .................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15775 ....... Hair transplant punch grafts ........................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15776 ....... Hair transplant punch grafts ........................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15780 ....... Abrasion treatment of skin ............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15781 ....... Abrasion treatment of skin ............................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

15782 ....... Abrasion treatment of skin ............................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

15783 ....... Abrasion treatment of skin ............................. ........... T ....... 0016 2.6253 161.59 32.68 32.32 

15786 ....... Abrasion, lesion, single .................................. ........... T ....... 0013 1.0876 66.94 .................... 13.39 

15787 ....... Abrasion, lesions, add-on .............................. ........... T ....... 0013 1.0876 66.94 .................... 13.39 

15788 ....... Chemical peel, face, epiderm ........................ ........... T ....... 0012 0.8076 49.71 10.30 9.94 

15789 ....... Chemical peel, face, dermal .......................... ........... T ....... 0015 1.6062 98.86 20.13 19.77 

15792 ....... Chemical peel, nonfacial ................................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 

15793 ....... Chemical peel, nonfacial ................................ ........... T ....... 0012 0.8076 49.71 10.30 9.94 

15819 ....... Plastic surgery, neck ...................................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15820 ....... Revision of lower eyelid ................................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15821 ....... Revision of lower eyelid ................................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15822 ....... Revision of upper eyelid ................................ ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15823 ....... Revision of upper eyelid ................................ CH .... T ....... 0686 13.3433 821.29 .................... 164.26 

15824 ....... Removal of forehead wrinkles ....................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15825 ....... Removal of neck wrinkles .............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15826 ....... Removal of brow wrinkles .............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15828 ....... Removal of face wrinkles ............................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15829 ....... Removal of skin wrinkles ............................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15831 ....... Excise excessive skin tissue .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15832 ....... Excise excessive skin tissue .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15833 ....... Excise excessive skin tissue .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15834 ....... Excise excessive skin tissue .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15835 ....... Excise excessive skin tissue .......................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

15836 ....... Excise excessive skin tissue .......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

15837 ....... Excise excessive skin tissue .......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

15838 ....... Excise excessive skin tissue .......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

15839 ....... Excise excessive skin tissue .......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

15840 ....... Graft for face nerve palsy .............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15841 ....... Graft for face nerve palsy .............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15842 ....... Flap for face nerve palsy ............................... ........... T ....... 0686 13.3433 821.29 .................... 164.26 

15845 ....... Skin and muscle repair, face ......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15850 ....... Removal of sutures ........................................ ........... T ....... 0016 2.6253 161.59 32.68 32.32 

15851 ....... Removal of sutures ........................................ ........... T ....... 0016 2.6253 161.59 32.68 32.32 

15852 ....... Dressing change not for burn ........................ ........... X ....... 0340 0.6211 38.23 .................... 7.65 

15860 ....... Test for blood flow in graft ............................. CH .... X ....... 0340 0.6211 38.23 .................... 7.65 

15876 ....... Suction assisted lipectomy ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15877 ....... Suction assisted lipectomy ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15878 ....... Suction assisted lipectomy ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

15879 ....... Suction assisted lipectomy ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15920 ....... Removal of tail bone ulcer ............................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

15922 ....... Removal of tail bone ulcer ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15931 ....... Remove sacrum pressure sore ...................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15933 ....... Remove sacrum pressure sore ...................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15934 ....... Remove sacrum pressure sore ...................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15935 ....... Remove sacrum pressure sore ...................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15936 ....... Remove sacrum pressure sore ...................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15937 ....... Remove sacrum pressure sore ...................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15940 ....... Remove hip pressure sore ............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15941 ....... Remove hip pressure sore ............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15944 ....... Remove hip pressure sore ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15945 ....... Remove hip pressure sore ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15946 ....... Remove hip pressure sore ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15950 ....... Remove thigh pressure sore .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15951 ....... Remove thigh pressure sore .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

15952 ....... Remove thigh pressure sore .......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15953 ....... Remove thigh pressure sore .......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15956 ....... Remove thigh pressure sore .......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 


sroberts on PROD1PC70 with PROPOSALS
49762 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

15958 ....... Remove thigh pressure sore .......................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

15999 ....... Removal of pressure sore .............................. ........... T ....... 0019 4.0123 246.96 71.87 49.39 

16000 ....... Initial treatment of burn(s) .............................. ........... T ....... 0012 0.8076 49.71 10.30 9.94 

16020 ....... Dress/debrid p-thick burn, s ........................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

16025 ....... Dress/debrid p-thick burn, m .......................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

16030 ....... Dress/debrid p-thick burn, l ............................ ........... T ....... 0015 1.6062 98.86 20.13 19.77 

16035 ....... Incision of burn scab, initi .............................. CH .... T ....... 0016 2.6253 161.59 32.68 32.32 

17000 ....... Destroy benign/premlg lesion ........................ ........... T ....... 0010 0.4829 29.72 8.14 5.94 

17003 ....... Destroy lesions, 2–14 .................................... ........... T ....... 0010 0.4829 29.72 8.14 5.94 

17004 ....... Destroy lesions, 15 or more ........................... ........... T ....... 0011 2.6478 162.97 .................... 32.59 

17106 ....... Destruction of skin lesions ............................. ........... T ....... 0011 2.6478 162.97 .................... 32.59 

17107 ....... Destruction of skin lesions ............................. ........... T ....... 0011 2.6478 162.97 .................... 32.59 

17108 ....... Destruction of skin lesions ............................. ........... T ....... 0011 2.6478 162.97 .................... 32.59 

17110 ....... Destruct lesion, 1–14 ..................................... CH .... T ....... 0012 0.8076 49.71 10.30 9.94 

17111 ....... Destruct lesion, 15 or more ........................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

17250 ....... Chemical cautery, tissue ................................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 

17260 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17261 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17262 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17263 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17264 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17266 ....... Destruction of skin lesions ............................. ........... T ....... 0016 2.6253 161.59 32.68 32.32 

17270 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17271 ....... Destruction of skin lesions ............................. ........... T ....... 0013 1.0876 66.94 .................... 13.39 

17272 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17273 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17274 ....... Destruction of skin lesions ............................. ........... T ....... 0016 2.6253 161.59 32.68 32.32 

17276 ....... Destruction of skin lesions ............................. ........... T ....... 0016 2.6253 161.59 32.68 32.32 

17280 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17281 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17282 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17283 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17284 ....... Destruction of skin lesions ............................. ........... T ....... 0016 2.6253 161.59 32.68 32.32 

17286 ....... Destruction of skin lesions ............................. ........... T ....... 0015 1.6062 98.86 20.13 19.77 

17304 ....... 1 stage mohs, up to 5 spec ........................... ........... T ....... 0694 3.4844 214.47 58.14 42.89 

17305 ....... 2 stage mohs, up to 5 spec ........................... ........... T ....... 0694 3.4844 214.47 58.14 42.89 

17306 ....... 3 stage mohs, up to 5 spec ........................... ........... T ....... 0694 3.4844 214.47 58.14 42.89 

17307 ....... Mohs addl stage up to 5 spec ....................... ........... T ....... 0694 3.4844 214.47 58.14 42.89 

17310 ....... Mohs any stage > 5 spec each ..................... ........... T ....... 0694 3.4844 214.47 58.14 42.89 

17340 ....... Cryotherapy of skin ........................................ CH .... T ....... 0016 2.6253 161.59 32.68 32.32 

17360 ....... Skin peel therapy ........................................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

17380 ....... Hair removal by electrolysis ........................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

17999 ....... Skin tissue procedure .................................... CH .... T ....... 0012 0.8076 49.71 10.30 9.94 

19000 ....... Drainage of breast lesion ............................... ........... T ....... 0004 2.0863 128.41 .................... 25.68 

19001 ....... Drain breast lesion add-on ............................. CH .... T ....... 0002 1.0948 67.39 .................... 13.48 

19020 ....... Incision of breast lesion ................................. ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

19030 ....... Injection for breast x-ray ................................ ........... N ....... .......... .................... .................... .................... ....................

19100 ....... Bx breast percut w/o image ........................... ........... T ....... 0005 3.8051 234.21 71.59 46.84 

19101 ....... Biopsy of breast, open ................................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19102 ....... Bx breast percut w/image .............................. ........... T ....... 0005 3.8051 234.21 71.59 46.84 

19103 ....... Bx breast percut w/device .............................. ........... T ....... 0658 6.4482 396.89 .................... 79.38 

19110 ....... Nipple exploration .......................................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19112 ....... Excise breast duct fistula ............................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19120 ....... Removal of breast lesion ............................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19125 ....... Excision, breast lesion ................................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19126 ....... Excision, addl breast lesion ........................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19140 ....... Removal of breast tissue ............................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19160 ....... Partial mastectomy ......................................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19162 ....... P-mastectomy w/ln removal ........................... ........... T ....... 0693 37.4843 2,307.20 731.74 461.44 

19180 ....... Removal of breast .......................................... ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19182 ....... Removal of breast .......................................... ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19240 ....... Removal of breast .......................................... ........... T ....... 0030 40.7495 2,508.17 763.55 501.63 

19260 ....... Removal of chest wall lesion ......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

19290 ....... Place needle wire, breast .............................. ........... N ....... .......... .................... .................... .................... ....................

19291 ....... Place needle wire, breast .............................. ........... N ....... .......... .................... .................... .................... ....................

19295 ....... Place breast clip, percut ................................ ........... S ....... 0657 1.7625 108.48 .................... 21.70 

19296 ....... Place po breast cath for rad .......................... CH .... T ....... 0030 40.7495 2,508.17 763.55 501.63 

19297 ....... Place breast cath for rad ............................... CH .... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19298 ....... Place breast rad tube/caths ........................... ........... S ....... 1524 .................... 3,250.00 .................... 650.00 

19316 ....... Suspension of breast ..................................... ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49763 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

19318 ....... Reduction of large breast ............................... ........... T ....... 0693 37.4843 2,307.20 731.74 461.44 

19324 ....... Enlarge breast ................................................ ........... T ....... 0693 37.4843 2,307.20 731.74 461.44 

19325 ....... Enlarge breast with implant ........................... ........... T ....... 0648 48.7796 3,002.43 .................... 600.49 

19328 ....... Removal of breast implant ............................. ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19330 ....... Removal of implant material .......................... ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19340 ....... Immediate breast prosthesis .......................... ........... T ....... 0030 40.7495 2,508.17 763.55 501.63 

19342 ....... Delayed breast prosthesis ............................. ........... T ....... 0648 48.7796 3,002.43 .................... 600.49 

19350 ....... Breast reconstruction ..................................... ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

19355 ....... Correct inverted nipple(s) ............................... ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19357 ....... Breast reconstruction ..................................... ........... T ....... 0648 48.7796 3,002.43 .................... 600.49 

19366 ....... Breast reconstruction ..................................... ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19370 ....... Surgery of breast capsule .............................. ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19371 ....... Removal of breast capsule ............................ ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19380 ....... Revise breast reconstruction ......................... ........... T ....... 0030 40.7495 2,508.17 763.55 501.63 

19396 ....... Design custom breast implant ....................... ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

19499 ....... Breast surgery procedure .............................. ........... T ....... 0028 19.2250 1,183.32 303.74 236.66 

20000 ....... Incision of abscess ......................................... ........... T ....... 0006 1.4821 91.22 21.76 18.24 

20005 ....... Incision of deep abscess ............................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20100 ....... Explore wound, neck ...................................... ........... T ....... 0023 4.1133 253.18 .................... 50.64 

20101 ....... Explore wound, chest ..................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

20102 ....... Explore wound, abdomen .............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

20103 ....... Explore wound, extremity ............................... ........... T ....... 0023 4.1133 253.18 .................... 50.64 

20150 ....... Excise epiphyseal bar .................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

20200 ....... Muscle biopsy ................................................ ........... T ....... 0021 14.9563 920.58 219.48 184.12 

20205 ....... Deep muscle biopsy ....................................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

20206 ....... Needle biopsy, muscle ................................... ........... T ....... 0005 3.8051 234.21 71.59 46.84 

20220 ....... Bone biopsy, trocar/needle ............................ ........... T ....... 0019 4.0123 246.96 71.87 49.39 

20225 ....... Bone biopsy, trocar/needle ............................ ........... T ....... 0020 6.5128 400.87 98.57 80.17 

20240 ....... Bone biopsy, excisional ................................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

20245 ....... Bone biopsy, excisional ................................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

20250 ....... Open bone biopsy .......................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20251 ....... Open bone biopsy .......................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20500 ....... Injection of sinus tract .................................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

20501 ....... Inject sinus tract for x-ray .............................. ........... N ....... .......... .................... .................... .................... ....................

20520 ....... Removal of foreign body ................................ ........... T ....... 0019 4.0123 246.96 71.87 49.39 

20525 ....... Removal of foreign body ................................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

20526 ....... Ther injection, carp tunnel ............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20550 ....... Inj tendon sheath/ligament ............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20551 ....... Inj tendon origin/insertion ............................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20552 ....... Inj trigger point, 1/2 muscl ............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20553 ....... Inject trigger points, =/> 3 .............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20600 ....... Drain/inject, joint/bursa ................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20605 ....... Drain/inject, joint/bursa ................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20610 ....... Drain/inject, joint/bursa ................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20612 ....... Aspirate/inj ganglion cyst ............................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

20615 ....... Treatment of bone cyst .................................. ........... T ....... 0004 2.0863 128.41 .................... 25.68 

20650 ....... Insert and remove bone pin ........................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20662 ....... Application of pelvis brace ............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20663 ....... Application of thigh brace .............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20665 ....... Removal of fixation device ............................. ........... X ....... 0340 0.6211 38.23 .................... 7.65 

20670 ....... Removal of support implant ........................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

20680 ....... Removal of support implant ........................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

20690 ....... Apply bone fixation device ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

20692 ....... Apply bone fixation device ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

20693 ....... Adjust bone fixation device ............................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20694 ....... Remove bone fixation device ......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

20822 ....... Replantation digit, complete ........................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

20900 ....... Removal of bone for graft .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

20902 ....... Removal of bone for graft .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

20910 ....... Remove cartilage for graft ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

20912 ....... Remove cartilage for graft ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

20920 ....... Removal of fascia for graft ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

20922 ....... Removal of fascia for graft ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

20924 ....... Removal of tendon for graft ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

20926 ....... Removal of tissue for graft ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

20950 ....... Fluid pressure, muscle ................................... ........... T ....... 0006 1.4821 91.22 21.76 18.24 

20972 ....... Bone/skin graft, metatarsal ............................ ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

20973 ....... Bone/skin graft, great toe ............................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

20975 ....... Electrical bone stimulation ............................. ........... X ....... 0340 0.6211 38.23 .................... 7.65 

20982 ....... Ablate, bone tumor(s) perq ............................ CH .... T ....... 0050 25.0600 1,542.47 .................... 308.49 


sroberts on PROD1PC70 with PROPOSALS
49764 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

20999 ....... Musculoskeletal surgery ................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

21010 ....... Incision of jaw joint ......................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21015 ....... Resection of facial tumor ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21025 ....... Excision of bone, lower jaw ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21026 ....... Excision of facial bone(s) ............................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21029 ....... Contour of face bone lesion ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21030 ....... Excise max/zygoma b9 tumor ........................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21031 ....... Remove exostosis, mandible ......................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21032 ....... Remove exostosis, maxilla ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21034 ....... Excise max/zygoma mlg tumor ...................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21040 ....... Excise mandible lesion .................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21044 ....... Removal of jaw bone lesion ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21046 ....... Remove mandible cyst complex .................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98

21047 ....... Excise lwr jaw cyst w/repair ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21048 ....... Remove maxilla cyst complex ....................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21049 ....... Excis uppr jaw cyst w/repair .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21050 ....... Removal of jaw joint ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21060 ....... Remove jaw joint cartilage ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21070 ....... Remove coronoid process ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21076 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21077 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21079 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21080 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21081 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21082 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21083 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21084 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21085 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21086 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21087 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21088 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21089 ....... Prepare face/oral prosthesis .......................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21100 ....... Maxillofacial fixation ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21110 ....... Interdental fixation .......................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

21116 ....... Injection, jaw joint x-ray ................................. ........... N ....... .......... .................... .................... .................... ....................

21120 ....... Reconstruction of chin ................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21121 ....... Reconstruction of chin ................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21122 ....... Reconstruction of chin ................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21123 ....... Reconstruction of chin ................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21125 ....... Augmentation, lower jaw bone ....................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21127 ....... Augmentation, lower jaw bone ....................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21137 ....... Reduction of forehead .................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21138 ....... Reduction of forehead .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21139 ....... Reduction of forehead .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21150 ....... Reconstruct midface, lefort ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21175 ....... Reconstruct orbit/forehead ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21181 ....... Contour cranial bone lesion ........................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21195 ....... Reconst lwr jaw w/o fixation .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21198 ....... Reconstr lwr jaw segment .............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21199 ....... Reconstr lwr jaw w/advance .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21206 ....... Reconstruct upper jaw bone .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21208 ....... Augmentation of facial bones ........................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21209 ....... Reduction of facial bones .............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21210 ....... Face bone graft .............................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21215 ....... Lower jaw bone graft ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21230 ....... Rib cartilage graft ........................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21235 ....... Ear cartilage graft ........................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21240 ....... Reconstruction of jaw joint ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21242 ....... Reconstruction of jaw joint ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21243 ....... Reconstruction of jaw joint ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21244 ....... Reconstruction of lower jaw ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21245 ....... Reconstruction of jaw ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21246 ....... Reconstruction of jaw ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21248 ....... Reconstruction of jaw ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21249 ....... Reconstruction of jaw ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21260 ....... Revise eye sockets ........................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21261 ....... Revise eye sockets ........................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21263 ....... Revise eye sockets ........................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21267 ....... Revise eye sockets ........................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21270 ....... Augmentation, cheek bone ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49765 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

21275 ....... Revision, orbitofacial bones ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21280 ....... Revision of eyelid ........................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21282 ....... Revision of eyelid ........................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50

21295 ....... Revision of jaw muscle/bone ......................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

21296 ....... Revision of jaw muscle/bone ......................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21299 ....... Cranio/maxillofacial surgery ........................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21300 ....... Treatment of skull fracture ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21310 ....... Treatment of nose fracture ............................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21315 ....... Treatment of nose fracture ............................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21320 ....... Treatment of nose fracture ............................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

21325 ....... Treatment of nose fracture ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21330 ....... Treatment of nose fracture ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21335 ....... Treatment of nose fracture ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21336 ....... Treat nasal septal fracture ............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

21337 ....... Treat nasal septal fracture ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21338 ....... Treat nasoethmoid fracture ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21339 ....... Treat nasoethmoid fracture ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21340 ....... Treatment of nose fracture ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21345 ....... Treat nose/jaw fracture .................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21355 ....... Treat cheek bone fracture .............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21356 ....... Treat cheek bone fracture .............................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21390 ....... Treat eye socket fracture ............................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21400 ....... Treat eye socket fracture ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

21401 ....... Treat eye socket fracture ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21406 ....... Treat eye socket fracture ............................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21407 ....... Treat eye socket fracture ............................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21408 ....... Treat eye socket fracture ............................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21421 ....... Treat mouth roof fracture ............................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21440 ....... Treat dental ridge fracture ............................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21445 ....... Treat dental ridge fracture ............................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21450 ....... Treat lower jaw fracture ................................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21451 ....... Treat lower jaw fracture ................................. ........... T ....... 0252 7.7261 475.55 111.84 95.11 

21452 ....... Treat lower jaw fracture ................................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21453 ....... Treat lower jaw fracture ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21454 ....... Treat lower jaw fracture ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

21461 ....... Treat lower jaw fracture ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21462 ....... Treat lower jaw fracture ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21465 ....... Treat lower jaw fracture ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21470 ....... Treat lower jaw fracture ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21480 ....... Reset dislocated jaw ...................................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21485 ....... Reset dislocated jaw ...................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21490 ....... Repair dislocated jaw ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

21495 ....... Treat hyoid bone fracture ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21497 ....... Interdental wiring ............................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

21499 ....... Head surgery procedure ................................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21501 ....... Drain neck/chest lesion .................................. ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

21502 ....... Drain chest lesion .......................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

21550 ....... Biopsy of neck/chest ...................................... CH .... T ....... 0020 6.5128 400.87 98.57 80.17 

21555 ....... Remove lesion, neck/chest ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

21556 ....... Remove lesion, neck/chest ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

21557 ....... Remove tumor, neck/chest ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

21600 ....... Partial removal of rib ...................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

21610 ....... Partial removal of rib ...................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

21685 ....... Hyoid myotomy&suspension .......................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

21700 ....... Revision of neck muscle ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

21720 ....... Revision of neck muscle ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

21725 ....... Revision of neck muscle ................................ ........... T ....... 0006 1.4821 91.22 21.76 18.24 

21742 ....... Repair stern/nuss w/o scope ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

21743 ....... Repair sternum/nuss w/scope ........................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

21800 ....... Treatment of rib fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

21805 ....... Treatment of rib fracture ................................ CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

21820 ....... Treat sternum fracture ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

21899 ....... Neck/chest surgery procedure ....................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

21920 ....... Biopsy soft tissue of back .............................. ........... T ....... 0020 6.5128 400.87 98.57 80.17 

21925 ....... Biopsy soft tissue of back .............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

21930 ....... Remove lesion, back or flank ........................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

21935 ....... Remove tumor, back ...................................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

22100 ....... Remove part of neck vertebra ....................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

22101 ....... Remove part, thorax vertebra ........................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

22102 ....... Remove part, lumbar vertebra ....................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 


sroberts on PROD1PC70 with PROPOSALS
49766 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

22103 ....... Remove extra spine segment ........................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

22222 ....... Revision of thorax spine ................................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

22305 ....... Treat spine process fracture .......................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

22310 ....... Treat spine fracture ........................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

22315 ....... Treat spine fracture ........................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

22505 ....... Manipulation of spine ..................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

22520 ....... Percut vertebroplasty thor .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

22521 ....... Percut vertebroplasty lumb ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

22522 ....... Percut vertebroplasty add’l ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

22523 ....... Percut kyphoplasty, thor ................................ ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

22524 ....... Percut kyphoplasty, lumbar ............................ ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

22525 ....... Percut kyphoplasty, add-on ........................... ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

22612 ....... Lumbar spine fusion ....................................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

22614 ....... Spine fusion, extra segment .......................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

22851 ....... Apply spine prosth device .............................. CH .... T ....... 0049 20.8214 1,281.58 .................... 256.32 

22899 ....... Spine surgery procedure ................................ CH .... T ....... 0049 20.8214 1,281.58 .................... 256.32 

22900 ....... Remove abdominal wall lesion ...................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

22999 ....... Abdomen surgery procedure ......................... CH .... T ....... 0049 20.8214 1,281.58 .................... 256.32 

23000 ....... Removal of calcium deposits ......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

23020 ....... Release shoulder joint ................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23030 ....... Drain shoulder lesion ..................................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

23031 ....... Drain shoulder bursa ...................................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

23035 ....... Drain shoulder bone lesion ............................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

23040 ....... Exploratory shoulder surgery ......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23044 ....... Exploratory shoulder surgery ......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23065 ....... Biopsy shoulder tissues ................................. CH .... T ....... 0020 6.5128 400.87 98.57 80.17 

23066 ....... Biopsy shoulder tissues ................................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

23075 ....... Removal of shoulder lesion ........................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

23076 ....... Removal of shoulder lesion ........................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

23077 ....... Remove tumor of shoulder ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

23100 ....... Biopsy of shoulder joint .................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

23101 ....... Shoulder joint surgery .................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23105 ....... Remove shoulder joint lining .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23106 ....... Incision of collarbone joint ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23107 ....... Explore treat shoulder joint ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23120 ....... Partial removal, collar bone ........................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23125 ....... Removal of collar bone .................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23130 ....... Remove shoulder bone, part ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23140 ....... Removal of bone lesion ................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

23145 ....... Removal of bone lesion ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23146 ....... Removal of bone lesion ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23150 ....... Removal of humerus lesion ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23155 ....... Removal of humerus lesion ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23156 ....... Removal of humerus lesion ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23170 ....... Remove collar bone lesion ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23172 ....... Remove shoulder blade lesion ...................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23174 ....... Remove humerus lesion ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23180 ....... Remove collar bone lesion ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23182 ....... Remove shoulder blade lesion ...................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23184 ....... Remove humerus lesion ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23190 ....... Partial removal of scapula ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23195 ....... Removal of head of humerus ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23330 ....... Remove shoulder foreign body ...................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

23331 ....... Remove shoulder foreign body ...................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

23350 ....... Injection for shoulder x-ray ............................ ........... N ....... .......... .................... .................... .................... ....................

23395 ....... Muscle transfer,shoulder/arm ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23397 ....... Muscle transfers ............................................. ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23400 ....... Fixation of shoulder blade .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23405 ....... Incision of tendon&muscle ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23406 ....... Incise tendon(s)&muscle(s) ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

23410 ....... Repair rotator cuff, acute ............................... CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23412 ....... Repair rotator cuff, chronic ............................ CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23415 ....... Release of shoulder ligament ........................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23420 ....... Repair of shoulder .......................................... CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23430 ....... Repair biceps tendon ..................................... CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23440 ....... Remove/transplant tendon ............................. CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85

23450 ....... Repair shoulder capsule ................................ ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23455 ....... Repair shoulder capsule ................................ ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23460 ....... Repair shoulder capsule ................................ ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23462 ....... Repair shoulder capsule ................................ CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49767 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

23465 ....... Repair shoulder capsule ................................ ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23466 ....... Repair shoulder capsule ................................ CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23470 ....... Reconstruct shoulder joint ............................. ........... T ....... 0425 105.1666 6,473.11 1,378.01 1,294.62 

23480 ....... Revision of collar bone .................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23485 ....... Revision of collar bone .................................. CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23490 ....... Reinforce clavicle ........................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23491 ....... Reinforce shoulder bones .............................. CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23500 ....... Treat clavicle fracture ..................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23505 ....... Treat clavicle fracture ..................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23515 ....... Treat clavicle fracture ..................................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

23520 ....... Treat clavicle dislocation ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23525 ....... Treat clavicle dislocation ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23530 ....... Treat clavicle dislocation ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

23532 ....... Treat clavicle dislocation ................................ CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

23540 ....... Treat clavicle dislocation ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23545 ....... Treat clavicle dislocation ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23550 ....... Treat clavicle dislocation ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

23552 ....... Treat clavicle dislocation ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

23570 ....... Treat shoulder blade fx .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23575 ....... Treat shoulder blade fx .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23585 ....... Treat scapula fracture .................................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

23600 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23605 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23615 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

23616 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

23620 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23625 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23630 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

23650 ....... Treat shoulder dislocation .............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23655 ....... Treat shoulder dislocation .............................. ........... T ....... 0045 14.5502 895.58 268.47 179.12 

23660 ....... Treat shoulder dislocation .............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

23665 ....... Treat dislocation/fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23670 ....... Treat dislocation/fracture ................................ CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

23675 ....... Treat dislocation/fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

23680 ....... Treat dislocation/fracture ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

23700 ....... Fixation of shoulder ........................................ ........... T ....... 0045 14.5502 895.58 268.47 179.12 

23800 ....... Fusion of shoulder joint .................................. CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

23802 ....... Fusion of shoulder joint .................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

23921 ....... Amputation follow-up surgery ........................ ........... T ....... 0025 5.0931 313.49 95.46 62.70 

23929 ....... Shoulder surgery procedure .......................... ........... T ....... 0043 1.6914 104.11 .................... 20.82

23930 ....... Drainage of arm lesion ................................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

23931 ....... Drainage of arm bursa ................................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

23935 ....... Drain arm/elbow bone lesion ......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24000 ....... Exploratory elbow surgery ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24006 ....... Release elbow joint ........................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24065 ....... Biopsy arm/elbow soft tissue ......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

24066 ....... Biopsy arm/elbow soft tissue ......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

24075 ....... Remove arm/elbow lesion .............................. ........... T ....... 0021 14.9563 920.58 219.48 184.12 

24076 ....... Remove arm/elbow lesion .............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

24077 ....... Remove tumor of arm/elbow .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

24100 ....... Biopsy elbow joint lining ................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24101 ....... Explore/treat elbow joint ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24102 ....... Remove elbow joint lining .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24105 ....... Removal of elbow bursa ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24110 ....... Remove humerus lesion ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24115 ....... Remove/graft bone lesion .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24116 ....... Remove/graft bone lesion .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24120 ....... Remove elbow lesion ..................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24125 ....... Remove/graft bone lesion .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24126 ....... Remove/graft bone lesion .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24130 ....... Removal of head of radius ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24134 ....... Removal of arm bone lesion .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24136 ....... Remove radius bone lesion ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24138 ....... Remove elbow bone lesion ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24140 ....... Partial removal of arm bone .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24145 ....... Partial removal of radius ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24147 ....... Partial removal of elbow ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24149 ....... Radical resection of elbow ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24150 ....... Extensive humerus surgery ........................... CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24151 ....... Extensive humerus surgery ........................... ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 


sroberts on PROD1PC70 with PROPOSALS
49768 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

24152 ....... Extensive radius surgery ................................ CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24153 ....... Extensive radius surgery ................................ ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

24155 ....... Removal of elbow joint ................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24160 ....... Remove elbow joint implant ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24164 ....... Remove radius head implant ......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24200 ....... Removal of arm foreign body ........................ ........... T ....... 0019 4.0123 246.96 71.87 49.39 

24201 ....... Removal of arm foreign body ........................ ........... T ....... 0021 14.9563 920.58 219.48 184.12 

24220 ....... Injection for elbow x-ray ................................. ........... N ....... .......... .................... .................... .................... ....................

24300 ....... Manipulate elbow w/anesth ............................ ........... T ....... 0045 14.5502 895.58 268.47 179.12 

24301 ....... Muscle/tendon transfer ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24305 ....... Arm tendon lengthening ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24310 ....... Revision of arm tendon .................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24320 ....... Repair of arm tendon ..................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24330 ....... Revision of arm muscles ................................ CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

24331 ....... Revision of arm muscles ................................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24332 ....... Tenolysis, triceps ........................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24340 ....... Repair of biceps tendon ................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24341 ....... Repair arm tendon/muscle ............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24342 ....... Repair of ruptured tendon .............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24343 ....... Repr elbow lat ligmnt w/tiss ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24344 ....... Reconstruct elbow lat ligmnt .......................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

24345 ....... Repr elbw med ligmnt w/tissu ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24346 ....... Reconstruct elbow med ligmnt ....................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24350 ....... Repair of tennis elbow ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24351 ....... Repair of tennis elbow ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24352 ....... Repair of tennis elbow ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24354 ....... Repair of tennis elbow ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24356 ....... Revision of tennis elbow ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24360 ....... Reconstruct elbow joint .................................. ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

24361 ....... Reconstruct elbow joint .................................. ........... T ....... 0425 105.1666 6,473.11 1,378.01 1,294.62 

24362 ....... Reconstruct elbow joint .................................. ........... T ....... 0048 47.1644 2,903.02 .................... 580.60 

24363 ....... Replace elbow joint ........................................ ........... T ....... 0425 105.1666 6,473.11 1,378.01 1,294.62 

24365 ....... Reconstruct head of radius ............................ ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

24366 ....... Reconstruct head of radius ............................ ........... T ....... 0425 105.1666 6,473.11 1,378.01 1,294.62 

24400 ....... Revision of humerus ...................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24410 ....... Revision of humerus ...................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24420 ....... Revision of humerus ...................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24430 ....... Repair of humerus ......................................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

24435 ....... Repair humerus with graft .............................. CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

24470 ....... Revision of elbow joint ................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24495 ....... Decompression of forearm ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

24498 ....... Reinforce humerus ......................................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

24500 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24505 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24515 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24516 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24530 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24535 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24538 ....... Treat humerus fracture .................................. CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

24545 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24546 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24560 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24565 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24566 ....... Treat humerus fracture .................................. CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

24575 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24576 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24577 ....... Treat humerus fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24579 ....... Treat humerus fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24582 ....... Treat humerus fracture .................................. CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

24586 ....... Treat elbow fracture ....................................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24587 ....... Treat elbow fracture ....................................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24600 ....... Treat elbow dislocation .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24605 ....... Treat elbow dislocation .................................. ........... T ....... 0045 14.5502 895.58 268.47 179.12 

24615 ....... Treat elbow dislocation .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24620 ....... Treat elbow fracture ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24635 ....... Treat elbow fracture ....................................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24640 ....... Treat elbow dislocation .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24650 ....... Treat radius fracture ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24655 ....... Treat radius fracture ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24665 ....... Treat radius fracture ....................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49769 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

24666 ....... Treat radius fracture ....................................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

24670 ....... Treat ulnar fracture ........................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24675 ....... Treat ulnar fracture ........................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

24685 ....... Treat ulnar fracture ........................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

24800 ....... Fusion of elbow joint ...................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24802 ....... Fusion/graft of elbow joint .............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

24925 ....... Amputation follow-up surgery ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

24935 ....... Revision of amputation .................................. ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

24999 ....... Upper arm/elbow surgery ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25000 ....... Incision of tendon sheath ............................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25001 ....... Incise flexor carpi radialis .............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25020 ....... Decompress forearm 1 space ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25023 ....... Decompress forearm 1 space ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25024 ....... Decompress forearm 2 spaces ...................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25025 ....... Decompress forearm 2 spaces ...................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25028 ....... Drainage of forearm lesion ............................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25031 ....... Drainage of forearm bursa ............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25035 ....... Treat forearm bone lesion .............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25040 ....... Explore/treat wrist joint ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25065 ....... Biopsy forearm soft tissues ............................ CH .... T ....... 0020 6.5128 400.87 98.57 80.17 

25066 ....... Biopsy forearm soft tissues ............................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

25075 ....... Removal forearm lesion subcu ...................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

25076 ....... Removal forearm lesion deep ........................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

25077 ....... Remove tumor, forearm/wrist ......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

25085 ....... Incision of wrist capsule ................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25100 ....... Biopsy of wrist joint ........................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25101 ....... Explore/treat wrist joint ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25105 ....... Remove wrist joint lining ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25107 ....... Remove wrist joint cartilage ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25110 ....... Remove wrist tendon lesion ........................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25111 ....... Remove wrist tendon lesion ........................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

25112 ....... Reremove wrist tendon lesion ....................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

25115 ....... Remove wrist/forearm lesion ......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25116 ....... Remove wrist/forearm lesion ......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25118 ....... Excise wrist tendon sheath ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25119 ....... Partial removal of ulna ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25120 ....... Removal of forearm lesion ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25125 ....... Remove/graft forearm lesion .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25126 ....... Remove/graft forearm lesion .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25130 ....... Removal of wrist lesion .................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25135 ....... Remove&graft wrist lesion ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25136 ....... Remove&graft wrist lesion ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25145 ....... Remove forearm bone lesion ......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25150 ....... Partial removal of ulna ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25151 ....... Partial removal of radius ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25170 ....... Extensive forearm surgery ............................. CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25210 ....... Removal of wrist bone ................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

25215 ....... Removal of wrist bones ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

25230 ....... Partial removal of radius ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25240 ....... Partial removal of ulna ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25246 ....... Injection for wrist x-ray ................................... ........... N ....... .......... .................... .................... .................... ....................

25248 ....... Remove forearm foreign body ....................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25250 ....... Removal of wrist prosthesis ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25251 ....... Removal of wrist prosthesis ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25259 ....... Manipulate wrist w/anesthes .......................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25260 ....... Repair forearm tendon/muscle ....................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25263 ....... Repair forearm tendon/muscle ....................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25265 ....... Repair forearm tendon/muscle ....................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25270 ....... Repair forearm tendon/muscle ....................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25272 ....... Repair forearm tendon/muscle ....................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25274 ....... Repair forearm tendon/muscle ....................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25275 ....... Repair forearm tendon sheath ....................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25280 ....... Revise wrist/forearm tendon .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25290 ....... Incise wrist/forearm tendon ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25295 ....... Release wrist/forearm tendon ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25300 ....... Fusion of tendons at wrist .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25301 ....... Fusion of tendons at wrist .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25310 ....... Transplant forearm tendon ............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25312 ....... Transplant forearm tendon ............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25315 ....... Revise palsy hand tendon(s) ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 


sroberts on PROD1PC70 with PROPOSALS
49770 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

25316 ....... Revise palsy hand tendon(s) ......................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

25320 ....... Repair/revise wrist joint .................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25332 ....... Revise wrist joint ............................................ ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

25335 ....... Realignment of hand ...................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25337 ....... Reconstruct ulna/radioulnar ........................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25350 ....... Revision of radius .......................................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

25355 ....... Revision of radius .......................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25360 ....... Revision of ulna ............................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25365 ....... Revise radius&ulna ........................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25370 ....... Revise radius or ulna ..................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25375 ....... Revise radius&ulna ........................................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25390 ....... Shorten radius or ulna ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25391 ....... Lengthen radius or ulna ................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25392 ....... Shorten radius&ulna ....................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25393 ....... Lengthen radius&ulna .................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25394 ....... Repair carpal bone, shorten .......................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

25400 ....... Repair radius or ulna ..................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25405 ....... Repair/graft radius or ulna ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25415 ....... Repair radius&ulna ......................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

25420 ....... Repair/graft radius&ulna ................................ CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

25425 ....... Repair/graft radius or ulna ............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25426 ....... Repair/graft radius&ulna ................................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25430 ....... Vasc graft into carpal bone ............................ ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

25431 ....... Repair nonunion carpal bone ......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

25440 ....... Repair/graft wrist bone ................................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

25441 ....... Reconstruct wrist joint .................................... ........... T ....... 0425 105.1666 6,473.11 1,378.01 1,294.62 

25442 ....... Reconstruct wrist joint .................................... ........... T ....... 0425 105.1666 6,473.11 1,378.01 1,294.62 

25443 ....... Reconstruct wrist joint .................................... ........... T ....... 0048 47.1644 2,903.02 .................... 580.60 

25444 ....... Reconstruct wrist joint .................................... ........... T ....... 0048 47.1644 2,903.02 .................... 580.60 

25445 ....... Reconstruct wrist joint .................................... ........... T ....... 0048 47.1644 2,903.02 .................... 580.60 

25446 ....... Wrist replacement .......................................... ........... T ....... 0425 105.1666 6,473.11 1,378.01 1,294.62 

25447 ....... Repair wrist joint(s) ........................................ ........... T ....... 0047 32.7543 2,016.06 537.03 403.21

25449 ....... Remove wrist joint implant ............................. ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

25450 ....... Revision of wrist joint ..................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25455 ....... Revision of wrist joint ..................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25490 ....... Reinforce radius ............................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25491 ....... Reinforce ulna ................................................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25492 ....... Reinforce radius and ulna .............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25500 ....... Treat fracture of radius .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25505 ....... Treat fracture of radius .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25515 ....... Treat fracture of radius .................................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

25520 ....... Treat fracture of radius .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25525 ....... Treat fracture of radius .................................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

25526 ....... Treat fracture of radius .................................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

25530 ....... Treat fracture of ulna ..................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25535 ....... Treat fracture of ulna ..................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25545 ....... Treat fracture of ulna ..................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

25560 ....... Treat fracture radius&ulna ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25565 ....... Treat fracture radius&ulna ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25574 ....... Treat fracture radius&ulna ............................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

25575 ....... Treat fracture radius/ulna ............................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

25600 ....... Treat fracture radius/ulna ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25605 ....... Treat fracture radius/ulna ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25611 ....... Treat fracture radius/ulna ............................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

25620 ....... Treat fracture radius/ulna ............................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

25622 ....... Treat wrist bone fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25624 ....... Treat wrist bone fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25628 ....... Treat wrist bone fracture ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

25630 ....... Treat wrist bone fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25635 ....... Treat wrist bone fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25645 ....... Treat wrist bone fracture ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

25650 ....... Treat wrist bone fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25651 ....... Pin ulnar styloid fracture ................................ CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

25652 ....... Treat fracture ulnar styloid ............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

25660 ....... Treat wrist dislocation .................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25670 ....... Treat wrist dislocation .................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

25671 ....... Pin radioulnar dislocation ............................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

25675 ....... Treat wrist dislocation .................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25676 ....... Treat wrist dislocation .................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

25680 ....... Treat wrist fracture ......................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49771 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

25685 ....... Treat wrist fracture ......................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

25690 ....... Treat wrist dislocation .................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

25695 ....... Treat wrist dislocation .................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

25800 ....... Fusion of wrist joint ........................................ CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

25805 ....... Fusion/graft of wrist joint ................................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

25810 ....... Fusion/graft of wrist joint ................................ CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

25820 ....... Fusion of hand bones .................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

25825 ....... Fuse hand bones with graft ........................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

25830 ....... Fusion, radioulnar jnt/ulna .............................. CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

25907 ....... Amputation follow-up surgery ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25922 ....... Amputate hand at wrist .................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

25929 ....... Amputation follow-up surgery ........................ ........... T ....... 0686 13.3433 821.29 .................... 164.26 

25999 ....... Forearm or wrist surgery ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26010 ....... Drainage of finger abscess ............................ ........... T ....... 0006 1.4821 91.22 21.76 18.24 

26011 ....... Drainage of finger abscess ............................ ........... T ....... 0007 10.9184 672.04 .................... 134.41 

26020 ....... Drain hand tendon sheath ............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26025 ....... Drainage of palm bursa ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26030 ....... Drainage of palm bursa(s) ............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26034 ....... Treat hand bone lesion .................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26035 ....... Decompress fingers/hand .............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26037 ....... Decompress fingers/hand .............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26040 ....... Release palm contracture .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26045 ....... Release palm contracture .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26055 ....... Incise finger tendon sheath ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26060 ....... Incision of finger tendon ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26070 ....... Explore/treat hand joint .................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26075 ....... Explore/treat finger joint ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26080 ....... Explore/treat finger joint ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26100 ....... Biopsy hand joint lining .................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26105 ....... Biopsy finger joint lining ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26110 ....... Biopsy finger joint lining ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26115 ....... Removal hand lesion subcut .......................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

26116 ....... Removal hand lesion, deep ........................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

26117 ....... Remove tumor, hand/finger ........................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

26121 ....... Release palm contracture .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26123 ....... Release palm contracture .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26125 ....... Release palm contracture .............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26130 ....... Remove wrist joint lining ................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26135 ....... Revise finger joint, each ................................ ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26140 ....... Revise finger joint, each ................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26145 ....... Tendon excision, palm/finger ......................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26160 ....... Remove tendon sheath lesion ....................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26170 ....... Removal of palm tendon, each ...................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26180 ....... Removal of finger tendon ............................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26185 ....... Remove finger bone ....................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26200 ....... Remove hand bone lesion ............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26205 ....... Remove/graft bone lesion .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26210 ....... Removal of finger lesion ................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26215 ....... Remove/graft finger lesion ............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26230 ....... Partial removal of hand bone ......................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26235 ....... Partial removal, finger bone ........................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26236 ....... Partial removal, finger bone ........................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26250 ....... Extensive hand surgery ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26255 ....... Extensive hand surgery ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26260 ....... Extensive finger surgery ................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26261 ....... Extensive finger surgery ................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26262 ....... Partial removal of finger ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26320 ....... Removal of implant from hand ....................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

26340 ....... Manipulate finger w/anesth ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26350 ....... Repair finger/hand tendon ............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26352 ....... Repair/graft hand tendon ............................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26356 ....... Repair finger/hand tendon ............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26357 ....... Repair finger/hand tendon ............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26358 ....... Repair/graft hand tendon ............................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26370 ....... Repair finger/hand tendon ............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26372 ....... Repair/graft hand tendon ............................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26373 ....... Repair finger/hand tendon ............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26390 ....... Revise hand/finger tendon ............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26392 ....... Repair/graft hand tendon ............................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26410 ....... Repair hand tendon ....................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 


sroberts on PROD1PC70 with PROPOSALS
49772 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

26412 ....... Repair/graft hand tendon ............................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26415 ....... Excision, hand/finger tendon .......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26416 ....... Graft hand or finger tendon ........................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26418 ....... Repair finger tendon ...................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26420 ....... Repair/graft finger tendon .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26426 ....... Repair finger/hand tendon ............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26428 ....... Repair/graft finger tendon .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26432 ....... Repair finger tendon ...................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26433 ....... Repair finger tendon ...................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26434 ....... Repair/graft finger tendon .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26437 ....... Realignment of tendons ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26440 ....... Release palm/finger tendon ........................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26442 ....... Release palm&finger tendon .......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26445 ....... Release hand/finger tendon ........................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26449 ....... Release forearm/hand tendon ....................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26450 ....... Incision of palm tendon .................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26455 ....... Incision of finger tendon ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26460 ....... Incise hand/finger tendon ............................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26471 ....... Fusion of finger tendons ................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26474 ....... Fusion of finger tendons ................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26476 ....... Tendon lengthening ....................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26477 ....... Tendon shortening ......................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26478 ....... Lengthening of hand tendon .......................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26479 ....... Shortening of hand tendon ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26480 ....... Transplant hand tendon ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26483 ....... Transplant/graft hand tendon ......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26485 ....... Transplant palm tendon ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26489 ....... Transplant/graft palm tendon ......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26490 ....... Revise thumb tendon ..................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26492 ....... Tendon transfer with graft .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26494 ....... Hand tendon/muscle transfer ......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26496 ....... Revise thumb tendon ..................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26497 ....... Finger tendon transfer .................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26498 ....... Finger tendon transfer .................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26499 ....... Revision of finger ........................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26500 ....... Hand tendon reconstruction ........................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26502 ....... Hand tendon reconstruction ........................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26504 ....... Hand tendon reconstruction ........................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26508 ....... Release thumb contracture ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26510 ....... Thumb tendon transfer ................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26516 ....... Fusion of knuckle joint ................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26517 ....... Fusion of knuckle joints ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26518 ....... Fusion of knuckle joints ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26520 ....... Release knuckle contracture .......................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26525 ....... Release finger contracture ............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26530 ....... Revise knuckle joint ....................................... ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

26531 ....... Revise knuckle with implant ........................... ........... T ....... 0048 47.1644 2,903.02 .................... 580.60 

26535 ....... Revise finger joint .......................................... ........... T ....... 0047 32.7543 2,016.06 537.03 403.21

26536 ....... Revise/implant finger joint .............................. ........... T ....... 0048 47.1644 2,903.02 .................... 580.60 

26540 ....... Repair hand joint ............................................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26541 ....... Repair hand joint with graft ............................ ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26542 ....... Repair hand joint with graft ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26545 ....... Reconstruct finger joint .................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26546 ....... Repair nonunion hand .................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26548 ....... Reconstruct finger joint .................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26550 ....... Construct thumb replacement ........................ ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26555 ....... Positional change of finger ............................ ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26560 ....... Repair of web finger ....................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26561 ....... Repair of web finger ....................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26562 ....... Repair of web finger ....................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26565 ....... Correct metacarpal flaw ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26567 ....... Correct finger deformity ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26568 ....... Lengthen metacarpal/finger ........................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26580 ....... Repair hand deformity .................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26587 ....... Reconstruct extra finger ................................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26590 ....... Repair finger deformity ................................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26591 ....... Repair muscles of hand ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26593 ....... Release muscles of hand .............................. ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26596 ....... Excision constricting tissue ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26600 ....... Treat metacarpal fracture ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49773 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

26605 ....... Treat metacarpal fracture ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26607 ....... Treat metacarpal fracture ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26608 ....... Treat metacarpal fracture ............................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

26615 ....... Treat metacarpal fracture ............................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

26641 ....... Treat thumb dislocation .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26645 ....... Treat thumb fracture ...................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26650 ....... Treat thumb fracture ...................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

26665 ....... Treat thumb fracture ...................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

26670 ....... Treat hand dislocation .................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26675 ....... Treat hand dislocation .................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26676 ....... Pin hand dislocation ....................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

26685 ....... Treat hand dislocation .................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

26686 ....... Treat hand dislocation .................................... CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

26700 ....... Treat knuckle dislocation ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26705 ....... Treat knuckle dislocation ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26706 ....... Pin knuckle dislocation ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26715 ....... Treat knuckle dislocation ............................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

26720 ....... Treat finger fracture, each ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26725 ....... Treat finger fracture, each ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26727 ....... Treat finger fracture, each ............................. CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

26735 ....... Treat finger fracture, each ............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

26740 ....... Treat finger fracture, each ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26742 ....... Treat finger fracture, each ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26746 ....... Treat finger fracture, each ............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

26750 ....... Treat finger fracture, each ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26755 ....... Treat finger fracture, each ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26756 ....... Pin finger fracture, each ................................. CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

26765 ....... Treat finger fracture, each ............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

26770 ....... Treat finger dislocation ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26775 ....... Treat finger dislocation ................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

26776 ....... Pin finger dislocation ...................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

26785 ....... Treat finger dislocation ................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

26820 ....... Thumb fusion with graft ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26841 ....... Fusion of thumb ............................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26842 ....... Thumb fusion with graft ................................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26843 ....... Fusion of hand joint ....................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26844 ....... Fusion/graft of hand joint ............................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26850 ....... Fusion of knuckle ........................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26852 ....... Fusion of knuckle with graft ........................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26860 ....... Fusion of finger joint ...................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26861 ....... Fusion of finger jnt, add-on ............................ ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26862 ....... Fusion/graft of finger joint .............................. ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26863 ....... Fuse/graft added joint .................................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26910 ....... Amputate metacarpal bone ............................ ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

26951 ....... Amputation of finger/thumb ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26952 ....... Amputation of finger/thumb ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

26989 ....... Hand/finger surgery ........................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

26990 ....... Drainage of pelvis lesion ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

26991 ....... Drainage of pelvis bursa ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27000 ....... Incision of hip tendon ..................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27001 ....... Incision of hip tendon ..................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27003 ....... Incision of hip tendon ..................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27033 ....... Exploration of hip joint ................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27035 ....... Denervation of hip joint .................................. CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27040 ....... Biopsy of soft tissues ..................................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

27041 ....... Biopsy of soft tissues ..................................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

27047 ....... Remove hip/pelvis lesion ............................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27048 ....... Remove hip/pelvis lesion ............................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27049 ....... Remove tumor, hip/pelvis .............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27050 ....... Biopsy of sacroiliac joint ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27052 ....... Biopsy of hip joint ........................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27060 ....... Removal of ischial bursa ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27062 ....... Remove femur lesion/bursa ........................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27065 ....... Removal of hip bone lesion ........................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27066 ....... Removal of hip bone lesion ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27067 ....... Remove/graft hip bone lesion ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27080 ....... Removal of tail bone ...................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27086 ....... Remove hip foreign body ............................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

27087 ....... Remove hip foreign body ............................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27093 ....... Injection for hip x-ray ..................................... ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
49774 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

27095 ....... Injection for hip x-ray ..................................... ........... N ....... .......... .................... .................... .................... ....................

27097 ....... Revision of hip tendon ................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27098 ....... Transfer tendon to pelvis ............................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27100 ....... Transfer of abdominal muscle ....................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27105 ....... Transfer of spinal muscle ............................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27110 ....... Transfer of iliopsoas muscle .......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27111 ....... Transfer of iliopsoas muscle .......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27193 ....... Treat pelvic ring fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27194 ....... Treat pelvic ring fracture ................................ ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27200 ....... Treat tail bone fracture ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27202 ....... Treat tail bone fracture ................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27216 ....... Treat pelvic ring fracture ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27220 ....... Treat hip socket fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27230 ....... Treat thigh fracture ......................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27235 ....... Treat thigh fracture ......................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27238 ....... Treat thigh fracture ......................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27246 ....... Treat thigh fracture ......................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27250 ....... Treat hip dislocation ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27252 ....... Treat hip dislocation ....................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27256 ....... Treat hip dislocation ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27257 ....... Treat hip dislocation ....................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27265 ....... Treat hip dislocation ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27266 ....... Treat hip dislocation ....................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27275 ....... Manipulation of hip joint ................................. ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27299 ....... Pelvis/hip joint surgery ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27301 ....... Drain thigh/knee lesion .................................. ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

27305 ....... Incise thigh tendon&fascia ............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27306 ....... Incision of thigh tendon .................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27307 ....... Incision of thigh tendons ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27310 ....... Exploration of knee joint ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27315 ....... Partial removal, thigh nerve ........................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

27320 ....... Partial removal, thigh nerve ........................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

27323 ....... Biopsy, thigh soft tissues ............................... CH .... T ....... 0020 6.5128 400.87 98.57 80.17 

27324 ....... Biopsy, thigh soft tissues ............................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27327 ....... Removal of thigh lesion ................................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27328 ....... Removal of thigh lesion ................................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27329 ....... Remove tumor, thigh/knee ............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27330 ....... Biopsy, knee joint lining ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27331 ....... Explore/treat knee joint .................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27332 ....... Removal of knee cartilage ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27333 ....... Removal of knee cartilage ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27334 ....... Remove knee joint lining ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27335 ....... Remove knee joint lining ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27340 ....... Removal of kneecap bursa ............................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27345 ....... Removal of knee cyst .................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27347 ....... Remove knee cyst ......................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27350 ....... Removal of kneecap ...................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27355 ....... Remove femur lesion ..................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27356 ....... Remove femur lesion/graft ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27357 ....... Remove femur lesion/graft ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27358 ....... Remove femur lesion/fixation ......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27360 ....... Partial removal, leg bone(s) ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27370 ....... Injection for knee x-ray .................................. ........... N ....... .......... .................... .................... .................... ....................

27372 ....... Removal of foreign body ................................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27380 ....... Repair of kneecap tendon .............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27381 ....... Repair/graft kneecap tendon .......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27385 ....... Repair of thigh muscle ................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27386 ....... Repair/graft of thigh muscle ........................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27390 ....... Incision of thigh tendon .................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27391 ....... Incision of thigh tendons ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27392 ....... Incision of thigh tendons ................................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27393 ....... Lengthening of thigh tendon .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27394 ....... Lengthening of thigh tendons ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27395 ....... Lengthening of thigh tendons ........................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27396 ....... Transplant of thigh tendon ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27397 ....... Transplants of thigh tendons ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27400 ....... Revise thigh muscles/tendons ....................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27403 ....... Repair of knee cartilage ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27405 ....... Repair of knee ligament ................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27407 ....... Repair of knee ligament ................................. CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49775 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

27409 ....... Repair of knee ligaments ............................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27412 ....... Autochondrocyte implant knee ....................... ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

27415 ....... Osteochondral knee allograft ......................... ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

27418 ....... Repair degenerated kneecap ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27420 ....... Revision of unstable kneecap ........................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27422 ....... Revision of unstable kneecap ........................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27424 ....... Revision/removal of kneecap ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27425 ....... Lat retinacular release open .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27427 ....... Reconstruction, knee ..................................... CH .... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27428 ....... Reconstruction, knee ..................................... ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

27429 ....... Reconstruction, knee ..................................... ........... T ....... 0052 65.8846 4,055.26 .................... 811.05 

27430 ....... Revision of thigh muscles .............................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27435 ....... Incision of knee joint ...................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27437 ....... Revise kneecap .............................................. ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

27438 ....... Revise kneecap with implant ......................... ........... T ....... 0048 47.1644 2,903.02 .................... 580.60 

27440 ....... Revision of knee joint ..................................... ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

27441 ....... Revision of knee joint ..................................... ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

27442 ....... Revision of knee joint ..................................... ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

27443 ....... Revision of knee joint ..................................... ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

27446 ....... Revision of knee joint ..................................... ........... T ....... 0681 173.0706 10,652.67 .................... 2,130.53 

27475 ....... Surgery to stop leg growth ............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27496 ....... Decompression of thigh/knee ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27497 ....... Decompression of thigh/knee ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27498 ....... Decompression of thigh/knee ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27499 ....... Decompression of thigh/knee ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27500 ....... Treatment of thigh fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27501 ....... Treatment of thigh fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27502 ....... Treatment of thigh fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27503 ....... Treatment of thigh fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27508 ....... Treatment of thigh fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27509 ....... Treatment of thigh fracture ............................ CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

27510 ....... Treatment of thigh fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27516 ....... Treat thigh fx growth plate ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27517 ....... Treat thigh fx growth plate ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27520 ....... Treat kneecap fracture ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27524 ....... Treat kneecap fracture ................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27530 ....... Treat knee fracture ......................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27532 ....... Treat knee fracture ......................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27538 ....... Treat knee fracture(s) .................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27550 ....... Treat knee dislocation .................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27552 ....... Treat knee dislocation .................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27560 ....... Treat kneecap dislocation .............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27562 ....... Treat kneecap dislocation .............................. ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27566 ....... Treat kneecap dislocation .............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27570 ....... Fixation of knee joint ...................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27594 ....... Amputation follow-up surgery ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27599 ....... Leg surgery procedure ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27600 ....... Decompression of lower leg .......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27601 ....... Decompression of lower leg .......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27602 ....... Decompression of lower leg .......................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27603 ....... Drain lower leg lesion .................................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

27604 ....... Drain lower leg bursa ..................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27605 ....... Incision of achilles tendon .............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

27606 ....... Incision of achilles tendon .............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27607 ....... Treat lower leg bone lesion ........................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27610 ....... Explore/treat ankle joint ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27612 ....... Exploration of ankle joint ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27613 ....... Biopsy lower leg soft tissue ........................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

27614 ....... Biopsy lower leg soft tissue ........................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27615 ....... Remove tumor, lower leg ............................... CH .... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27618 ....... Remove lower leg lesion ................................ ........... T ....... 0021 14.9563 920.58 219.48 184.12 

27619 ....... Remove lower leg lesion ................................ ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

27620 ....... Explore/treat ankle joint ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27625 ....... Remove ankle joint lining ............................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27626 ....... Remove ankle joint lining ............................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27630 ....... Removal of tendon lesion .............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27635 ....... Remove lower leg bone lesion ...................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27637 ....... Remove/graft leg bone lesion ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27638 ....... Remove/graft leg bone lesion ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27640 ....... Partial removal of tibia ................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 


sroberts on PROD1PC70 with PROPOSALS
49776 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

27641 ....... Partial removal of fibula ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27647 ....... Extensive ankle/heel surgery ......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27648 ....... Injection for ankle x-ray .................................. ........... N ....... .......... .................... .................... .................... ....................

27650 ....... Repair achilles tendon ................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27652 ....... Repair/graft achilles tendon ........................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

27654 ....... Repair of achilles tendon ............................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27656 ....... Repair leg fascia defect ................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27658 ....... Repair of leg tendon, each ............................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27659 ....... Repair of leg tendon, each ............................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27664 ....... Repair of leg tendon, each ............................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27665 ....... Repair of leg tendon, each ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27675 ....... Repair lower leg tendons ............................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27676 ....... Repair lower leg tendons ............................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27680 ....... Release of lower leg tendon .......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27681 ....... Release of lower leg tendons ........................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27685 ....... Revision of lower leg tendon ......................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27686 ....... Revise lower leg tendons ............................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27687 ....... Revision of calf tendon .................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27690 ....... Revise lower leg tendon ................................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27691 ....... Revise lower leg tendon ................................ ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27692 ....... Revise additional leg tendon .......................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27695 ....... Repair of ankle ligament ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27696 ....... Repair of ankle ligaments .............................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27698 ....... Repair of ankle ligament ................................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27700 ....... Revision of ankle joint .................................... ........... T ....... 0047 32.7543 2,016.06 537.03 403.21 

27704 ....... Removal of ankle implant .............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27705 ....... Incision of tibia ............................................... ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27707 ....... Incision of fibula ............................................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27709 ....... Incision of tibia&fibula .................................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27730 ....... Repair of tibia epiphysis ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27732 ....... Repair of fibula epiphysis ............................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27734 ....... Repair lower leg epiphyses ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27740 ....... Repair of leg epiphyses ................................. ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27742 ....... Repair of leg epiphyses ................................. ........... T ....... 0051 41.2543 2,539.24 .................... 507.85 

27745 ....... Reinforce tibia ................................................ CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

27750 ....... Treatment of tibia fracture .............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27752 ....... Treatment of tibia fracture .............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27756 ....... Treatment of tibia fracture .............................. CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

27758 ....... Treatment of tibia fracture .............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27759 ....... Treatment of tibia fracture .............................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

27760 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27762 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27766 ....... Treatment of ankle fracture ............................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27780 ....... Treatment of fibula fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27781 ....... Treatment of fibula fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27784 ....... Treatment of fibula fracture ............................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27786 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27788 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27792 ....... Treatment of ankle fracture ............................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27808 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27810 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27814 ....... Treatment of ankle fracture ............................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27816 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27818 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27822 ....... Treatment of ankle fracture ............................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27823 ....... Treatment of ankle fracture ............................ CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

27824 ....... Treat lower leg fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27825 ....... Treat lower leg fracture .................................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27826 ....... Treat lower leg fracture .................................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27827 ....... Treat lower leg fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

27828 ....... Treat lower leg fracture .................................. CH .... T ....... 0064 56.4195 3,472.68 825.22 694.54 

27829 ....... Treat lower leg joint ....................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27830 ....... Treat lower leg dislocation ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27831 ....... Treat lower leg dislocation ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27832 ....... Treat lower leg dislocation ............................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27840 ....... Treat ankle dislocation ................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

27842 ....... Treat ankle dislocation ................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

27846 ....... Treat ankle dislocation ................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27848 ....... Treat ankle dislocation ................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

27860 ....... Fixation of ankle joint ..................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49777 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

27870 ....... Fusion of ankle joint, open ............................. CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

27871 ....... Fusion of tibiofibular joint ............................... CH .... T ....... 0052 65.8846 4,055.26 .................... 811.05 

27884 ....... Amputation follow-up surgery ........................ ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27889 ....... Amputation of foot at ankle ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

27892 ....... Decompression of leg .................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27893 ....... Decompression of leg .................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27894 ....... Decompression of leg .................................... ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

27899 ....... Leg/ankle surgery procedure ......................... ........... T ....... 0043 1.6914 104.11 .................... 20.82

28001 ....... Drainage of bursa of foot ............................... ........... T ....... 0007 10.9184 672.04 .................... 134.41 

28002 ....... Treatment of foot infection ............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

28003 ....... Treatment of foot infection ............................. ........... T ....... 0049 20.8214 1,281.58 .................... 256.32 

28005 ....... Treat foot bone lesion .................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28008 ....... Incision of foot fascia ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28010 ....... Incision of toe tendon ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28011 ....... Incision of toe tendons ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28020 ....... Exploration of foot joint .................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28022 ....... Exploration of foot joint .................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28024 ....... Exploration of toe joint ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28030 ....... Removal of foot nerve .................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

28035 ....... Decompression of tibia nerve ........................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

28043 ....... Excision of foot lesion .................................... CH .... T ....... 0022 19.9760 1,229.54 354.45 245.91 

28045 ....... Excision of foot lesion .................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28046 ....... Resection of tumor, foot ................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28050 ....... Biopsy of foot joint lining ................................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28052 ....... Biopsy of foot joint lining ................................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28054 ....... Biopsy of toe joint lining ................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28060 ....... Partial removal, foot fascia ............................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28062 ....... Removal of foot fascia ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28070 ....... Removal of foot joint lining ............................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28072 ....... Removal of foot joint lining ............................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28080 ....... Removal of foot lesion ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28086 ....... Excise foot tendon sheath ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28088 ....... Excise foot tendon sheath ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28090 ....... Removal of foot lesion ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28092 ....... Removal of toe lesions .................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28100 ....... Removal of ankle/heel lesion ......................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28102 ....... Remove/graft foot lesion ................................ ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28103 ....... Remove/graft foot lesion ................................ ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28104 ....... Removal of foot lesion ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28106 ....... Remove/graft foot lesion ................................ ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28107 ....... Remove/graft foot lesion ................................ ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28108 ....... Removal of toe lesions .................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28110 ....... Part removal of metatarsal ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28111 ....... Part removal of metatarsal ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28112 ....... Part removal of metatarsal ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28113 ....... Part removal of metatarsal ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28114 ....... Removal of metatarsal heads ........................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28116 ....... Revision of foot .............................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28118 ....... Removal of heel bone .................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28119 ....... Removal of heel spur ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28120 ....... Part removal of ankle/heel ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28122 ....... Partial removal of foot bone ........................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28124 ....... Partial removal of toe ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28126 ....... Partial removal of toe ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28130 ....... Removal of ankle bone .................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28140 ....... Removal of metatarsal ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28150 ....... Removal of toe ............................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98

28153 ....... Partial removal of toe ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28160 ....... Partial removal of toe ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28171 ....... Extensive foot surgery ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28173 ....... Extensive foot surgery ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28175 ....... Extensive foot surgery ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28190 ....... Removal of foot foreign body ......................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

28192 ....... Removal of foot foreign body ......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

28193 ....... Removal of foot foreign body ......................... ........... T ....... 0020 6.5128 400.87 98.57 80.17 

28200 ....... Repair of foot tendon ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28202 ....... Repair/graft of foot tendon ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28208 ....... Repair of foot tendon ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28210 ....... Repair/graft of foot tendon ............................. ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28220 ....... Release of foot tendon ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 


sroberts on PROD1PC70 with PROPOSALS
49778 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

28222 ....... Release of foot tendons ................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28225 ....... Release of foot tendon ................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28226 ....... Release of foot tendons ................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28230 ....... Incision of foot tendon(s) ............................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28232 ....... Incision of toe tendon ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28234 ....... Incision of foot tendon .................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28238 ....... Revision of foot tendon .................................. ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28240 ....... Release of big toe .......................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28250 ....... Revision of foot fascia .................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28260 ....... Release of midfoot joint ................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28261 ....... Revision of foot tendon .................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28262 ....... Revision of foot and ankle ............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28264 ....... Release of midfoot joint ................................. ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28270 ....... Release of foot contracture ............................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28272 ....... Release of toe joint, each .............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28280 ....... Fusion of toes ................................................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28285 ....... Repair of hammertoe ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28286 ....... Repair of hammertoe ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28288 ....... Partial removal of foot bone ........................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28289 ....... Repair hallux rigidus ...................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28290 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28292 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28293 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28294 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28296 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28297 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28298 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28299 ....... Correction of bunion ....................................... ........... T ....... 0057 28.0970 1,729.40 475.91 345.88 

28300 ....... Incision of heel bone ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28302 ....... Incision of ankle bone .................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28304 ....... Incision of midfoot bones ............................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28305 ....... Incise/graft midfoot bones .............................. ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28306 ....... Incision of metatarsal ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28307 ....... Incision of metatarsal ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28308 ....... Incision of metatarsal ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28309 ....... Incision of metatarsals ................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28310 ....... Revision of big toe ......................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28312 ....... Revision of toe ............................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28313 ....... Repair deformity of toe .................................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28315 ....... Removal of sesamoid bone ........................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28320 ....... Repair of foot bones ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28322 ....... Repair of metatarsals ..................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28340 ....... Resect enlarged toe tissue ............................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28341 ....... Resect enlarged toe ....................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28344 ....... Repair extra toe(s) ......................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28345 ....... Repair webbed toe(s) ..................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28360 ....... Reconstruct cleft foot ..................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28400 ....... Treatment of heel fracture ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28405 ....... Treatment of heel fracture ............................. ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28406 ....... Treatment of heel fracture ............................. CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28415 ....... Treat heel fracture .......................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28420 ....... Treat/graft heel fracture ................................. CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28430 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28435 ....... Treatment of ankle fracture ............................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28436 ....... Treatment of ankle fracture ............................ CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28445 ....... Treat ankle fracture ........................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28450 ....... Treat midfoot fracture, each ........................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28455 ....... Treat midfoot fracture, each ........................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28456 ....... Treat midfoot fracture ..................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28465 ....... Treat midfoot fracture, each ........................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28470 ....... Treat metatarsal fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28475 ....... Treat metatarsal fracture ................................ ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28476 ....... Treat metatarsal fracture ................................ CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28485 ....... Treat metatarsal fracture ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28490 ....... Treat big toe fracture ..................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28495 ....... Treat big toe fracture ..................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28496 ....... Treat big toe fracture ..................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28505 ....... Treat big toe fracture ..................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28510 ....... Treatment of toe fracture ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28515 ....... Treatment of toe fracture ............................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49779 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

28525 ....... Treat toe fracture ........................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28530 ....... Treat sesamoid bone fracture ........................ ........... T ....... 0043 1.6914 104.11 .................... 20.82

28531 ....... Treat sesamoid bone fracture ........................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28540 ....... Treat foot dislocation ...................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28545 ....... Treat foot dislocation ...................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28546 ....... Treat foot dislocation ...................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28555 ....... Repair foot dislocation ................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28570 ....... Treat foot dislocation ...................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28575 ....... Treat foot dislocation ...................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28576 ....... Treat foot dislocation ...................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28585 ....... Repair foot dislocation ................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28600 ....... Treat foot dislocation ...................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28605 ....... Treat foot dislocation ...................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28606 ....... Treat foot dislocation ...................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28615 ....... Repair foot dislocation ................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28630 ....... Treat toe dislocation ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28635 ....... Treat toe dislocation ....................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

28636 ....... Treat toe dislocation ....................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28645 ....... Repair toe dislocation .................................... CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28660 ....... Treat toe dislocation ....................................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

28665 ....... Treat toe dislocation ....................................... ........... T ....... 0045 14.5502 895.58 268.47 179.12 

28666 ....... Treat toe dislocation ....................................... CH .... T ....... 0062 25.6702 1,580.03 375.46 316.01 

28675 ....... Repair of toe dislocation ................................ CH .... T ....... 0063 37.5680 2,312.35 549.49 462.47 

28705 ....... Fusion of foot bones ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28715 ....... Fusion of foot bones ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28725 ....... Fusion of foot bones ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28730 ....... Fusion of foot bones ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28735 ....... Fusion of foot bones ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28737 ....... Revision of foot bones ................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28740 ....... Fusion of foot bones ...................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28750 ....... Fusion of big toe joint .................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28755 ....... Fusion of big toe joint .................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28760 ....... Fusion of big toe joint .................................... ........... T ....... 0056 41.2239 2,537.37 .................... 507.47 

28810 ....... Amputation toe&metatarsal ............................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28820 ....... Amputation of toe ........................................... ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28825 ....... Partial amputation of toe ................................ ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

28890 ....... High energy eswt, plantar f ............................ CH .... T ....... 0050 25.0600 1,542.47 .................... 308.49 

28899 ....... Foot/toes surgery procedure .......................... ........... T ....... 0043 1.6914 104.11 .................... 20.82 

29000 ....... Application of body cast ................................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29010 ....... Application of body cast ................................. ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29015 ....... Application of body cast ................................. ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29020 ....... Application of body cast ................................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29025 ....... Application of body cast ................................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29035 ....... Application of body cast ................................. ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29040 ....... Application of body cast ................................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29044 ....... Application of body cast ................................. ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29046 ....... Application of body cast ................................. ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29049 ....... Application of figure eight .............................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29055 ....... Application of shoulder cast ........................... ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29058 ....... Application of shoulder cast ........................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29065 ....... Application of long arm cast .......................... ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29075 ....... Application of forearm cast ............................ ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29085 ....... Apply hand/wrist cast ..................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29086 ....... Apply finger cast ............................................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29105 ....... Apply long arm splint ..................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29125 ....... Apply forearm splint ....................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29126 ....... Apply forearm splint ....................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29130 ....... Application of finger splint .............................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29131 ....... Application of finger splint .............................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29200 ....... Strapping of chest .......................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29220 ....... Strapping of low back .................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29240 ....... Strapping of shoulder ..................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29260 ....... Strapping of elbow or wrist ............................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29280 ....... Strapping of hand or finger ............................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29305 ....... Application of hip cast .................................... ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29325 ....... Application of hip casts .................................. ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29345 ....... Application of long leg cast ............................ ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29355 ....... Application of long leg cast ............................ ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29358 ....... Apply long leg cast brace .............................. ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29365 ....... Application of long leg cast ............................ ........... S ....... 0426 2.2728 139.89 .................... 27.98 


sroberts on PROD1PC70 with PROPOSALS
49780 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

29405 ....... Apply short leg cast ....................................... ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29425 ....... Apply short leg cast ....................................... ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29435 ....... Apply short leg cast ....................................... ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29440 ....... Addition of walker to cast ............................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29445 ....... Apply rigid leg cast ......................................... ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29450 ....... Application of leg cast .................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29505 ....... Application, long leg splint ............................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29515 ....... Application lower leg splint ............................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29520 ....... Strapping of hip .............................................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29530 ....... Strapping of knee ........................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29540 ....... Strapping of ankle and/or ft ........................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29550 ....... Strapping of toes ............................................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29580 ....... Application of paste boot ............................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29590 ....... Application of foot splint ................................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29700 ....... Removal/revision of cast ................................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29705 ....... Removal/revision of cast ................................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29710 ....... Removal/revision of cast ................................ ........... S ....... 0426 2.2728 139.89 .................... 27.98 

29715 ....... Removal/revision of cast ................................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29720 ....... Repair of body cast ........................................ ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29730 ....... Windowing of cast .......................................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29740 ....... Wedging of cast ............................................. ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29750 ....... Wedging of clubfoot cast ............................... ........... S ....... 0058 1.0504 64.65 .................... 12.93 

29799 ....... Casting/strapping procedure .......................... ........... S ....... 0058 1.0504 64.65 .................... 12.93

29800 ....... Jaw arthroscopy/surgery ................................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29804 ....... Jaw arthroscopy/surgery ................................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29805 ....... Shoulder arthroscopy, dx ............................... ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29806 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29807 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29819 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29820 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29821 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29822 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29823 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29824 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29825 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29826 ....... Shoulder arthroscopy/surgery ........................ ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29827 ....... Arthroscop rotator cuff repr ............................ ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29830 ....... Elbow arthroscopy .......................................... ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29834 ....... Elbow arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29835 ....... Elbow arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29836 ....... Elbow arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29837 ....... Elbow arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29838 ....... Elbow arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29840 ....... Wrist arthroscopy ........................................... ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29843 ....... Wrist arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29844 ....... Wrist arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29845 ....... Wrist arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29846 ....... Wrist arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29847 ....... Wrist arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29848 ....... Wrist endoscopy/surgery ................................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29850 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29851 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29855 ....... Tibial arthroscopy/surgery .............................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29856 ....... Tibial arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29860 ....... Hip arthroscopy, dx ........................................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29861 ....... Hip arthroscopy/surgery ................................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29862 ....... Hip arthroscopy/surgery ................................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29863 ....... Hip arthroscopy/surgery ................................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29866 ....... Autgrft implnt, knee w/scope .......................... ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29867 ....... Allgrft implnt, knee w/scope ........................... ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29868 ....... Meniscal trnspl, knee w/scpe ......................... ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29870 ....... Knee arthroscopy, dx ..................................... ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29871 ....... Knee arthroscopy/drainage ............................ ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29873 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29874 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29875 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29876 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29877 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29879 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29880 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49781 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

29881 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29882 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29883 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29884 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29885 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29886 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29887 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29888 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29889 ....... Knee arthroscopy/surgery .............................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29891 ....... Ankle arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29892 ....... Ankle arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29893 ....... Scope, plantar fasciotomy .............................. ........... T ....... 0055 20.2255 1,244.90 355.34 248.98 

29894 ....... Ankle arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29895 ....... Ankle arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29897 ....... Ankle arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29898 ....... Ankle arthroscopy/surgery ............................. ........... T ....... 0041 28.6279 1,762.08 .................... 352.42 

29899 ....... Ankle arthroscopy/surgery ............................. ........... T ....... 0042 45.0637 2,773.72 804.74 554.74 

29900 ....... Mcp joint arthroscopy, dx ............................... ........... T ....... 0053 16.0343 986.93 253.49 197.39 

29901 ....... Mcp joint arthroscopy, surg ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

29902 ....... Mcp joint arthroscopy, surg ............................ ........... T ....... 0053 16.0343 986.93 253.49 197.39 

29999 ....... Arthroscopy of joint ........................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

30110 ....... Removal of nose polyp(s) .............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30115 ....... Removal of nose polyp(s) .............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30117 ....... Removal of intranasal lesion .......................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30118 ....... Removal of intranasal lesion .......................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

30120 ....... Revision of nose ............................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30124 ....... Removal of nose lesion ................................. ........... T ....... 0252 7.7261 475.55 111.84 95.11 

30125 ....... Removal of nose lesion ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30130 ....... Excise inferior turbinate ................................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30140 ....... Resect inferior turbinate ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

30150 ....... Partial removal of nose .................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30160 ....... Removal of nose ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30200 ....... Injection treatment of nose ............................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

30210 ....... Nasal sinus therapy ....................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

30220 ....... Insert nasal septal button ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

30300 ....... Remove nasal foreign body ........................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

30310 ....... Remove nasal foreign body ........................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30320 ....... Remove nasal foreign body ........................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30400 ....... Reconstruction of nose .................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30410 ....... Reconstruction of nose .................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30420 ....... Reconstruction of nose .................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30430 ....... Revision of nose ............................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

30435 ....... Revision of nose ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30450 ....... Revision of nose ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30460 ....... Revision of nose ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30462 ....... Revision of nose ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30465 ....... Repair nasal stenosis ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30520 ....... Repair of nasal septum .................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

30540 ....... Repair nasal defect ........................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30545 ....... Repair nasal defect ........................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30560 ....... Release of nasal adhesions ........................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

30580 ....... Repair upper jaw fistula ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30600 ....... Repair mouth/nose fistula .............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30620 ....... Intranasal reconstruction ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

30630 ....... Repair nasal septum defect ........................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

30801 ....... Ablate inf turbinate, superf ............................. ........... T ....... 0252 7.7261 475.55 111.84 95.11 

30802 ....... Cauterization, inner nose ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

30901 ....... Control of nosebleed ...................................... ........... T ....... 0250 1.2021 73.99 25.50 14.80 

30903 ....... Control of nosebleed ...................................... ........... T ....... 0250 1.2021 73.99 25.50 14.80 

30905 ....... Control of nosebleed ...................................... ........... T ....... 0250 1.2021 73.99 25.50 14.80 

30906 ....... Repeat control of nosebleed .......................... ........... T ....... 0250 1.2021 73.99 25.50 14.80 

30915 ....... Ligation, nasal sinus artery ............................ CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

30920 ....... Ligation, upper jaw artery .............................. ........... T ....... 0092 24.5817 1,513.03 306.56 302.61 

30930 ....... Ther fx, nasal inf turbinate ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

30999 ....... Nasal surgery procedure ................................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

31000 ....... Irrigation, maxillary sinus ............................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

31002 ....... Irrigation, sphenoid sinus ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

31020 ....... Exploration, maxillary sinus ........................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31030 ....... Exploration, maxillary sinus ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31032 ....... Explore sinus, remove polyps ........................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 


sroberts on PROD1PC70 with PROPOSALS
49782 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

31040 ....... Exploration behind upper jaw ........................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31050 ....... Exploration, sphenoid sinus ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31051 ....... Sphenoid sinus surgery ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31070 ....... Exploration of frontal sinus ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31075 ....... Exploration of frontal sinus ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31080 ....... Removal of frontal sinus ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31081 ....... Removal of frontal sinus ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31084 ....... Removal of frontal sinus ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31085 ....... Removal of frontal sinus ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31086 ....... Removal of frontal sinus ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31087 ....... Removal of frontal sinus ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31090 ....... Exploration of sinuses .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31200 ....... Removal of ethmoid sinus ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31201 ....... Removal of ethmoid sinus ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31205 ....... Removal of ethmoid sinus ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31231 ....... Nasal endoscopy, dx ...................................... ........... T ....... 0072 1.4038 86.41 21.27 17.28 

31233 ....... Nasal/sinus endoscopy, dx ............................ ........... T ....... 0072 1.4038 86.41 21.27 17.28 

31235 ....... Nasal/sinus endoscopy, dx ............................ ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31237 ....... Nasal/sinus endoscopy, surg ......................... CH .... T ....... 0074 15.1300 931.27 295.70 186.25 

31238 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31239 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31240 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31254 ....... Revision of ethmoid sinus .............................. ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31255 ....... Removal of ethmoid sinus ............................. ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31256 ....... Exploration maxillary sinus ............................ ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31267 ....... Endoscopy, maxillary sinus ............................ ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31276 ....... Sinus endoscopy, surgical ............................. ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31287 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31288 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31292 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31293 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31294 ....... Nasal/sinus endoscopy, surg ......................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31299 ....... Sinus surgery procedure ................................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

31300 ....... Removal of larynx lesion ................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31320 ....... Diagnostic incision, larynx .............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31400 ....... Revision of larynx ........................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31420 ....... Removal of epiglottis ...................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31500 ....... Insert emergency airway ................................ ........... S ....... 0094 2.4630 151.60 46.29 30.32 

31502 ....... Change of windpipe airway ............................ ........... T ....... 0121 2.3431 144.22 43.80 28.84 

31505 ....... Diagnostic laryngoscopy ................................ ........... T ....... 0071 0.7572 46.61 11.03 9.32 

31510 ....... Laryngoscopy with biopsy .............................. ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31511 ....... Remove foreign body, larynx ......................... ........... T ....... 0072 1.4038 86.41 21.27 17.28 

31512 ....... Removal of larynx lesion ................................ ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31513 ....... Injection into vocal cord ................................. ........... T ....... 0072 1.4038 86.41 21.27 17.28 

31515 ....... Laryngoscopy for aspiration ........................... ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31520 ....... Dx laryngoscopy, newborn ............................. ........... T ....... 0072 1.4038 86.41 21.27 17.28 

31525 ....... Dx laryngoscopy excl nb ................................ ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31526 ....... Dx laryngoscopy w/oper scope ...................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31527 ....... Laryngoscopy for treatment ........................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31528 ....... Laryngoscopy and dilation ............................. ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31529 ....... Laryngoscopy and dilation ............................. ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31530 ....... Laryngoscopy w/fb removal ........................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31531 ....... Laryngoscopy w/fb&op scope ........................ ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31535 ....... Laryngoscopy w/biopsy .................................. ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31536 ....... Laryngoscopy w/bx&op scope ....................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31540 ....... Laryngoscopy w/exc of tumor ........................ ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31541 ....... Larynscop w/tumr exc + scope ...................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31545 ....... Remove vc lesion w/scope ............................ ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31546 ....... Remove vc lesion scope/graft ........................ ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31560 ....... Laryngoscop w/arytenoidectom ..................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31561 ....... Larynscop, remve cart + scop ....................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31570 ....... Laryngoscope w/vc inj .................................... ........... T ....... 0074 15.1300 931.27 295.70 186.25 

31571 ....... Laryngoscop w/vc inj + scope ....................... ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31575 ....... Diagnostic laryngoscopy ................................ ........... T ....... 0072 1.4038 86.41 21.27 17.28 

31576 ....... Laryngoscopy with biopsy .............................. ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31577 ....... Remove foreign body, larynx ......................... ........... T ....... 0073 3.8737 238.43 69.72 47.69 

31578 ....... Removal of larynx lesion ................................ ........... T ....... 0075 21.8010 1,341.87 445.92 268.37 

31579 ....... Diagnostic laryngoscopy ................................ ........... T ....... 0073 3.8737 238.43 69.72 47.69 

31580 ....... Revision of larynx ........................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31582 ....... Revision of larynx ........................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49783 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

31588 ....... Revision of larynx ........................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31590 ....... Reinnervate larynx ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31595 ....... Larynx nerve surgery ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31599 ....... Larynx surgery procedure .............................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

31600 ....... Incision of windpipe ........................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31601 ....... Incision of windpipe ........................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31603 ....... Incision of windpipe ........................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

31605 ....... Incision of windpipe ........................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

31610 ....... Incision of windpipe ........................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31611 ....... Surgery/speech prosthesis ............................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31612 ....... Puncture/clear windpipe ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31613 ....... Repair windpipe opening ............................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31614 ....... Repair windpipe opening ............................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31615 ....... Visualization of windpipe ................................ ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31620 ....... Endobronchial us add-on ............................... ........... S ....... 0670 29.7322 1,830.05 536.10 366.01 

31622 ....... Dx bronchoscope/wash .................................. ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31623 ....... Dx bronchoscope/brush ................................. ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31624 ....... Dx bronchoscope/lavage ................................ ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31625 ....... Bronchoscopy w/biopsy(s) ............................. ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31628 ....... Bronchoscopy/lung bx, each .......................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31629 ....... Bronchoscopy/needle bx, each ...................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31630 ....... Bronchoscopy dilate/fx repr ........................... ........... T ....... 0415 21.8803 1,346.75 459.92 269.35 

31631 ....... Bronchoscopy, dilate w/stent ......................... ........... T ....... 0415 21.8803 1,346.75 459.92 269.35 

31632 ....... Bronchoscopy/lung bx, add’l .......................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31633 ....... Bronchoscopy/needle bx add’l ....................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31635 ....... Bronchoscopy w/fb removal ........................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31636 ....... Bronchoscopy, bronch stents ......................... ........... T ....... 0415 21.8803 1,346.75 459.92 269.35 

31637 ....... Bronchoscopy, stent add-on .......................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31638 ....... Bronchoscopy, revise stent ............................ ........... T ....... 0415 21.8803 1,346.75 459.92 269.35 

31640 ....... Bronchoscopy w/tumor excise ....................... ........... T ....... 0415 21.8803 1,346.75 459.92 269.35 

31641 ....... Bronchoscopy, treat blockage ........................ ........... T ....... 0415 21.8803 1,346.75 459.92 269.35 

31643 ....... Diag bronchoscope/catheter .......................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31645 ....... Bronchoscopy, clear airways ......................... ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31646 ....... Bronchoscopy, reclear airway ........................ ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31656 ....... Bronchoscopy, inj for x-ray ............................ ........... T ....... 0076 9.3905 577.99 189.82 115.60 

31700 ....... Insertion of airway catheter ............................ ........... T ....... 0072 1.4038 86.41 21.27 17.28 

31708 ....... Instill airway contrast dye ............................... ........... N ....... .......... .................... .................... .................... ....................

31710 ....... Insertion of airway catheter ............................ ........... N ....... .......... .................... .................... .................... ....................

31715 ....... Injection for bronchus x-ray ........................... ........... N ....... .......... .................... .................... .................... ....................

31717 ....... Bronchial brush biopsy ................................... ........... T ....... 0073 3.8737 238.43 69.72 47.69 

31720 ....... Clearance of airways ..................................... ........... T ....... 0071 0.7572 46.61 11.03 9.32 

31730 ....... Intro, windpipe wire/tube ................................ ........... T ....... 0073 3.8737 238.43 69.72 47.69 

31750 ....... Repair of windpipe ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31755 ....... Repair of windpipe ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

31785 ....... Remove windpipe lesion ................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31820 ....... Closure of windpipe lesion ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

31825 ....... Repair of windpipe defect .............................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31830 ....... Revise windpipe scar ..................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

31899 ....... Airways surgical procedure ............................ ........... T ....... 0076 9.3905 577.99 189.82 115.60 

32000 ....... Drainage of chest ........................................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

32002 ....... Treatment of collapsed lung .......................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

32005 ....... Treat lung lining chemically ........................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

32019 ....... Insert pleural catheter .................................... CH .... T ....... 0652 29.2259 1,798.88 .................... 359.78 

32020 ....... Insertion of chest tube ................................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

32201 ....... Drain, percut, lung lesion ............................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

32400 ....... Needle biopsy chest lining ............................. ........... T ....... 0685 6.0729 373.79 115.47 74.76 

32405 ....... Biopsy, lung or mediastinum .......................... ........... T ....... 0685 6.0729 373.79 115.47 74.76 

32420 ....... Puncture/clear lung ........................................ ........... T ....... 0070 3.6425 224.20 .................... 44.84 

32601 ....... Thoracoscopy, diagnostic .............................. ........... T ....... 0069 31.5464 1,941.71 591.64 388.34 

32602 ....... Thoracoscopy, diagnostic .............................. ........... T ....... 0069 31.5464 1,941.71 591.64 388.34 

32603 ....... Thoracoscopy, diagnostic .............................. ........... T ....... 0069 31.5464 1,941.71 591.64 388.34 

32604 ....... Thoracoscopy, diagnostic .............................. ........... T ....... 0069 31.5464 1,941.71 591.64 388.34 

32605 ....... Thoracoscopy, diagnostic .............................. ........... T ....... 0069 31.5464 1,941.71 591.64 388.34 

32606 ....... Thoracoscopy, diagnostic .............................. ........... T ....... 0069 31.5464 1,941.71 591.64 388.34 

32960 ....... Therapeutic pneumothorax ............................ ........... T ....... 0070 3.6425 224.20 .................... 44.84

32999 ....... Chest surgery procedure ............................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

33010 ....... Drainage of heart sac .................................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

33011 ....... Repeat drainage of heart sac ........................ ........... T ....... 0070 3.6425 224.20 .................... 44.84

33206 ....... Insertion of heart pacemaker ......................... ........... T ....... 0089 121.9402 7,505.54 1,682.28 1,501.11 

33207 ....... Insertion of heart pacemaker ......................... ........... T ....... 0089 121.9402 7,505.54 1,682.28 1,501.11 


sroberts on PROD1PC70 with PROPOSALS
49784 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

33208 ....... Insertion of heart pacemaker ......................... ........... T ....... 0655 153.1524 9,426.68 .................... 1,885.34 

33210 ....... Insertion of heart electrode ............................ ........... T ....... 0106 44.7574 2,754.86 .................... 550.97 

33211 ....... Insertion of heart electrode ............................ ........... T ....... 0106 44.7574 2,754.86 .................... 550.97 

33212 ....... Insertion of pulse generator ........................... ........... T ....... 0090 97.8357 6,021.89 1,612.80 1,204.38 

33213 ....... Insertion of pulse generator ........................... ........... T ....... 0654 112.2347 6,908.16 .................... 1,381.63 

33214 ....... Upgrade of pacemaker system ...................... ........... T ....... 0655 153.1524 9,426.68 .................... 1,885.34 

33215 ....... Reposition pacing-defib lead .......................... ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

33216 ....... Insert lead pace-defib, one ............................ ........... T ....... 0106 44.7574 2,754.86 .................... 550.97 

33217 ....... Insert lead pace-defib, dual ........................... ........... T ....... 0106 44.7574 2,754.86 .................... 550.97 

33218 ....... Repair lead pace-defib, one ........................... ........... T ....... 0106 44.7574 2,754.86 .................... 550.97 

33220 ....... Repair lead pace-defib, dual .......................... ........... T ....... 0106 44.7574 2,754.86 .................... 550.97 

33222 ....... Revise pocket, pacemaker ............................. ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

33223 ....... Revise pocket, pacing-defib ........................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

33224 ....... Insert pacing lead&connect ............................ ........... T ....... 0418 267.8870 16,488.71 .................... 3,297.74 

33225 ....... L ventric pacing lead add-on ......................... ........... T ....... 0418 267.8870 16,488.71 .................... 3,297.74 

33226 ....... Reposition l ventric lead ................................. ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

33233 ....... Removal of pacemaker system ..................... ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

33234 ....... Removal of pacemaker system ..................... ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

33235 ....... Removal pacemaker electrode ...................... ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

33241 ....... Remove pulse generator ................................ ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

33244 ....... Remove eltrd, transven .................................. ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

33282 ....... Implant pat-active ht record ........................... ........... S ....... 0680 74.8877 4,609.41 .................... 921.88 

33284 ....... Remove pat-active ht record .......................... ........... T ....... 0109 10.9541 674.24 .................... 134.85 

33508 ....... Endoscopic vein harvest ................................ ........... N ....... .......... .................... .................... .................... ....................

33999 ....... Cardiac surgery procedure ............................ ........... T ....... 0070 3.6425 224.20 .................... 44.84 

34101 ....... Removal of artery clot .................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34111 ....... Removal of arm artery clot ............................ ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34201 ....... Removal of artery clot .................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34203 ....... Removal of leg artery clot .............................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34421 ....... Removal of vein clot ...................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34471 ....... Removal of vein clot ...................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34490 ....... Removal of vein clot ...................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34501 ....... Repair valve, femoral vein ............................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34510 ....... Transposition of vein valve ............................ ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34520 ....... Cross-over vein graft ...................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

34530 ....... Leg vein fusion ............................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

35011 ....... Repair defect of artery ................................... ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

35180 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35184 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35188 ....... Repair blood vessel lesion ............................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

35190 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35201 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35206 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35207 ....... Repair blood vessel lesion ............................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

35226 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35231 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35236 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35256 ....... Repair blood vessel lesion ............................. ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35261 ....... Repair blood vessel lesion ............................. ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

35266 ....... Repair blood vessel lesion ............................. ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

35286 ....... Repair blood vessel lesion ............................. ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

35321 ....... Rechanneling of artery ................................... ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35458 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35459 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35460 ....... Repair venous blockage ................................ ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35470 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35471 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35472 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35473 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35474 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35475 ....... Repair arterial blockage ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35476 ....... Repair venous blockage ................................ ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35484 ....... Atherectomy, open ......................................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35485 ....... Atherectomy, open ......................................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35490 ....... Atherectomy, percutaneous ........................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35491 ....... Atherectomy, percutaneous ........................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35492 ....... Atherectomy, percutaneous ........................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35493 ....... Atherectomy, percutaneous ........................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35494 ....... Atherectomy, percutaneous ........................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35495 ....... Atherectomy, percutaneous ........................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49785 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

35500 ....... Harvest vein for bypass ................................. ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

35572 ....... Harvest femoropopliteal vein ......................... ........... N ....... .......... .................... .................... .................... ....................

35685 ....... Bypass graft patency/patch ............................ ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35686 ....... Bypass graft/av fist patency ........................... ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35761 ....... Exploration of artery/vein ............................... ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

35860 ....... Explore limb vessels ...................................... ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

35875 ....... Removal of clot in graft .................................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

35876 ....... Removal of clot in graft .................................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

35879 ....... Revise graft w/vein ......................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

35881 ....... Revise graft w/vein ......................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

35903 ....... Excision, graft, extremity ................................ ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

36000 ....... Place needle in vein ....................................... ........... N ....... .......... .................... .................... .................... ....................

36002 ....... Pseudoaneurysm injection trt ......................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

36005 ....... Injection ext venography ................................ ........... N ....... .......... .................... .................... .................... ....................

36010 ....... Place catheter in vein .................................... ........... N ....... .......... .................... .................... .................... ....................

36011 ....... Place catheter in vein .................................... ........... N ....... .......... .................... .................... .................... ....................

36012 ....... Place catheter in vein .................................... ........... N ....... .......... .................... .................... .................... ....................

36013 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36014 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36015 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36100 ....... Establish access to artery .............................. ........... N ....... .......... .................... .................... .................... ....................

36120 ....... Establish access to artery .............................. ........... N ....... .......... .................... .................... .................... ....................

36140 ....... Establish access to artery .............................. ........... N ....... .......... .................... .................... .................... ....................

36145 ....... Artery to vein shunt ........................................ ........... N ....... .......... .................... .................... .................... ....................

36160 ....... Establish access to aorta ............................... ........... N ....... .......... .................... .................... .................... ....................

36200 ....... Place catheter in aorta ................................... ........... N ....... .......... .................... .................... .................... ....................

36215 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36216 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36217 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36218 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36245 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36246 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36247 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36248 ....... Place catheter in artery .................................. ........... N ....... .......... .................... .................... .................... ....................

36260 ....... Insertion of infusion pump .............................. ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36261 ....... Revision of infusion pump .............................. ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36262 ....... Removal of infusion pump ............................. ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36299 ....... Vessel injection procedure ............................. ........... N ....... .......... .................... .................... .................... ....................

36400 ....... Bl draw < 3 yrs fem/jugular ............................ ........... N ....... .......... .................... .................... .................... ....................

36405 ....... Bl draw < 3 yrs scalp vein ............................. ........... N ....... .......... .................... .................... .................... ....................

36406 ....... Bl draw < 3 yrs other vein ............................. ........... N ....... .......... .................... .................... .................... ....................

36410 ....... Non-routine bl draw > 3 yrs ........................... ........... N ....... .......... .................... .................... .................... ....................

36416 ....... Capillary blood draw ...................................... ........... N ....... .......... .................... .................... .................... ....................

36420 ....... Vein access cutdown < 1 yr .......................... ........... T ....... 0035 0.2016 12.41 .................... 2.48 

36425 ....... Vein access cutdown > 1 yr .......................... ........... T ....... 0035 0.2016 12.41 .................... 2.48 

36430 ....... Blood transfusion service ............................... ........... S ....... 0110 3.4570 212.78 .................... 42.56 

36440 ....... Bl push transfuse, 2 yr or < ........................... ........... S ....... 0110 3.4570 212.78 .................... 42.56 

36450 ....... Bl exchange/transfuse, nb ............................. ........... S ....... 0110 3.4570 212.78 .................... 42.56 

36455 ....... Bl exchange/transfuse non-nb ....................... ........... S ....... 0110 3.4570 212.78 .................... 42.56 

36460 ....... Transfusion service, fetal ............................... ........... S ....... 0110 3.4570 212.78 .................... 42.56 

36468 ....... Injection(s), spider veins ................................ ........... T ....... 0098 1.1035 67.92 .................... 13.58 

36469 ....... Injection(s), spider veins ................................ ........... T ....... 0098 1.1035 67.92 .................... 13.58 

36470 ....... Injection therapy of vein ................................. ........... T ....... 0098 1.1035 67.92 .................... 13.58 

36471 ....... Injection therapy of veins ............................... ........... T ....... 0098 1.1035 67.92 .................... 13.58 

36475 ....... Endovenous rf, 1st vein ................................. ........... T ....... 0091 34.6279 2,131.38 .................... 426.28 

36476 ....... Endovenous rf, vein add-on ........................... ........... T ....... 0091 34.6279 2,131.38 .................... 426.28 

36478 ....... Endovenous laser, 1st vein ............................ CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

36479 ....... Endovenous laser vein addon ....................... CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

36481 ....... Insertion of catheter, vein .............................. ........... N ....... .......... .................... .................... .................... ....................

36500 ....... Insertion of catheter, vein .............................. ........... N ....... .......... .................... .................... .................... ....................

36510 ....... Insertion of catheter, vein .............................. ........... N ....... .......... .................... .................... .................... ....................

36511 ....... Apheresis wbc ................................................ ........... S ....... 0111 11.7005 720.18 198.40 144.04 

36512 ....... Apheresis rbc ................................................. ........... S ....... 0111 11.7005 720.18 198.40 144.04 

36513 ....... Apheresis platelets ......................................... ........... S ....... 0111 11.7005 720.18 198.40 144.04 

36514 ....... Apheresis plasma ........................................... ........... S ....... 0111 11.7005 720.18 198.40 144.04 

36515 ....... Apheresis, adsorp/reinfuse ............................ ........... S ....... 0112 30.6602 1,887.17 433.29 377.43 

36516 ....... Apheresis, selective ....................................... ........... S ....... 0112 30.6602 1,887.17 433.29 377.43 

36522 ....... Photopheresis ................................................ ........... S ....... 0112 30.6602 1,887.17 433.29 377.43

36540 ....... Collect blood venous device .......................... CH .... Q ....... 0624 0.5336 32.84 13.13 6.57 

36550 ....... Declot vascular device ................................... ........... T ....... 0676 2.0612 126.87 .................... 25.37 


sroberts on PROD1PC70 with PROPOSALS
49786 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

36555 ....... Insert non-tunnel cv cath ............................... ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36556 ....... Insert non-tunnel cv cath ............................... ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36557 ....... Insert tunneled cv cath ................................... ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36558 ....... Insert tunneled cv cath ................................... ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36560 ....... Insert tunneled cv cath ................................... ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36561 ....... Insert tunneled cv cath ................................... ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36563 ....... Insert tunneled cv cath ................................... ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36565 ....... Insert tunneled cv cath ................................... ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36566 ....... Insert tunneled cv cath ................................... CH .... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36568 ....... Insert picc cath ............................................... ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36569 ....... Insert picc cath ............................................... ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36570 ....... Insert picvad cath ........................................... ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36571 ....... Insert picvad cath ........................................... ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36575 ....... Repair tunneled cv cath ................................. ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36576 ....... Repair tunneled cv cath ................................. ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36578 ....... Replace tunneled cv cath .............................. ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36580 ....... Replace cvad cath ......................................... ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36581 ....... Replace tunneled cv cath .............................. ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36582 ....... Replace tunneled cv cath .............................. ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36583 ....... Replace tunneled cv cath .............................. ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36584 ....... Replace picc cath ........................................... ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36585 ....... Replace picvad cath ....................................... ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36589 ....... Removal tunneled cv cath ............................. ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36590 ....... Removal tunneled cv cath ............................. ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36595 ....... Mech remov tunneled cv cath ........................ ........... T ....... 0622 22.6984 1,397.11 .................... 279.42 

36596 ....... Mech remov tunneled cv cath ........................ ........... T ....... 0621 8.7841 540.67 .................... 108.13

36597 ....... Reposition venous catheter ........................... ........... T ....... 0621 8.7841 540.67 .................... 108.13 

36598 ....... Inj w/fluor, eval cv device ............................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

36600 ....... Withdrawal of arterial blood ........................... CH .... Q ....... 0035 0.2016 12.41 .................... 2.48 

36620 ....... Insertion catheter, artery ................................ ........... N ....... .......... .................... .................... .................... ....................

36625 ....... Insertion catheter, artery ................................ ........... N ....... .......... .................... .................... .................... ....................

36640 ....... Insertion catheter, artery ................................ ........... T ....... 0623 28.4646 1,752.02 .................... 350.40 

36680 ....... Insert needle, bone cavity .............................. ........... T ....... 0002 1.0948 67.39 .................... 13.48 

36800 ....... Insertion of cannula ........................................ ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

36810 ....... Insertion of cannula ........................................ ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

36815 ....... Insertion of cannula ........................................ ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

36818 ....... Av fuse, uppr arm, cephalic ........................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36819 ....... Av fuse, uppr arm, basilic .............................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36820 ....... Av fusion/forearm vein ................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36821 ....... Av fusion direct any site ................................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36825 ....... Artery-vein autograft ....................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36830 ....... Artery-vein nonautograft ................................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36831 ....... Open thrombect av fistula .............................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36832 ....... Av fistula revision, open ................................. ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36833 ....... Av fistula revision ........................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36834 ....... Repair A-V aneurysm ..................................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36835 ....... Artery to vein shunt ........................................ ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

36838 ....... Dist revas ligation, hemo ............................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

36860 ....... External cannula declotting ............................ ........... T ....... 0676 2.0612 126.87 .................... 25.37 

36861 ....... Cannula declotting ......................................... ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

36870 ....... Percut thrombect av fistula ............................ ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

37183 ....... Remove hepatic shunt (tips) .......................... ........... T ....... 0229 66.0804 4,067.31 .................... 813.46 

37184 ....... Prim art mech thrombectomy ......................... ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

37185 ....... Prim art m-thrombect add-on ......................... ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

37186 ....... Sec art m-thrombect add-on .......................... ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

37187 ....... Venous mech thrombectomy ......................... ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

37188 ....... Venous m-thrombectomy add-on ................... ........... T ....... 0653 31.0004 1,908.11 .................... 381.62 

37195 ....... Thrombolytic therapy, stroke .......................... ........... T ....... 0676 2.0612 126.87 .................... 25.37 

37200 ....... Transcatheter biopsy ...................................... ........... T ....... 0685 6.0729 373.79 115.47 74.76 

37201 ....... Transcatheter therapy infuse ......................... ........... T ....... 0676 2.0612 126.87 .................... 25.37 

37202 ....... Transcatheter therapy infuse ......................... ........... T ....... 0676 2.0612 126.87 .................... 25.37 

37203 ....... Transcatheter retrieval ................................... ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

37204 ....... Transcatheter occlusion ................................. ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

37205 ....... Transcath iv stent, percut .............................. ........... T ....... 0229 66.0804 4,067.31 .................... 813.46 

37206 ....... Transcath iv stent/perc addl ........................... ........... T ....... 0229 66.0804 4,067.31 .................... 813.46 

37207 ....... Transcath iv stent, open ................................ ........... T ....... 0229 66.0804 4,067.31 .................... 813.46 

37208 ....... Transcath iv stent/open addl .......................... ........... T ....... 0229 66.0804 4,067.31 .................... 813.46 

37209 ....... Change iv cath at thromb tx .......................... ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

37250 ....... Iv us first vessel add-on ................................. ........... S ....... 0416 32.2182 1,983.06 .................... 396.61 

37251 ....... Iv us each add vessel add-on ........................ ........... S ....... 0416 32.2182 1,983.06 .................... 396.61 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49787 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

37500 ....... Endoscopy ligate perf veins ........................... CH .... T ....... 0091 34.6279 2,131.38 .................... 426.28 

37501 ....... Vascular endoscopy procedure ..................... ........... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37565 ....... Ligation of neck vein ...................................... ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

37600 ....... Ligation of neck artery ................................... ........... T ....... 0093 21.9703 1,352.29 .................... 270.46 

37605 ....... Ligation of neck artery ................................... ........... T ....... 0091 34.6279 2,131.38 .................... 426.28 

37606 ....... Ligation of neck artery ................................... CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37607 ....... Ligation of a-v fistula ...................................... ........... T ....... 0092 24.5817 1,513.03 306.56 302.61

37609 ....... Temporal artery procedure ............................ ........... T ....... 0021 14.9563 920.58 219.48 184.12 

37615 ....... Ligation of neck artery ................................... CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37620 ....... Revision of major vein ................................... ........... T ....... 0091 34.6279 2,131.38 .................... 426.28 

37650 ....... Revision of major vein ................................... CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37700 ....... Revise leg vein ............................................... ........... T ....... 0091 34.6279 2,131.38 .................... 426.28 

37718 ....... Ligate/strip short leg vein ............................... CH .... T ....... 0091 34.6279 2,131.38 .................... 426.28 

37722 ....... Ligate/strip long leg vein ................................ CH .... T ....... 0091 34.6279 2,131.38 .................... 426.28 

37735 ....... Removal of leg veins/lesion ........................... CH .... T ....... 0091 34.6279 2,131.38 .................... 426.28 

37760 ....... Ligation, leg veins, open ................................ CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37765 ....... Phleb veins - extrem - to 20 .......................... CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37766 ....... Phleb veins - extrem 20+ ............................... CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37780 ....... Revision of leg vein ........................................ CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37785 ....... Ligate/divide/excise vein ................................ CH .... T ....... 0092 24.5817 1,513.03 306.56 302.61 

37790 ....... Penile venous occlusion ................................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

37799 ....... Vascular surgery procedure ........................... ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

38120 ....... Laparoscopy, splenectomy ............................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

38129 ....... Laparoscope proc, spleen .............................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

38200 ....... Injection for spleen x-ray ................................ ........... N ....... .......... .................... .................... .................... ....................

38204 ....... Bl donor search management ........................ ........... N ....... .......... .................... .................... .................... ....................

38205 ....... Harvest allogenic stem cells .......................... ........... S ....... 0111 11.7005 720.18 198.40 144.04 

38206 ....... Harvest auto stem cells ................................. ........... S ....... 0111 11.7005 720.18 198.40 144.04 

38220 ....... Bone marrow aspiration ................................. ........... T ....... 0003 2.4295 149.54 .................... 29.91 

38221 ....... Bone marrow biopsy ...................................... ........... T ....... 0003 2.4295 149.54 .................... 29.91 

38230 ....... Bone marrow collection .................................. ........... S ....... 0123 23.2490 1,431.00 .................... 286.20 

38240 ....... Bone marrow/stem transplant ........................ ........... S ....... 0123 23.2490 1,431.00 .................... 286.20 

38241 ....... Bone marrow/stem transplant ........................ ........... S ....... 0123 23.2490 1,431.00 .................... 286.20 

38242 ....... Lymphocyte infuse transplant ........................ ........... S ....... 0111 11.7005 720.18 198.40 144.04 

38300 ....... Drainage, lymph node lesion ......................... ........... T ....... 0007 10.9184 672.04 .................... 134.41 

38305 ....... Drainage, lymph node lesion ......................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

38308 ....... Incision of lymph channels ............................. ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38500 ....... Biopsy/removal, lymph nodes ........................ ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38505 ....... Needle biopsy, lymph nodes .......................... ........... T ....... 0005 3.8051 234.21 71.59 46.84 

38510 ....... Biopsy/removal, lymph nodes ........................ ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38520 ....... Biopsy/removal, lymph nodes ........................ ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38525 ....... Biopsy/removal, lymph nodes ........................ ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38530 ....... Biopsy/removal, lymph nodes ........................ ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38542 ....... Explore deep node(s), neck ........................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

38550 ....... Removal, neck/armpit lesion .......................... ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38555 ....... Removal, neck/armpit lesion .......................... ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38570 ....... Laparoscopy, lymph node biop ...................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

38571 ....... Laparoscopy, lymphadenectomy ................... ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

38572 ....... Laparoscopy, lymphadenectomy ................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

38589 ....... Laparoscope proc, lymphatic ......................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

38700 ....... Removal of lymph nodes, neck ..................... ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38720 ....... Removal of lymph nodes, neck ..................... ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38740 ....... Remove armpit lymph nodes ......................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

38745 ....... Remove armpit lymph nodes ......................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

38760 ....... Remove groin lymph nodes ........................... ........... T ....... 0113 21.3673 1,315.18 .................... 263.04 

38790 ....... Inject for lymphatic x-ray ................................ ........... N ....... .......... .................... .................... .................... ....................

38792 ....... Identify sentinel node ..................................... CH .... Q ....... 0389 1.4072 86.61 33.98 17.32 

38794 ....... Access thoracic lymph duct ........................... ........... N ....... .......... .................... .................... .................... ....................

38999 ....... Blood/lymph system procedure ...................... ........... S ....... 0110 3.4570 212.78 .................... 42.56 

39400 ....... Visualization of chest ..................................... ........... T ....... 0069 31.5464 1,941.71 591.64 388.34 

40490 ....... Biopsy of lip .................................................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

40500 ....... Partial excision of lip ...................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50

40510 ....... Partial excision of lip ...................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06

40520 ....... Partial excision of lip ...................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50

40525 ....... Reconstruct lip with flap ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

40527 ....... Reconstruct lip with flap ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

40530 ....... Partial removal of lip ...................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

40650 ....... Repair lip ........................................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

40652 ....... Repair lip ........................................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

40654 ....... Repair lip ........................................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 


sroberts on PROD1PC70 with PROPOSALS
49788 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

40700 ....... Repair cleft lip/nasal ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

40701 ....... Repair cleft lip/nasal ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

40702 ....... Repair cleft lip/nasal ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

40720 ....... Repair cleft lip/nasal ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

40761 ....... Repair cleft lip/nasal ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

40799 ....... Lip surgery procedure .................................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

40800 ....... Drainage of mouth lesion ............................... CH .... T ....... 0006 1.4821 91.22 21.76 18.24 

40801 ....... Drainage of mouth lesion ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

40804 ....... Removal, foreign body, mouth ....................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

40805 ....... Removal, foreign body, mouth ....................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

40806 ....... Incision of lip fold ........................................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

40808 ....... Biopsy of mouth lesion ................................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

40810 ....... Excision of mouth lesion ................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

40812 ....... Excise/repair mouth lesion ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

40814 ....... Excise/repair mouth lesion ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

40816 ....... Excision of mouth lesion ................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

40818 ....... Excise oral mucosa for graft .......................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

40819 ....... Excise lip or cheek fold .................................. ........... T ....... 0252 7.7261 475.55 111.84 95.11 

40820 ....... Treatment of mouth lesion ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

40830 ....... Repair mouth laceration ................................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

40831 ....... Repair mouth laceration ................................. ........... T ....... 0252 7.7261 475.55 111.84 95.11 

40840 ....... Reconstruction of mouth ................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

40842 ....... Reconstruction of mouth ................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

40843 ....... Reconstruction of mouth ................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

40844 ....... Reconstruction of mouth ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

40845 ....... Reconstruction of mouth ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

40899 ....... Mouth surgery procedure ............................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

41000 ....... Drainage of mouth lesion ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41005 ....... Drainage of mouth lesion ............................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

41006 ....... Drainage of mouth lesion ............................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41007 ....... Drainage of mouth lesion ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41008 ....... Drainage of mouth lesion ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41009 ....... Drainage of mouth lesion ............................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

41010 ....... Incision of tongue fold .................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41015 ....... Drainage of mouth lesion ............................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

41016 ....... Drainage of mouth lesion ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41017 ....... Drainage of mouth lesion ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41018 ....... Drainage of mouth lesion ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41100 ....... Biopsy of tongue ............................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41105 ....... Biopsy of tongue ............................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41108 ....... Biopsy of floor of mouth ................................. ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41110 ....... Excision of tongue lesion ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41112 ....... Excision of tongue lesion ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41113 ....... Excision of tongue lesion ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41114 ....... Excision of tongue lesion ............................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41115 ....... Excision of tongue fold ................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41116 ....... Excision of mouth lesion ................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41120 ....... Partial removal of tongue ............................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41250 ....... Repair tongue laceration ................................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

41251 ....... Repair tongue laceration ................................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

41252 ....... Repair tongue laceration ................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41500 ....... Fixation of tongue .......................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41510 ....... Tongue to lip surgery ..................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41520 ....... Reconstruction, tongue fold ........................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41599 ....... Tongue and mouth surgery ............................ ........... T ....... 0251 2.3768 146.29 .................... 29.26

41800 ....... Drainage of gum lesion .................................. CH .... T ....... 0006 1.4821 91.22 21.76 18.24 

41805 ....... Removal foreign body, gum ........................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41806 ....... Removal foreign body,jawbone ...................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41820 ....... Excision, gum, each quadrant ....................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41821 ....... Excision of gum flap ....................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

41822 ....... Excision of gum lesion ................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41823 ....... Excision of gum lesion ................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41825 ....... Excision of gum lesion ................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41826 ....... Excision of gum lesion ................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41827 ....... Excision of gum lesion ................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41828 ....... Excision of gum lesion ................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41830 ....... Removal of gum tissue .................................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41850 ....... Treatment of gum lesion ................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

41870 ....... Gum graft ....................................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41872 ....... Repair gum ..................................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49789 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

41874 ....... Repair tooth socket ........................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

41899 ....... Dental surgery procedure .............................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42000 ....... Drainage mouth roof lesion ............................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42100 ....... Biopsy roof of mouth ...................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

42104 ....... Excision lesion, mouth roof ............................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42106 ....... Excision lesion, mouth roof ............................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42107 ....... Excision lesion, mouth roof ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42120 ....... Remove palate/lesion ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42140 ....... Excision of uvula ............................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

42145 ....... Repair palate, pharynx/uvula ......................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42160 ....... Treatment mouth roof lesion .......................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42180 ....... Repair palate .................................................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42182 ....... Repair palate .................................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42200 ....... Reconstruct cleft palate ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42205 ....... Reconstruct cleft palate ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42210 ....... Reconstruct cleft palate ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42215 ....... Reconstruct cleft palate ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42220 ....... Reconstruct cleft palate ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42225 ....... Reconstruct cleft palate ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42226 ....... Lengthening of palate .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42227 ....... Lengthening of palate .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42235 ....... Repair palate .................................................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42260 ....... Repair nose to lip fistula ................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42280 ....... Preparation, palate mold ................................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42281 ....... Insertion, palate prosthesis ............................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42299 ....... Palate/uvula surgery ...................................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42300 ....... Drainage of salivary gland ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42305 ....... Drainage of salivary gland ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42310 ....... Drainage of salivary gland ............................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42320 ....... Drainage of salivary gland ............................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42330 ....... Removal of salivary stone .............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42335 ....... Removal of salivary stone .............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42340 ....... Removal of salivary stone .............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42400 ....... Biopsy of salivary gland ................................. ........... T ....... 0005 3.8051 234.21 71.59 46.84 

42405 ....... Biopsy of salivary gland ................................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42408 ....... Excision of salivary cyst ................................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42409 ....... Drainage of salivary cyst ................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42410 ....... Excise parotid gland/lesion ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42415 ....... Excise parotid gland/lesion ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42420 ....... Excise parotid gland/lesion ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42425 ....... Excise parotid gland/lesion ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42440 ....... Excise submaxillary gland .............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42450 ....... Excise sublingual gland ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42500 ....... Repair salivary duct ....................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42505 ....... Repair salivary duct ....................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42507 ....... Parotid duct diversion .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42508 ....... Parotid duct diversion .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42509 ....... Parotid duct diversion .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42510 ....... Parotid duct diversion .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42550 ....... Injection for salivary x-ray .............................. ........... N ....... .......... .................... .................... .................... ....................

42600 ....... Closure of salivary fistula ............................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42650 ....... Dilation of salivary duct .................................. ........... T ....... 0252 7.7261 475.55 111.84 95.11 

42660 ....... Dilation of salivary duct .................................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42665 ....... Ligation of salivary duct ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42699 ....... Salivary surgery procedure ............................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42700 ....... Drainage of tonsil abscess ............................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

42720 ....... Drainage of throat abscess ............................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42725 ....... Drainage of throat abscess ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42800 ....... Biopsy of throat .............................................. CH .... T ....... 0252 7.7261 475.55 111.84 95.11 

42802 ....... Biopsy of throat .............................................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42804 ....... Biopsy of upper nose/throat ........................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42806 ....... Biopsy of upper nose/throat ........................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42808 ....... Excise pharynx lesion .................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42809 ....... Remove pharynx foreign body ....................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

42810 ....... Excision of neck cyst ..................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42815 ....... Excision of neck cyst ..................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42820 ....... Remove tonsils and adenoids ........................ ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42821 ....... Remove tonsils and adenoids ........................ ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42825 ....... Removal of tonsils .......................................... ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42826 ....... Removal of tonsils .......................................... ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 


sroberts on PROD1PC70 with PROPOSALS
49790 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

42830 ....... Removal of adenoids ..................................... ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42831 ....... Removal of adenoids ..................................... ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42835 ....... Removal of adenoids ..................................... ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42836 ....... Removal of adenoids ..................................... ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42842 ....... Extensive surgery of throat ............................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42844 ....... Extensive surgery of throat ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42860 ....... Excision of tonsil tags .................................... ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42870 ....... Excision of lingual tonsil ................................. ........... T ....... 0258 22.7757 1,401.87 437.25 280.37 

42890 ....... Partial removal of pharynx ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42892 ....... Revision of pharyngeal walls ......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42900 ....... Repair throat wound ....................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

42950 ....... Reconstruction of throat ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42955 ....... Surgical opening of throat .............................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

42960 ....... Control throat bleeding ................................... ........... T ....... 0250 1.2021 73.99 25.50 14.80 

42962 ....... Control throat bleeding ................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

42970 ....... Control nose/throat bleeding .......................... ........... T ....... 0250 1.2021 73.99 25.50 14.80 

42972 ....... Control nose/throat bleeding .......................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

42999 ....... Throat surgery procedure .............................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

43020 ....... Incision of esophagus .................................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

43030 ....... Throat muscle surgery ................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

43130 ....... Removal of esophagus pouch ....................... CH .... T ....... 0256 37.7719 2,324.90 .................... 464.98 

43200 ....... Esophagus endoscopy ................................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43201 ....... Esoph scope w/submucous inj ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43202 ....... Esophagus endoscopy, biopsy ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43204 ....... Esoph scope w/sclerosis inj ........................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43205 ....... Esophagus endoscopy/ligation ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43215 ....... Esophagus endoscopy ................................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43216 ....... Esophagus endoscopy/lesion ........................ ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43217 ....... Esophagus endoscopy ................................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43219 ....... Esophagus endoscopy ................................... ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

43220 ....... Esoph endoscopy, dilation ............................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43226 ....... Esoph endoscopy, dilation ............................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43227 ....... Esoph endoscopy, repair ............................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43228 ....... Esoph endoscopy, ablation ............................ ........... T ....... 0422 27.5493 1,695.69 448.81 339.14 

43231 ....... Esoph endoscopy w/us exam ........................ ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43232 ....... Esoph endoscopy w/us fn bx ......................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43234 ....... Upper GI endoscopy, exam ........................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43235 ....... Uppr gi endoscopy, diagnosis ........................ ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43236 ....... Uppr gi scope w/submuc inj ........................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43237 ....... Endoscopic us exam, esoph .......................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43238 ....... Uppr gi endoscopy w/us fn bx ....................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43239 ....... Upper GI endoscopy, biopsy ......................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43240 ....... Esoph endoscope w/drain cyst ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43241 ....... Upper GI endoscopy with tube ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43242 ....... Uppr gi endoscopy w/us fn bx ....................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43243 ....... Upper gi endoscopy&inject ............................ ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43244 ....... Upper GI endoscopy/ligation .......................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43245 ....... Uppr gi scope dilate strictr ............................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43246 ....... Place gastrostomy tube ................................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43247 ....... Operative upper GI endoscopy ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43248 ....... Uppr gi endoscopy/guide wire ....................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43249 ....... Esoph endoscopy, dilation ............................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43250 ....... Upper GI endoscopy/tumor ............................ ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43251 ....... Operative upper GI endoscopy ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43255 ....... Operative upper GI endoscopy ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43256 ....... Uppr gi endoscopy w/stent ............................ ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

43257 ....... Uppr gi scope w/thrml txmnt .......................... ........... T ....... 0422 27.5493 1,695.69 448.81 339.14 

43258 ....... Operative upper GI endoscopy ...................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43259 ....... Endoscopic ultrasound exam ......................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43260 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43261 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43262 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43263 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43264 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43265 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43267 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43268 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

43269 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

43271 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 

43272 ....... Endo cholangiopancreatograph ..................... ........... T ....... 0151 19.8125 1,219.48 245.46 243.90 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49791 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

43280 ....... Laparoscopy, fundoplasty .............................. ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

43289 ....... Laparoscope proc, esoph .............................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

43450 ....... Dilate esophagus ........................................... ........... T ....... 0140 5.3134 327.05 91.40 65.41 

43453 ....... Dilate esophagus ........................................... ........... T ....... 0140 5.3134 327.05 91.40 65.41 

43456 ....... Dilate esophagus ........................................... ........... T ....... 0140 5.3134 327.05 91.40 65.41 

43458 ....... Dilate esophagus ........................................... ........... T ....... 0140 5.3134 327.05 91.40 65.41 

43499 ....... Esophagus surgery procedure ....................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43510 ....... Surgical opening of stomach ......................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43600 ....... Biopsy of stomach .......................................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43651 ....... Laparoscopy, vagus nerve ............................. ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

43652 ....... Laparoscopy, vagus nerve ............................. ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

43653 ....... Laparoscopy, gastrostomy ............................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

43659 ....... Laparoscope proc, stom ................................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

43750 ....... Place gastrostomy tube ................................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43752 ....... Nasal/orogastric w/stent ................................. ........... X ....... 0272 1.2985 79.92 31.64 15.98 

43760 ....... Change gastrostomy tube .............................. ........... T ....... 0121 2.3431 144.22 43.80 28.84 

43761 ....... Reposition gastrostomy tube ......................... ........... T ....... 0122 7.2859 448.45 .................... 89.69

43830 ....... Place gastrostomy tube ................................. ........... T ....... 0422 27.5493 1,695.69 448.81 339.14 

43831 ....... Place gastrostomy tube ................................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43870 ....... Repair stomach opening ................................ ........... T ....... 0141 8.3070 511.30 143.38 102.26 

43886 ....... Revise gastric port, open ............................... ........... T ....... 0025 5.0931 313.49 95.46 62.70 

43887 ....... Remove gastric port, open ............................. ........... T ....... 0025 5.0931 313.49 95.46 62.70 

43888 ....... Change gastric port, open ............................. ........... T ....... 0686 13.3433 821.29 .................... 164.26 

43999 ....... Stomach surgery procedure ........................... ........... T ....... 0141 8.3070 511.30 143.38 102.26 

44100 ....... Biopsy of bowel .............................................. ........... T ....... 0141 8.3070 511.30 143.38 102.26 

44180 ....... Lap, enterolysis .............................................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

44186 ....... Lap, jejunostomy ............................................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

44206 ....... Lap part colectomy w/stoma .......................... ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

44207 ....... L colectomy/coloproctostomy ......................... ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

44208 ....... L colectomy/coloproctostomy ......................... ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

44213 ....... Lap, mobil splenic fl add-on ........................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

44238 ....... Laparoscope proc, intestine ........................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

44312 ....... Revision of ileostomy ..................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

44340 ....... Revision of colostomy .................................... ........... T ....... 0027 21.2645 1,308.85 329.72 261.77 

44360 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44361 ....... Small bowel endoscopy/biopsy ...................... ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44363 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44364 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44365 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44366 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44369 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44370 ....... Small bowel endoscopy/stent ........................ ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

44372 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44373 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44376 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44377 ....... Small bowel endoscopy/biopsy ...................... ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44378 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44379 ....... S bowel endoscope w/stent ........................... ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

44380 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44382 ....... Small bowel endoscopy ................................. ........... T ....... 0142 9.3878 577.83 152.78 115.57 

44383 ....... Ileoscopy w/stent ............................................ ........... T ....... 0384 22.6777 1,395.84 292.31 279.17

44385 ....... Endoscopy of bowel pouch ............................ ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44386 ....... Endoscopy, bowel pouch/biop ....................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44388 ....... Colonoscopy ................................................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44389 ....... Colonoscopy with biopsy ............................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44390 ....... Colonoscopy for foreign body ........................ ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44391 ....... Colonoscopy for bleeding .............................. ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44392 ....... Colonoscopy&polypectomy ............................ ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44393 ....... Colonoscopy, lesion removal ......................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44394 ....... Colonoscopy w/snare ..................................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

44397 ....... Colonoscopy w/stent ...................................... ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

44500 ....... Intro, gastrointestinal tube .............................. ........... T ....... 0121 2.3431 144.22 43.80 28.84 

44701 ....... Intraop colon lavage add-on .......................... ........... N ....... .......... .................... .................... .................... ....................

44799 ....... Unlisted procedure intestine .......................... CH .... T ....... 0153 22.1758 1,364.94 397.95 272.99 

44901 ....... Drain app abscess, percut ............................. ........... T ....... 0037 10.2616 631.61 228.76 126.32 

44970 ....... Laparoscopy, appendectomy ......................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

44979 ....... Laparoscope proc, app .................................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

45000 ....... Drainage of pelvic abscess ............................ ........... T ....... 0148 4.8970 301.42 .................... 60.28 

45005 ....... Drainage of rectal abscess ............................ ........... T ....... 0155 12.8778 792.64 .................... 158.53 

45020 ....... Drainage of rectal abscess ............................ ........... T ....... 0155 12.8778 792.64 .................... 158.53 


sroberts on PROD1PC70 with PROPOSALS
49792 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

45100 ....... Biopsy of rectum ............................................ ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45108 ....... Removal of anorectal lesion .......................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45150 ....... Excision of rectal stricture .............................. ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45160 ....... Excision of rectal lesion ................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45170 ....... Excision of rectal lesion ................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45190 ....... Destruction, rectal tumor ................................ CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45300 ....... Proctosigmoidoscopy dx ................................ ........... T ....... 0146 4.8005 295.48 64.40 59.10 

45303 ....... Proctosigmoidoscopy dilate ........................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45305 ....... Proctosigmoidoscopy w/bx ............................. ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45307 ....... Proctosigmoidoscopy fb ................................. ........... T ....... 0428 20.4902 1,261.19 .................... 252.24 

45308 ....... Proctosigmoidoscopy removal ....................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45309 ....... Proctosigmoidoscopy removal ....................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45315 ....... Proctosigmoidoscopy removal ....................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45317 ....... Proctosigmoidoscopy bleed ........................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45320 ....... Proctosigmoidoscopy ablate .......................... ........... T ....... 0428 20.4902 1,261.19 .................... 252.24 

45321 ....... Proctosigmoidoscopy volvul ........................... ........... T ....... 0428 20.4902 1,261.19 .................... 252.24 

45327 ....... Proctosigmoidoscopy w/stent ......................... ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

45330 ....... Diagnostic sigmoidoscopy .............................. ........... T ....... 0146 4.8005 295.48 64.40 59.10 

45331 ....... Sigmoidoscopy and biopsy ............................ ........... T ....... 0146 4.8005 295.48 64.40 59.10 

45332 ....... Sigmoidoscopy w/fb removal ......................... ........... T ....... 0146 4.8005 295.48 64.40 59.10 

45333 ....... Sigmoidoscopy&polypectomy ........................ ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45334 ....... Sigmoidoscopy for bleeding ........................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45335 ....... Sigmoidoscopy w/submuc inj ......................... ........... T ....... 0146 4.8005 295.48 64.40 59.10 

45337 ....... Sigmoidoscopy&decompress ......................... ........... T ....... 0146 4.8005 295.48 64.40 59.10 

45338 ....... Sigmoidoscopy w/tumr remove ...................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45339 ....... Sigmoidoscopy w/ablate tumr ........................ ........... T ....... 0147 8.5644 527.15 .................... 105.43

45340 ....... Sig w/balloon dilation ..................................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45341 ....... Sigmoidoscopy w/ultrasound ......................... ........... T ....... 0147 8.5644 527.15 .................... 105.43

45342 ....... Sigmoidoscopy w/us guide bx ....................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

45345 ....... Sigmoidoscopy w/stent .................................. ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

45355 ....... Surgical colonoscopy ..................................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45378 ....... Diagnostic colonoscopy ................................. ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45379 ....... Colonoscopy w/fb removal ............................. ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45380 ....... Colonoscopy and biopsy ................................ ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45381 ....... Colonoscopy, submucous inj ......................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45382 ....... Colonoscopy/control bleeding ........................ ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45383 ....... Lesion removal colonoscopy .......................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45384 ....... Lesion remove colonoscopy .......................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45385 ....... Lesion removal colonoscopy .......................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45386 ....... Colonoscopy dilate stricture ........................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45387 ....... Colonoscopy w/stent ...................................... ........... T ....... 0384 22.6777 1,395.84 292.31 279.17 

45391 ....... Colonoscopy w/endoscope us ....................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45392 ....... Colonoscopy w/endoscopic fnb ..................... ........... T ....... 0143 8.8143 542.53 186.06 108.51 

45499 ....... Laparoscope proc, rectum ............................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

45500 ....... Repair of rectum ............................................ ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45505 ....... Repair of rectum ............................................ ........... T ....... 0150 29.4386 1,811.98 437.12 362.40 

45520 ....... Treatment of rectal prolapse .......................... ........... T ....... 0098 1.1035 67.92 .................... 13.58 

45541 ....... Correct rectal prolapse ................................... ........... T ....... 0150 29.4386 1,811.98 437.12 362.40 

45560 ....... Repair of rectocele ......................................... ........... T ....... 0150 29.4386 1,811.98 437.12 362.40 

45900 ....... Reduction of rectal prolapse .......................... ........... T ....... 0148 4.8970 301.42 .................... 60.28 

45905 ....... Dilation of anal sphincter ............................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45910 ....... Dilation of rectal narrowing ............................ ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

45915 ....... Remove rectal obstruction ............................. ........... T ....... 0148 4.8970 301.42 .................... 60.28 

45990 ....... Surg dx exam, anorectal ................................ ........... T ....... 0148 4.8970 301.42 .................... 60.28 

45999 ....... Rectum surgery procedure ............................ ........... T ....... 0148 4.8970 301.42 .................... 60.28

46020 ....... Placement of seton ........................................ CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46030 ....... Removal of rectal marker ............................... ........... T ....... 0148 4.8970 301.42 .................... 60.28 

46040 ....... Incision of rectal abscess ............................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46045 ....... Incision of rectal abscess ............................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46050 ....... Incision of anal abscess ................................. ........... T ....... 0148 4.8970 301.42 .................... 60.28 

46060 ....... Incision of rectal abscess ............................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46070 ....... Incision of anal septum .................................. ........... T ....... 0155 12.8778 792.64 .................... 158.53 

46080 ....... Incision of anal sphincter ............................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46083 ....... Incise external hemorrhoid ............................. CH .... T ....... 0164 2.1159 130.24 .................... 26.05 

46200 ....... Removal of anal fissure ................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46210 ....... Removal of anal crypt .................................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46211 ....... Removal of anal crypts .................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46220 ....... Removal of anal tag ....................................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46221 ....... Ligation of hemorrhoid(s) ............................... ........... T ....... 0148 4.8970 301.42 .................... 60.28 

46230 ....... Removal of anal tags ..................................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49793 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

46250 ....... Hemorrhoidectomy ......................................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46255 ....... Hemorrhoidectomy ......................................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46257 ....... Remove hemorrhoids&fissure ........................ CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46258 ....... Remove hemorrhoids&fistula ......................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46260 ....... Hemorrhoidectomy ......................................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46261 ....... Remove hemorrhoids&fissure ........................ CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46262 ....... Remove hemorrhoids&fistula ......................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46270 ....... Removal of anal fistula .................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46275 ....... Removal of anal fistula .................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46280 ....... Removal of anal fistula .................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46285 ....... Removal of anal fistula .................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46288 ....... Repair anal fistula .......................................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46320 ....... Removal of hemorrhoid clot ........................... CH .... T ....... 0155 12.8778 792.64 .................... 158.53 

46500 ....... Injection into hemorrhoid(s) ........................... ........... T ....... 0155 12.8778 792.64 .................... 158.53 

46505 ....... Chemodenervation anal musc ....................... ........... T ....... 0148 4.8970 301.42 .................... 60.28 

46600 ....... Diagnostic anoscopy ...................................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

46604 ....... Anoscopy and dilation .................................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

46606 ....... Anoscopy and biopsy ..................................... ........... T ....... 0146 4.8005 295.48 64.40 59.10 

46608 ....... Anoscopy, remove for body ........................... ........... T ....... 0147 8.5644 527.15 .................... 105.43 

46610 ....... Anoscopy, remove lesion ............................... ........... T ....... 0428 20.4902 1,261.19 .................... 252.24 

46611 ....... Anoscopy ........................................................ ........... T ....... 0147 8.5644 527.15 .................... 105.43 

46612 ....... Anoscopy, remove lesions ............................. ........... T ....... 0428 20.4902 1,261.19 .................... 252.24 

46614 ....... Anoscopy, control bleeding ............................ ........... T ....... 0146 4.8005 295.48 64.40 59.10 

46615 ....... Anoscopy ........................................................ ........... T ....... 0428 20.4902 1,261.19 .................... 252.24 

46700 ....... Repair of anal stricture ................................... CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46706 ....... Repr of anal fistula w/glue ............................. ........... T ....... 0150 29.4386 1,811.98 437.12 362.40 

46750 ....... Repair of anal sphincter ................................. CH .... T ....... 0171 37.2425 2,292.31 705.28 458.46 

46753 ....... Reconstruction of anus .................................. CH .... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46754 ....... Removal of suture from anus ........................ ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46760 ....... Repair of anal sphincter ................................. CH .... T ....... 0171 37.2425 2,292.31 705.28 458.46 

46761 ....... Repair of anal sphincter ................................. CH .... T ....... 0171 37.2425 2,292.31 705.28 458.46 

46762 ....... Implant artificial sphincter .............................. CH .... T ....... 0171 37.2425 2,292.31 705.28 458.46 

46900 ....... Destruction, anal lesion(s) ............................. ........... T ....... 0016 2.6253 161.59 32.68 32.32 

46910 ....... Destruction, anal lesion(s) ............................. ........... T ....... 0017 17.7392 1,091.87 227.84 218.37 

46916 ....... Cryosurgery, anal lesion(s) ............................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 

46917 ....... Laser surgery, anal lesions ............................ ........... T ....... 0695 20.5802 1,266.73 266.59 253.35 

46922 ....... Excision of anal lesion(s) ............................... ........... T ....... 0695 20.5802 1,266.73 266.59 253.35 

46924 ....... Destruction, anal lesion(s) ............................. ........... T ....... 0695 20.5802 1,266.73 266.59 253.35 

46934 ....... Destruction of hemorrhoids ............................ ........... T ....... 0155 12.8778 792.64 .................... 158.53 

46935 ....... Destruction of hemorrhoids ............................ ........... T ....... 0155 12.8778 792.64 .................... 158.53 

46936 ....... Destruction of hemorrhoids ............................ ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46937 ....... Cryotherapy of rectal lesion ........................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46938 ....... Cryotherapy of rectal lesion ........................... ........... T ....... 0150 29.4386 1,811.98 437.12 362.40 

46940 ....... Treatment of anal fissure ............................... ........... T ....... 0149 22.2336 1,368.50 293.06 273.70 

46942 ....... Treatment of anal fissure ............................... ........... T ....... 0148 4.8970 301.42 .................... 60.28 

46945 ....... Ligation of hemorrhoids ................................. ........... T ....... 0155 12.8778 792.64 .................... 158.53 

46946 ....... Ligation of hemorrhoids ................................. ........... T ....... 0155 12.8778 792.64 .................... 158.53 

46947 ....... Hemorrhoidopexy by stapling ........................ ........... T ....... 0150 29.4386 1,811.98 437.12 362.40 

46999 ....... Anus surgery procedure ................................. ........... T ....... 0148 4.8970 301.42 .................... 60.28 

47000 ....... Needle biopsy of liver .................................... ........... T ....... 0685 6.0729 373.79 115.47 74.76 

47001 ....... Needle biopsy, liver add-on ........................... ........... N ....... .......... .................... .................... .................... ....................

47011 ....... Percut drain, liver lesion ................................ ........... T ....... 0037 10.2616 631.61 228.76 126.32 

47370 ....... Laparo ablate liver tumor rf ............................ ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

47371 ....... Laparo ablate liver cryosurg .......................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

47379 ....... Laparoscope procedure, liver ........................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

47382 ....... Percut ablate liver rf ....................................... ........... T ....... 0423 39.0235 2,401.94 .................... 480.39 

47399 ....... Liver surgery procedure ................................. CH .... T ....... 0004 2.0863 128.41 .................... 25.68 

47490 ....... Incision of gallbladder .................................... ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47500 ....... Injection for liver x-rays .................................. ........... N ....... .......... .................... .................... .................... ....................

47505 ....... Injection for liver x-rays .................................. ........... N ....... .......... .................... .................... .................... ....................

47510 ....... Insert catheter, bile duct ................................ ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47511 ....... Insert bile duct drain ...................................... ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47525 ....... Change bile duct catheter .............................. ........... T ....... 0427 11.5220 709.19 .................... 141.84 

47530 ....... Revise/reinsert bile tube ................................ ........... T ....... 0427 11.5220 709.19 .................... 141.84 

47552 ....... Biliary endoscopy thru skin ............................ ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47553 ....... Biliary endoscopy thru skin ............................ ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47554 ....... Biliary endoscopy thru skin ............................ ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47555 ....... Biliary endoscopy thru skin ............................ ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47556 ....... Biliary endoscopy thru skin ............................ ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47560 ....... Laparoscopy w/cholangio ............................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 


sroberts on PROD1PC70 with PROPOSALS
49794 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

47561 ....... Laparo w/cholangio/biopsy ............................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

47562 ....... Laparoscopic cholecystectomy ...................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

47563 ....... Laparo cholecystectomy/graph ...................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

47564 ....... Laparo cholecystectomy/explr ........................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

47579 ....... Laparoscope proc, biliary ............................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

47630 ....... Remove bile duct stone ................................. ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

47999 ....... Bile tract surgery procedure ........................... ........... T ....... 0152 19.4515 1,197.26 .................... 239.45 

48102 ....... Needle biopsy, pancreas ............................... ........... T ....... 0685 6.0729 373.79 115.47 74.76 

48511 ....... Drain pancreatic pseudocyst .......................... ........... T ....... 0037 10.2616 631.61 228.76 126.32 

48999 ....... Pancreas surgery procedure .......................... ........... T ....... 0004 2.0863 128.41 .................... 25.68

49021 ....... Drain abdominal abscess ............................... ........... T ....... 0037 10.2616 631.61 228.76 126.32 

49041 ....... Drain, percut, abdom abscess ....................... ........... T ....... 0037 10.2616 631.61 228.76 126.32 

49061 ....... Drain, percut, retroper absc ........................... ........... T ....... 0037 10.2616 631.61 228.76 126.32 

49080 ....... Puncture, peritoneal cavity ............................. ........... T ....... 0070 3.6425 224.20 .................... 44.84 

49081 ....... Removal of abdominal fluid ........................... ........... T ....... 0070 3.6425 224.20 .................... 44.84 

49085 ....... Remove abdomen foreign body ..................... ........... T ....... 0153 22.1758 1,364.94 397.95 272.99 

49180 ....... Biopsy, abdominal mass ................................ ........... T ....... 0685 6.0729 373.79 115.47 74.76 

49200 ....... Removal of abdominal lesion ......................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

49250 ....... Excision of umbilicus ...................................... ........... T ....... 0153 22.1758 1,364.94 397.95 272.99 

49320 ....... Diag laparo separate proc ............................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

49321 ....... Laparoscopy, biopsy ...................................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

49322 ....... Laparoscopy, aspiration ................................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

49323 ....... Laparo drain lymphocele ................................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

49329 ....... Laparo proc, abdm/per/oment ........................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

49400 ....... Air injection into abdomen ............................. ........... N ....... .......... .................... .................... .................... ....................

49419 ....... Insrt abdom cath for chemotx ........................ ........... T ....... 0115 29.4757 1,814.26 378.68 362.85 

49420 ....... Insert abdom drain, temp ............................... ........... T ....... 0652 29.2259 1,798.88 .................... 359.78 

49421 ....... Insert abdom drain, perm ............................... ........... T ....... 0652 29.2259 1,798.88 .................... 359.78 

49422 ....... Remove perm cannula/catheter ..................... ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

49423 ....... Exchange drainage catheter .......................... ........... T ....... 0427 11.5220 709.19 .................... 141.84 

49424 ....... Assess cyst, contrast inject ............................ ........... N ....... .......... .................... .................... .................... ....................

49426 ....... Revise abdomen-venous shunt ..................... ........... T ....... 0153 22.1758 1,364.94 397.95 272.99 

49427 ....... Injection, abdominal shunt ............................. ........... N ....... .......... .................... .................... .................... ....................

49429 ....... Removal of shunt ........................................... ........... T ....... 0105 23.4666 1,444.39 370.40 288.88 

49491 ....... Rpr hern preemie reduc ................................. ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49492 ....... Rpr ing hern premie, blocked ........................ ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49495 ....... Rpr ing hernia baby, reduc ............................ ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49496 ....... Rpr ing hernia baby, blocked ......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49500 ....... Rpr ing hernia, init, reduce ............................ ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49501 ....... Rpr ing hernia, init blocked ............................ ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49505 ....... Prp i/hern init reduc >5 yr .............................. ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49507 ....... Prp i/hern init block >5 yr ............................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49520 ....... Rerepair ing hernia, reduce ........................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49521 ....... Rerepair ing hernia, blocked .......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49525 ....... Repair ing hernia, sliding ............................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49540 ....... Repair lumbar hernia ..................................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49550 ....... Rpr rem hernia, init, reduce ........................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49553 ....... Rpr fem hernia, init blocked ........................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49555 ....... Rerepair fem hernia, reduce .......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49557 ....... Rerepair fem hernia, blocked ......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49560 ....... Rpr ventral hern init, reduc ............................ ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49561 ....... Rpr ventral hern init, block ............................. ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49565 ....... Rerepair ventrl hern, reduce .......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49566 ....... Rerepair ventrl hern, block ............................. ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49568 ....... Hernia repair w/mesh ..................................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49570 ....... Rpr epigastric hern, reduce ........................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49572 ....... Rpr epigastric hern, blocked .......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49580 ....... Rpr umbil hern, reduc < 5 yr ......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49582 ....... Rpr umbil hern, block < 5 yr .......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49585 ....... Rpr umbil hern, reduc > 5 yr ......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49587 ....... Rpr umbil hern, block > 5 yr .......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49590 ....... Repair spigelian hernia .................................. ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49600 ....... Repair umbilical lesion ................................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

49650 ....... Laparo hernia repair initial ............................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

49651 ....... Laparo hernia repair recur ............................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

49659 ....... Laparo proc, hernia repair ............................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

49999 ....... Abdomen surgery procedure ......................... ........... T ....... 0153 22.1758 1,364.94 397.95 272.99 

50020 ....... Renal abscess, open drain ............................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

50021 ....... Renal abscess, percut drain .......................... ........... T ....... 0037 10.2616 631.61 228.76 126.32 

50080 ....... Removal of kidney stone ............................... ........... T ....... 0429 42.9327 2,642.55 .................... 528.51 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49795 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

50081 ....... Removal of kidney stone ............................... ........... T ....... 0429 42.9327 2,642.55 .................... 528.51 

50200 ....... Biopsy of kidney ............................................. ........... T ....... 0685 6.0729 373.79 115.47 74.76 

50382 ....... Change ureter stent, percut ........................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50384 ....... Remove ureter stent, percut .......................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50387 ....... Change ext/int ureter stent ............................ ........... T ....... 0122 7.2859 448.45 .................... 89.69 

50389 ....... Remove renal tube w/fluoro ........................... ........... T ....... 0156 3.5688 219.66 .................... 43.93 

50390 ....... Drainage of kidney lesion .............................. ........... T ....... 0685 6.0729 373.79 115.47 74.76 

50391 ....... Instll rx agnt into rnal tub ............................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

50392 ....... Insert kidney drain .......................................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30

50393 ....... Insert ureteral tube ......................................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30

50394 ....... Injection for kidney x-ray ................................ ........... N ....... .......... .................... .................... .................... ....................

50395 ....... Create passage to kidney .............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50396 ....... Measure kidney pressure ............................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

50398 ....... Change kidney tube ....................................... ........... T ....... 0122 7.2859 448.45 .................... 89.69 

50541 ....... Laparo ablate renal cyst ................................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

50542 ....... Laparo ablate renal mass .............................. ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

50543 ....... Laparo partial nephrectomy ........................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

50544 ....... Laparoscopy, pyeloplasty ............................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

50549 ....... Laparoscope proc, renal ................................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

50551 ....... Kidney endoscopy .......................................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50553 ....... Kidney endoscopy .......................................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50555 ....... Kidney endoscopy&biopsy ............................. ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50557 ....... Kidney endoscopy&treatment ........................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

50561 ....... Kidney endoscopy&treatment ........................ ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50562 ....... Renal scope w/tumor resect .......................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50570 ....... Kidney endoscopy .......................................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50572 ....... Kidney endoscopy .......................................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50574 ....... Kidney endoscopy&biopsy ............................. ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50575 ....... Kidney endoscopy .......................................... ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

50576 ....... Kidney endoscopy&treatment ........................ ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50590 ....... Fragmenting of kidney stone ......................... ........... T ....... 0169 44.1144 2,715.29 1,009.47 543.06 

50592 ....... Perc rf ablate renal tumor .............................. ........... T ....... 0423 39.0235 2,401.94 .................... 480.39 

50684 ....... Injection for ureter x-ray ................................. ........... N ....... .......... .................... .................... .................... ....................

50686 ....... Measure ureter pressure ................................ CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

50688 ....... Change of ureter tube/stent ........................... ........... T ....... 0122 7.2859 448.45 .................... 89.69 

50690 ....... Injection for ureter x-ray ................................. ........... N ....... .......... .................... .................... .................... ....................

50945 ....... Laparoscopy ureterolithotomy ........................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

50947 ....... Laparo new ureter/bladder ............................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

50948 ....... Laparo new ureter/bladder ............................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

50949 ....... Laparoscope proc, ureter ............................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

50951 ....... Endoscopy of ureter ....................................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50953 ....... Endoscopy of ureter ....................................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50955 ....... Ureter endoscopy&biopsy .............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50957 ....... Ureter endoscopy&treatment ......................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50961 ....... Ureter endoscopy&treatment ......................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50970 ....... Ureter endoscopy ........................................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50972 ....... Ureter endoscopy&catheter ........................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

50974 ....... Ureter endoscopy&biopsy .............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50976 ....... Ureter endoscopy&treatment ......................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

50980 ....... Ureter endoscopy&treatment ......................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

51000 ....... Drainage of bladder ....................................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

51005 ....... Drainage of bladder ....................................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

51010 ....... Drainage of bladder ....................................... ........... T ....... 0165 18.2333 1,122.28 .................... 224.46 

51020 ....... Incise&treat bladder ....................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

51030 ....... Incise&treat bladder ....................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

51040 ....... Incise&drain bladder ...................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

51045 ....... Incise bladder/drain ureter ............................. ........... T ....... 0160 6.7325 414.39 105.06 82.88 

51050 ....... Removal of bladder stone .............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

51065 ....... Remove ureter calculus ................................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

51080 ....... Drainage of bladder abscess ......................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

51500 ....... Removal of bladder cyst ................................ ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

51520 ....... Removal of bladder lesion ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

51600 ....... Injection for bladder x-ray .............................. ........... N ....... .......... .................... .................... .................... ....................

51605 ....... Preparation for bladder xray .......................... ........... N ....... .......... .................... .................... .................... ....................

51610 ....... Injection for bladder x-ray .............................. ........... N ....... .......... .................... .................... .................... ....................

51700 ....... Irrigation of bladder ........................................ ........... T ....... 0164 2.1159 130.24 .................... 26.05 

51701 ....... Insert bladder catheter ................................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

51702 ....... Insert temp bladder cath ................................ ........... X ....... 0340 0.6211 38.23 .................... 7.65 

51703 ....... Insert bladder cath, complex .......................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

51705 ....... Change of bladder tube ................................. ........... T ....... 0121 2.3431 144.22 43.80 28.84 


sroberts on PROD1PC70 with PROPOSALS
49796 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

51710 ....... Change of bladder tube ................................. ........... T ....... 0122 7.2859 448.45 .................... 89.69 

51715 ....... Endoscopic injection/implant .......................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

51720 ....... Treatment of bladder lesion ........................... CH .... T ....... 0164 2.1159 130.24 .................... 26.05 

51725 ....... Simple cystometrogram ................................. CH .... T ....... 0164 2.1159 130.24 .................... 26.05 

51726 ....... Complex cystometrogram .............................. ........... T ....... 0156 3.5688 219.66 .................... 43.93

51736 ....... Urine flow measurement ................................ CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

51741 ....... Electro-uroflowmetry, first .............................. CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

51772 ....... Urethra pressure profile ................................. CH .... T ....... 0164 2.1159 130.24 .................... 26.05

51784 ....... Anal/urinary muscle study .............................. CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

51785 ....... Anal/urinary muscle study .............................. CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

51792 ....... Urinary reflex study ........................................ CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

51795 ....... Urine voiding pressure study ......................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

51797 ....... Intraabdominal pressure test ......................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

51798 ....... Us urine capacity measure ............................ ........... X ....... 0340 0.6211 38.23 .................... 7.65 

51880 ....... Repair of bladder opening ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

51990 ....... Laparo urethral suspension ........................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

51992 ....... Laparo sling operation ................................... CH .... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

51999 ....... Laparoscope proc, bladder ............................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

52000 ....... Cystoscopy ..................................................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

52001 ....... Cystoscopy, removal of clots ......................... ........... T ....... 0160 6.7325 414.39 105.06 82.88 

52005 ....... Cystoscopy&ureter catheter ........................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52007 ....... Cystoscopy and biopsy .................................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52010 ....... Cystoscopy&duct catheter ............................. ........... T ....... 0160 6.7325 414.39 105.06 82.88 

52204 ....... Cystoscopy ..................................................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52214 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52224 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52234 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52235 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52240 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52250 ....... Cystoscopy and radiotracer ........................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52260 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52265 ....... Cystoscopy and treatment ............................. ........... T ....... 0160 6.7325 414.39 105.06 82.88 

52270 ....... Cystoscopy&revise urethra ............................ ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52275 ....... Cystoscopy&revise urethra ............................ ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52276 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52277 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52281 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52282 ....... Cystoscopy, implant stent .............................. ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

52283 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52285 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52290 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52300 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52301 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52305 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52310 ....... Cystoscopy and treatment ............................. ........... T ....... 0160 6.7325 414.39 105.06 82.88 

52315 ....... Cystoscopy and treatment ............................. ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52317 ....... Remove bladder stone ................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52318 ....... Remove bladder stone ................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52320 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52325 ....... Cystoscopy, stone removal ............................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52327 ....... Cystoscopy, inject material ............................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52330 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52332 ....... Cystoscopy and treatment ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52334 ....... Create passage to kidney .............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52341 ....... Cysto w/ureter stricture tx .............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52342 ....... Cysto w/up stricture tx ................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52343 ....... Cysto w/renal stricture tx ............................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52344 ....... Cysto/uretero, stricture tx ............................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52345 ....... Cysto/uretero w/up stricture ........................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52346 ....... Cystouretero w/renal strict ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52351 ....... Cystouretero&or pyeloscope .......................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

52352 ....... Cystouretero w/stone remove ........................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52353 ....... Cystouretero w/lithotripsy ............................... ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

52354 ....... Cystouretero w/biopsy .................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52355 ....... Cystouretero w/excise tumor ......................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52400 ....... Cystouretero w/congen repr ........................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52402 ....... Cystourethro cut ejacul duct .......................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52450 ....... Incision of prostate ......................................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52500 ....... Revision of bladder neck ............................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52510 ....... Dilation prostatic urethra ................................ ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49797 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

52601 ....... Prostatectomy (TURP) ................................... ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

52606 ....... Control postop bleeding ................................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52612 ....... Prostatectomy, first stage .............................. ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

52614 ....... Prostatectomy, second stage ......................... ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

52620 ....... Remove residual prostate .............................. ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

52630 ....... Remove prostate regrowth ............................. ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

52640 ....... Relieve bladder contracture ........................... ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

52647 ....... Laser surgery of prostate ............................... ........... T ....... 0429 42.9327 2,642.55 .................... 528.51 

52648 ....... Laser surgery of prostate ............................... ........... T ....... 0429 42.9327 2,642.55 .................... 528.51 

52700 ....... Drainage of prostate abscess ........................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

53000 ....... Incision of urethra .......................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53010 ....... Incision of urethra .......................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53020 ....... Incision of urethra .......................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53025 ....... Incision of urethra .......................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53040 ....... Drainage of urethra abscess .......................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53060 ....... Drainage of urethra abscess .......................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53080 ....... Drainage of urinary leakage ........................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53085 ....... Drainage of urinary leakage ........................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53200 ....... Biopsy of urethra ............................................ ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53210 ....... Removal of urethra ........................................ ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53215 ....... Removal of urethra ........................................ ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53220 ....... Treatment of urethra lesion ............................ ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53230 ....... Removal of urethra lesion .............................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53235 ....... Removal of urethra lesion .............................. ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53240 ....... Surgery for urethra pouch .............................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53250 ....... Removal of urethra gland .............................. ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53260 ....... Treatment of urethra lesion ............................ ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53265 ....... Treatment of urethra lesion ............................ ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53270 ....... Removal of urethra gland .............................. ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53275 ....... Repair of urethra defect ................................. ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53400 ....... Revise urethra, stage 1 .................................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53405 ....... Revise urethra, stage 2 .................................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53410 ....... Reconstruction of urethra ............................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53420 ....... Reconstruct urethra, stage 1 ......................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53425 ....... Reconstruct urethra, stage 2 ......................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53430 ....... Reconstruction of urethra ............................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53431 ....... Reconstruct urethra/bladder ........................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53440 ....... Male sling procedure ...................................... ........... S ....... 0385 79.3730 4,885.49 .................... 977.10 

53442 ....... Remove/revise male sling .............................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53444 ....... Insert tandem cuff .......................................... ........... S ....... 0385 79.3730 4,885.49 .................... 977.10 

53445 ....... Insert uro/ves nck sphincter ........................... ........... S ....... 0386 135.7295 8,354.29 .................... 1,670.86 

53446 ....... Remove uro sphincter .................................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53447 ....... Remove/replace ur sphincter ......................... ........... S ....... 0386 135.7295 8,354.29 .................... 1,670.86 

53449 ....... Repair uro sphincter ....................................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53450 ....... Revision of urethra ......................................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53460 ....... Revision of urethra ......................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53500 ....... Urethrlys, transvag w/scope ........................... ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53502 ....... Repair of urethra injury .................................. ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53505 ....... Repair of urethra injury .................................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53510 ....... Repair of urethra injury .................................. ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53515 ....... Repair of urethra injury .................................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53520 ....... Repair of urethra defect ................................. ........... T ....... 0168 28.5971 1,760.18 388.16 352.04 

53600 ....... Dilate urethra stricture .................................... ........... T ....... 0156 3.5688 219.66 .................... 43.93 

53601 ....... Dilate urethra stricture .................................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

53605 ....... Dilate urethra stricture .................................... ........... T ....... 0161 19.2766 1,186.49 249.36 237.30 

53620 ....... Dilate urethra stricture .................................... ........... T ....... 0165 18.2333 1,122.28 .................... 224.46 

53621 ....... Dilate urethra stricture .................................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

53660 ....... Dilation of urethra ........................................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

53661 ....... Dilation of urethra ........................................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

53665 ....... Dilation of urethra ........................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

53850 ....... Prostatic microwave thermotx ........................ ........... T ....... 0675 42.3176 2,604.69 .................... 520.94 

53852 ....... Prostatic rf thermotx ....................................... ........... T ....... 0675 42.3176 2,604.69 .................... 520.94 

53853 ....... Prostatic water thermother ............................. ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

53899 ....... Urology surgery procedure ............................ CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

54000 ....... Slitting of prepuce .......................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

54001 ....... Slitting of prepuce .......................................... ........... T ....... 0166 18.5138 1,139.54 .................... 227.91 

54015 ....... Drain penis lesion .......................................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

54050 ....... Destruction, penis lesion(s) ............................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 

54055 ....... Destruction, penis lesion(s) ............................ ........... T ....... 0017 17.7392 1,091.87 227.84 218.37 

54056 ....... Cryosurgery, penis lesion(s) .......................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 


sroberts on PROD1PC70 with PROPOSALS
49798 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

54057 ....... Laser surg, penis lesion(s) ............................. ........... T ....... 0017 17.7392 1,091.87 227.84 218.37 

54060 ....... Excision of penis lesion(s) ............................. ........... T ....... 0017 17.7392 1,091.87 227.84 218.37 

54065 ....... Destruction, penis lesion(s) ............................ ........... T ....... 0695 20.5802 1,266.73 266.59 253.35 

54100 ....... Biopsy of penis ............................................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

54105 ....... Biopsy of penis ............................................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

54110 ....... Treatment of penis lesion .............................. ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54111 ....... Treat penis lesion, graft ................................. ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54112 ....... Treat penis lesion, graft ................................. ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54115 ....... Treatment of penis lesion .............................. ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

54120 ....... Partial removal of penis ................................. ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54150 ....... Circumcision ................................................... ........... T ....... 0180 20.7418 1,276.68 304.87 255.34 

54152 ....... Circumcision ................................................... ........... T ....... 0180 20.7418 1,276.68 304.87 255.34 

54160 ....... Circumcision ................................................... ........... T ....... 0180 20.7418 1,276.68 304.87 255.34 

54161 ....... Circumcision ................................................... ........... T ....... 0180 20.7418 1,276.68 304.87 255.34 

54162 ....... Lysis penil circumic lesion ............................. ........... T ....... 0180 20.7418 1,276.68 304.87 255.34 

54163 ....... Repair of circumcision .................................... ........... T ....... 0180 20.7418 1,276.68 304.87 255.34 

54164 ....... Frenulotomy of penis ..................................... ........... T ....... 0180 20.7418 1,276.68 304.87 255.34 

54200 ....... Treatment of penis lesion .............................. CH .... T ....... 0164 2.1159 130.24 .................... 26.05 

54205 ....... Treatment of penis lesion .............................. ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54220 ....... Treatment of penis lesion .............................. CH .... T ....... 0164 2.1159 130.24 .................... 26.05 

54230 ....... Prepare penis study ....................................... ........... N ....... .......... .................... .................... .................... ....................

54231 ....... Dynamic cavernosometry ............................... ........... T ....... 0165 18.2333 1,122.28 .................... 224.46 

54235 ....... Penile injection ............................................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

54240 ....... Penis study ..................................................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

54250 ....... Penis study ..................................................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

54300 ....... Revision of penis ............................................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23

54304 ....... Revision of penis ............................................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23

54308 ....... Reconstruction of urethra ............................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54312 ....... Reconstruction of urethra ............................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54316 ....... Reconstruction of urethra ............................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54318 ....... Reconstruction of urethra ............................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54322 ....... Reconstruction of urethra ............................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54324 ....... Reconstruction of urethra ............................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54326 ....... Reconstruction of urethra ............................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54328 ....... Revise penis/urethra ...................................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54340 ....... Secondary urethral surgery ............................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54344 ....... Secondary urethral surgery ............................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54348 ....... Secondary urethral surgery ............................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54352 ....... Reconstruct urethra/penis .............................. ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54360 ....... Penis plastic surgery ...................................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54380 ....... Repair penis ................................................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54385 ....... Repair penis ................................................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54400 ....... Insert semi-rigid prosthesis ............................ ........... S ....... 0385 79.3730 4,885.49 .................... 977.10 

54401 ....... Insert self-contd prosthesis ............................ ........... S ....... 0386 135.7295 8,354.29 .................... 1,670.86 

54405 ....... Insert multi-comp penis pros .......................... ........... S ....... 0386 135.7295 8,354.29 .................... 1,670.86 

54406 ....... Remove muti-comp penis pros ...................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54408 ....... Repair multi-comp penis pros ........................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54410 ....... Remove/replace penis prosth ........................ ........... S ....... 0386 135.7295 8,354.29 .................... 1,670.86 

54415 ....... Remove self-contd penis pros ....................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54416 ....... Remv/repl penis contain pros ........................ ........... S ....... 0386 135.7295 8,354.29 .................... 1,670.86 

54420 ....... Revision of penis ............................................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23

54435 ....... Revision of penis ............................................ ........... T ....... 0181 32.9991 2,031.13 621.82 406.23

54440 ....... Repair of penis ............................................... ........... T ....... 0181 32.9991 2,031.13 621.82 406.23 

54450 ....... Preputial stretching ........................................ ........... T ....... 0156 3.5688 219.66 .................... 43.93 

54500 ....... Biopsy of testis ............................................... ........... T ....... 0037 10.2616 631.61 228.76 126.32

54505 ....... Biopsy of testis ............................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54512 ....... Excise lesion testis ......................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54520 ....... Removal of testis ........................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54522 ....... Orchiectomy, partial ....................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54530 ....... Removal of testis ........................................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

54550 ....... Exploration for testis ...................................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

54560 ....... Exploration for testis ...................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54600 ....... Reduce testis torsion ..................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54620 ....... Suspension of testis ....................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54640 ....... Suspension of testis ....................................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

54660 ....... Revision of testis ............................................ ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54670 ....... Repair testis injury ......................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54680 ....... Relocation of testis(es) .................................. ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54690 ....... Laparoscopy, orchiectomy ............................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

54692 ....... Laparoscopy, orchiopexy ............................... ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49799 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

54699 ....... Laparoscope proc, testis ................................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

54700 ....... Drainage of scrotum ....................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54800 ....... Biopsy of epididymis ...................................... ........... T ....... 0004 2.0863 128.41 .................... 25.68 

54820 ....... Exploration of epididymis ............................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54830 ....... Remove epididymis lesion ............................. ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54840 ....... Remove epididymis lesion ............................. ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54860 ....... Removal of epididymis ................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54861 ....... Removal of epididymis ................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54900 ....... Fusion of spermatic ducts .............................. ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

54901 ....... Fusion of spermatic ducts .............................. ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55000 ....... Drainage of hydrocele .................................... ........... T ....... 0004 2.0863 128.41 .................... 25.68 

55040 ....... Removal of hydrocele .................................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

55041 ....... Removal of hydroceles .................................. ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

55060 ....... Repair of hydrocele ........................................ ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55100 ....... Drainage of scrotum abscess ........................ CH .... T ....... 0007 10.9184 672.04 .................... 134.41 

55110 ....... Explore scrotum ............................................. ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55120 ....... Removal of scrotum lesion ............................ ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55150 ....... Removal of scrotum ....................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55175 ....... Revision of scrotum ....................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55180 ....... Revision of scrotum ....................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55200 ....... Incision of sperm duct .................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55250 ....... Removal of sperm duct(s) .............................. ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55300 ....... Prepare, sperm duct x-ray ............................. ........... N ....... .......... .................... .................... .................... ....................

55400 ....... Repair of sperm duct ..................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55450 ....... Ligation of sperm duct ................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55500 ....... Removal of hydrocele .................................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55520 ....... Removal of sperm cord lesion ....................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55530 ....... Revise spermatic cord veins .......................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55535 ....... Revise spermatic cord veins .......................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

55540 ....... Revise hernia&sperm veins ........................... ........... T ....... 0154 29.1491 1,794.16 464.85 358.83 

55550 ....... Laparo ligate spermatic vein .......................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

55559 ....... Laparo proc, spermatic cord .......................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

55600 ....... Incise sperm duct pouch ................................ ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55680 ....... Remove sperm pouch lesion ......................... ........... T ....... 0183 23.7072 1,459.20 .................... 291.84 

55700 ....... Biopsy of prostate .......................................... ........... T ....... 0184 5.9892 368.64 96.27 73.73 

55705 ....... Biopsy of prostate .......................................... ........... T ....... 0184 5.9892 368.64 96.27 73.73 

55720 ....... Drainage of prostate abscess ........................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

55725 ....... Drainage of prostate abscess ........................ ........... T ....... 0162 23.8562 1,468.37 .................... 293.67 

55859 ....... Percut/needle insert, pros .............................. ........... T ....... 0163 35.1024 2,160.59 .................... 432.12 

55860 ....... Surgical exposure, prostate ........................... ........... T ....... 0165 18.2333 1,122.28 .................... 224.46 

55870 ....... Electroejaculation ........................................... ........... T ....... 0197 4.4108 271.49 .................... 54.30 

55873 ....... Cryoablate prostate ........................................ ........... T ....... 0674 107.8298 6,637.03 .................... 1,327.41 

55899 ....... Genital surgery procedure ............................. CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

56405 ....... I&D of vulva/perineum .................................... ........... T ....... 0189 2.9902 184.05 .................... 36.81 

56420 ....... Drainage of gland abscess ............................ CH .... T ....... 0188 1.4050 86.48 .................... 17.30 

56440 ....... Surgery for vulva lesion ................................. ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

56441 ....... Lysis of labial lesion(s) ................................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

56501 ....... Destroy, vulva lesions, sim ............................ ........... T ....... 0017 17.7392 1,091.87 227.84 218.37 

56515 ....... Destroy vulva lesion/s compl ......................... ........... T ....... 0695 20.5802 1,266.73 266.59 253.35 

56605 ....... Biopsy of vulva/perineum ............................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

56606 ....... Biopsy of vulva/perineum ............................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

56620 ....... Partial removal of vulva ................................. ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

56625 ....... Complete removal of vulva ............................ ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

56700 ....... Partial removal of hymen ............................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

56720 ....... Incision of hymen ........................................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

56740 ....... Remove vagina gland lesion .......................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

56800 ....... Repair of vagina ............................................. ........... T ....... 0194 20.5113 1,262.49 397.84 252.50

56805 ....... Repair clitoris ................................................. ........... T ....... 0193 14.7958 910.70 .................... 182.14 

56810 ....... Repair of perineum ........................................ ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

56820 ....... Exam of vulva w/scope .................................. ........... T ....... 0188 1.4050 86.48 .................... 17.30 

56821 ....... Exam/biopsy of vulva w/scope ....................... ........... T ....... 0189 2.9902 184.05 .................... 36.81 

57000 ....... Exploration of vagina ..................................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

57010 ....... Drainage of pelvic abscess ............................ ........... T ....... 0193 14.7958 910.70 .................... 182.14 

57020 ....... Drainage of pelvic fluid .................................. ........... T ....... 0192 6.9265 426.33 .................... 85.27 

57022 ....... I&d vaginal hematoma, pp ............................. ........... T ....... 0007 10.9184 672.04 .................... 134.41 

57023 ....... I&d vag hematoma, non-ob ........................... ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

57061 ....... Destroy vag lesions, simple ........................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57065 ....... Destroy vag lesions, complex ........................ ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57100 ....... Biopsy of vagina ............................................. ........... T ....... 0192 6.9265 426.33 .................... 85.27 

57105 ....... Biopsy of vagina ............................................. ........... T ....... 0194 20.5113 1,262.49 397.84 252.50


sroberts on PROD1PC70 with PROPOSALS
49800 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

57106 ....... Remove vagina wall, partial ........................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57107 ....... Remove vagina tissue, part ........................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57109 ....... Vaginectomy partial w/nodes ......................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57120 ....... Closure of vagina ........................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57130 ....... Remove vagina lesion .................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57135 ....... Remove vagina lesion .................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57150 ....... Treat vagina infection ..................................... ........... T ....... 0191 0.1501 9.24 .................... 1.85 

57155 ....... Insert uteri tandems/ovoids ............................ ........... T ....... 0192 6.9265 426.33 .................... 85.27 

57160 ....... Insert pessary/other device ............................ ........... T ....... 0188 1.4050 86.48 .................... 17.30 

57170 ....... Fitting of diaphragm/cap ................................ ........... T ....... 0191 0.1501 9.24 .................... 1.85 

57180 ....... Treat vaginal bleeding .................................... ........... T ....... 0189 2.9902 184.05 .................... 36.81 

57200 ....... Repair of vagina ............................................. ........... T ....... 0194 20.5113 1,262.49 397.84 252.50

57210 ....... Repair vagina/perineum ................................. ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57220 ....... Revision of urethra ......................................... ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

57230 ....... Repair of urethral lesion ................................. ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57240 ....... Repair bladder&vagina ................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57250 ....... Repair rectum&vagina .................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57260 ....... Repair of vagina ............................................. ........... T ....... 0195 28.7410 1,769.04 483.80 353.81

57265 ....... Extensive repair of vagina ............................. ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

57267 ....... Insert mesh/pelvic flr addon ........................... CH .... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57268 ....... Repair of bowel bulge .................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57284 ....... Repair paravaginal defect .............................. ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

57287 ....... Revise/remove sling repair ............................ CH .... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57288 ....... Repair bladder defect ..................................... ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

57289 ....... Repair bladder&vagina ................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57291 ....... Construction of vagina ................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57292 ....... Construct vagina with graft ............................ CH .... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57295 ....... Change vaginal graft ...................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57300 ....... Repair rectum-vagina fistula .......................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57310 ....... Repair urethrovaginal lesion .......................... ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

57320 ....... Repair bladder-vagina lesion ......................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57330 ....... Repair bladder-vagina lesion ......................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57335 ....... Repair vagina ................................................. CH .... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57400 ....... Dilation of vagina ........................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50

57410 ....... Pelvic examination ......................................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

57415 ....... Remove vaginal foreign body ........................ ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57420 ....... Exam of vagina w/scope ................................ ........... T ....... 0189 2.9902 184.05 .................... 36.81 

57421 ....... Exam/biopsy of vag w/scope ......................... ........... T ....... 0189 2.9902 184.05 .................... 36.81 

57425 ....... Laparoscopy, surg, colpopexy ....................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

57452 ....... Exam of cervix w/scope ................................. CH .... T ....... 0188 1.4050 86.48 .................... 17.30 

57454 ....... Bx/curett of cervix w/scope ............................ ........... T ....... 0189 2.9902 184.05 .................... 36.81 

57455 ....... Biopsy of cervix w/scope ............................... ........... T ....... 0189 2.9902 184.05 .................... 36.81 

57456 ....... Endocerv curettage w/scope .......................... ........... T ....... 0189 2.9902 184.05 .................... 36.81

57460 ....... Bx of cervix w/scope, leep ............................. ........... T ....... 0193 14.7958 910.70 .................... 182.14 

57461 ....... Conz of cervix w/scope, leep ......................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57500 ....... Biopsy of cervix .............................................. CH .... T ....... 0189 2.9902 184.05 .................... 36.81 

57505 ....... Endocervical curettage ................................... ........... T ....... 0189 2.9902 184.05 .................... 36.81 

57510 ....... Cauterization of cervix ................................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

57511 ....... Cryocautery of cervix ..................................... CH .... T ....... 0188 1.4050 86.48 .................... 17.30

57513 ....... Laser surgery of cervix .................................. ........... T ....... 0193 14.7958 910.70 .................... 182.14 

57520 ....... Conization of cervix ........................................ ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

57522 ....... Conization of cervix ........................................ ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57530 ....... Removal of cervix .......................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57550 ....... Removal of residual cervix ............................. ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57555 ....... Remove cervix/repair vagina ......................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

57556 ....... Remove cervix, repair bowel ......................... ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

57700 ....... Revision of cervix ........................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50

57720 ....... Revision of cervix ........................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50

57800 ....... Dilation of cervical canal ................................ ........... T ....... 0193 14.7958 910.70 .................... 182.14 

57820 ....... D&c of residual cervix .................................... ........... T ....... 0196 17.7635 1,093.36 338.23 218.67 

58100 ....... Biopsy of uterus lining .................................... ........... T ....... 0188 1.4050 86.48 .................... 17.30 

58110 ....... Bx done w/colposcopy add-on ....................... ........... T ....... 0188 1.4050 86.48 .................... 17.30 

58120 ....... Dilation and curettage .................................... ........... T ....... 0196 17.7635 1,093.36 338.23 218.67 

58145 ....... Myomectomy vag method .............................. ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58301 ....... Remove intrauterine device ........................... CH .... T ....... 0188 1.4050 86.48 .................... 17.30 

58321 ....... Artificial insemination ..................................... ........... T ....... 0197 4.4108 271.49 .................... 54.30 

58322 ....... Artificial insemination ..................................... ........... T ....... 0197 4.4108 271.49 .................... 54.30 

58323 ....... Sperm washing .............................................. ........... T ....... 0197 4.4108 271.49 .................... 54.30 

58340 ....... Catheter for hysterography ............................ ........... N ....... .......... .................... .................... .................... ....................

58345 ....... Reopen fallopian tube .................................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49801 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

58346 ....... Insert heyman uteri capsule ........................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

58350 ....... Reopen fallopian tube .................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58353 ....... Endometr ablate, thermal ............................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58356 ....... Endometrial cryoablation ................................ ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

58545 ....... Laparoscopic myomectomy ........................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

58546 ....... Laparo-myomectomy, complex ...................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58550 ....... Laparo-asst vag hysterectomy ....................... ........... T ....... 0132 70.8854 4,363.07 1,239.22 872.61 

58552 ....... Laparo-vag hyst incl t/o .................................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58553 ....... Laparo-vag hyst, complex .............................. ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58554 ....... Laparo-vag hyst w/t/o, compl ......................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58555 ....... Hysteroscopy, dx, sep proc ........................... ........... T ....... 0190 21.4199 1,318.42 424.28 263.68 

58558 ....... Hysteroscopy, biopsy ..................................... ........... T ....... 0190 21.4199 1,318.42 424.28 263.68 

58559 ....... Hysteroscopy, lysis ........................................ ........... T ....... 0190 21.4199 1,318.42 424.28 263.68 

58560 ....... Hysteroscopy, resect septum ......................... ........... T ....... 0387 33.3029 2,049.83 655.55 409.97 

58561 ....... Hysteroscopy, remove myoma ...................... ........... T ....... 0387 33.3029 2,049.83 655.55 409.97 

58562 ....... Hysteroscopy, remove fb ............................... ........... T ....... 0190 21.4199 1,318.42 424.28 263.68 

58563 ....... Hysteroscopy, ablation ................................... ........... T ....... 0387 33.3029 2,049.83 655.55 409.97 

58565 ....... Hysteroscopy, sterilization ............................. ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

58578 ....... Laparo proc, uterus ........................................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

58579 ....... Hysteroscope procedure ................................ ........... T ....... 0190 21.4199 1,318.42 424.28 263.68 

58600 ....... Division of fallopian tube ................................ ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58615 ....... Occlude fallopian tube(s) ............................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

58660 ....... Laparoscopy, lysis .......................................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58661 ....... Laparoscopy, remove adnexa ........................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58662 ....... Laparoscopy, excise lesions .......................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58670 ....... Laparoscopy, tubal cautery ............................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58671 ....... Laparoscopy, tubal block ............................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58672 ....... Laparoscopy, fimbrioplasty ............................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58673 ....... Laparoscopy, salpingostomy .......................... ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

58679 ....... Laparo proc, oviduct-ovary ............................ ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

58770 ....... Create new tubal opening .............................. ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58800 ....... Drainage of ovarian cyst(s) ............................ ........... T ....... 0193 14.7958 910.70 .................... 182.14 

58820 ....... Drain ovary abscess, open ............................ ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58823 ....... Drain pelvic abscess, percut .......................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

58900 ....... Biopsy of ovary(s) .......................................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

58920 ....... Partial removal of ovary(s) ............................. ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58925 ....... Removal of ovarian cyst(s) ............................ ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

58970 ....... Retrieval of oocyte ......................................... ........... T ....... 0197 4.4108 271.49 .................... 54.30 

58974 ....... Transfer of embryo ......................................... ........... T ....... 0197 4.4108 271.49 .................... 54.30 

58976 ....... Transfer of embryo ......................................... ........... T ....... 0197 4.4108 271.49 .................... 54.30 

58999 ....... Genital surgery procedure ............................. ........... T ....... 0191 0.1501 9.24 .................... 1.85 

59000 ....... Amniocentesis, diagnostic .............................. ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59001 ....... Amniocentesis, therapeutic ............................ ........... T ....... 0192 6.9265 426.33 .................... 85.27 

59012 ....... Fetal cord puncture,prenatal .......................... ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59015 ....... Chorion biopsy ............................................... ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59020 ....... Fetal contract stress test ................................ CH .... T ....... 0189 2.9902 184.05 .................... 36.81 

59025 ....... Fetal non-stress test ...................................... ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59030 ....... Fetal scalp blood sample ............................... ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59070 ....... Transabdom amnioinfus w/us ........................ ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59072 ....... Umbilical cord occlud w/us ............................ ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59074 ....... Fetal fluid drainage w/us ................................ ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59076 ....... Fetal shunt placement, w/us .......................... ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59100 ....... Remove uterus lesion .................................... ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

59150 ....... Treat ectopic pregnancy ................................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

59151 ....... Treat ectopic pregnancy ................................ ........... T ....... 0131 43.5124 2,678.23 1,001.89 535.65 

59160 ....... D&c after delivery ........................................... ........... T ....... 0196 17.7635 1,093.36 338.23 218.67

59200 ....... Insert cervical dilator ...................................... ........... T ....... 0189 2.9902 184.05 .................... 36.81 

59300 ....... Episiotomy or vaginal repair .......................... ........... T ....... 0193 14.7958 910.70 .................... 182.14 

59320 ....... Revision of cervix ........................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50

59409 ....... Obstetrical care .............................................. ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

59412 ....... Antepartum manipulation ............................... ........... T ....... 0700 2.8011 172.41 .................... 34.48 

59414 ....... Deliver placenta ............................................. ........... T ....... 0193 14.7958 910.70 .................... 182.14 

59612 ....... Vbac delivery only .......................................... ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

59812 ....... Treatment of miscarriage ............................... ........... T ....... 0201 18.5251 1,140.24 329.65 228.05 

59820 ....... Care of miscarriage ........................................ ........... T ....... 0201 18.5251 1,140.24 329.65 228.05 

59821 ....... Treatment of miscarriage ............................... ........... T ....... 0201 18.5251 1,140.24 329.65 228.05 

59840 ....... Abortion .......................................................... ........... T ....... 0200 17.2607 1,062.41 248.39 212.48 

59841 ....... Abortion .......................................................... ........... T ....... 0200 17.2607 1,062.41 248.39 212.48 

59866 ....... Abortion (mpr) ................................................ ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59870 ....... Evacuate mole of uterus ................................ ........... T ....... 0201 18.5251 1,140.24 329.65 228.05 


sroberts on PROD1PC70 with PROPOSALS
49802 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

59871 ....... Remove cerclage suture ................................ ........... T ....... 0194 20.5113 1,262.49 397.84 252.50 

59897 ....... Fetal invas px w/us ........................................ ........... T ....... 0198 1.4026 86.33 32.19 17.27 

59898 ....... Laparo proc, ob care/deliver .......................... ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

59899 ....... Maternity care procedure ............................... ........... T ....... 0198 1.4026 86.33 32.19 17.27 

60000 ....... Drain thyroid/tongue cyst ............................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

60001 ....... Aspirate/inject thyriod cyst ............................. ........... T ....... 0004 2.0863 128.41 .................... 25.68 

60100 ....... Biopsy of thyroid ............................................ ........... T ....... 0004 2.0863 128.41 .................... 25.68 

60200 ....... Remove thyroid lesion ................................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60210 ....... Partial thyroid excision ................................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60212 ....... Partial thyroid excision ................................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60220 ....... Partial removal of thyroid ............................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60225 ....... Partial removal of thyroid ............................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60240 ....... Removal of thyroid ......................................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60252 ....... Removal of thyroid ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

60260 ....... Repeat thyroid surgery ................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

60280 ....... Remove thyroid duct lesion ........................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60281 ....... Remove thyroid duct lesion ........................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

60500 ....... Explore parathyroid glands ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

60512 ....... Autotransplant parathyroid ............................. ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

60659 ....... Laparo proc, endocrine .................................. ........... T ....... 0130 31.9353 1,965.65 659.53 393.13 

60699 ....... Endocrine surgery procedure ......................... ........... T ....... 0114 37.1283 2,285.28 461.19 457.06 

61000 ....... Remove cranial cavity fluid ............................ ........... T ....... 0212 3.0383 187.01 65.96 37.40 

61001 ....... Remove cranial cavity fluid ............................ ........... T ....... 0212 3.0383 187.01 65.96 37.40 

61020 ....... Remove brain cavity fluid ............................... ........... T ....... 0212 3.0383 187.01 65.96 37.40 

61026 ....... Injection into brain canal ................................ ........... T ....... 0212 3.0383 187.01 65.96 37.40 

61050 ....... Remove brain canal fluid ............................... ........... T ....... 0212 3.0383 187.01 65.96 37.40 

61055 ....... Injection into brain canal ................................ ........... T ....... 0212 3.0383 187.01 65.96 37.40 

61070 ....... Brain canal shunt procedure .......................... ........... T ....... 0212 3.0383 187.01 65.96 37.40 

61215 ....... Insert brain-fluid device .................................. ........... T ....... 0224 45.6712 2,811.11 .................... 562.22 

61330 ....... Decompress eye socket ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

61334 ....... Explore orbit/remove object ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

61623 ....... Endovasc tempory vessel occl ...................... ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

61626 ....... Transcath occlusion, non-cns ........................ ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

61720 ....... Incise skull/brain surgery ............................... CH .... T ....... 0221 33.3035 2,049.86 463.62 409.97 

61790 ....... Treat trigeminal nerve .................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

61791 ....... Treat trigeminal tract ...................................... ........... T ....... 0206 5.5439 341.23 75.55 68.25 

61795 ....... Brain surgery using computer ........................ ........... S ....... 0302 5.5005 338.56 105.94 67.71 

61880 ....... Revise/remove neuroelectrode ...................... ........... T ....... 0687 17.1830 1,057.63 423.05 211.53 

61885 ....... Insrt/redo neurostim 1 array ........................... ........... S ....... 0039 175.9328 10,828.84 .................... 2,165.77 

61886 ....... Implant neurostim arrays ............................... ........... T ....... 0315 235.5774 14,500.02 .................... 2,900.00 

61888 ....... Revise/remove neuroreceiver ........................ ........... T ....... 0688 33.9521 2,089.79 835.91 417.96 

62000 ....... Treat skull fracture ......................................... CH .... T ....... 0254 23.1564 1,425.30 321.35 285.06 

62160 ....... Neuroendoscopy add-on ................................ ........... T ....... 0122 7.2859 448.45 .................... 89.69 

62194 ....... Replace/irrigate catheter ................................ ........... T ....... 0427 11.5220 709.19 .................... 141.84 

62225 ....... Replace/irrigate catheter ................................ ........... T ....... 0427 11.5220 709.19 .................... 141.84 

62230 ....... Replace/revise brain shunt ............................ ........... T ....... 0224 45.6712 2,811.11 .................... 562.22 

62252 ....... Csf shunt reprogram ...................................... ........... S ....... 0691 2.8253 173.90 60.61 34.78 

62263 ....... Epidural lysis mult sessions ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

62264 ....... Epidural lysis on single day ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

62268 ....... Drain spinal cord cyst .................................... ........... T ....... 0212 3.0383 187.01 65.96 37.40 

62269 ....... Needle biopsy, spinal cord ............................. ........... T ....... 0685 6.0729 373.79 115.47 74.76 

62270 ....... Spinal fluid tap, diagnostic ............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

62272 ....... Drain cerebro spinal fluid ............................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

62273 ....... Inject epidural patch ....................................... ........... T ....... 0206 5.5439 341.23 75.55 68.25 

62280 ....... Treat spinal cord lesion .................................. ........... T ....... 0207 6.3788 392.62 86.92 78.52 

62281 ....... Treat spinal cord lesion .................................. ........... T ....... 0207 6.3788 392.62 86.92 78.52 

62282 ....... Treat spinal canal lesion ................................ ........... T ....... 0207 6.3788 392.62 86.92 78.52 

62284 ....... Injection for myelogram .................................. ........... N ....... .......... .................... .................... .................... ....................

62287 ....... Percutaneous diskectomy .............................. ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

62290 ....... Inject for spine disk x-ray ............................... ........... N ....... .......... .................... .................... .................... ....................

62291 ....... Inject for spine disk x-ray ............................... ........... N ....... .......... .................... .................... .................... ....................

62292 ....... Injection into disk lesion ................................. ........... T ....... 0212 3.0383 187.01 65.96 37.40 

62294 ....... Injection into spinal artery .............................. ........... T ....... 0212 3.0383 187.01 65.96 37.40 

62310 ....... Inject spine c/t ................................................ ........... T ....... 0207 6.3788 392.62 86.92 78.52 

62311 ....... Inject spine l/s (cd) ......................................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 

62318 ....... Inject spine w/cath, c/t ................................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 

62319 ....... Inject spine w/cath l/s (cd) ............................. ........... T ....... 0207 6.3788 392.62 86.92 78.52 

62350 ....... Implant spinal canal cath ............................... ........... T ....... 0223 29.2931 1,803.02 .................... 360.60 

62351 ....... Implant spinal canal cath ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

62355 ....... Remove spinal canal catheter ....................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49803 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

62360 ....... Insert spine infusion device ........................... ........... T ....... 0226 112.0147 6,894.62 .................... 1,378.92 

62361 ....... Implant spine infusion pump .......................... ........... T ....... 0227 183.1974 11,275.98 .................... 2,255.20 

62362 ....... Implant spine infusion pump .......................... ........... T ....... 0227 183.1974 11,275.98 .................... 2,255.20 

62365 ....... Remove spine infusion device ....................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

62367 ....... Analyze spine infusion pump ......................... ........... S ....... 0691 2.8253 173.90 60.61 34.78 

62368 ....... Analyze spine infusion pump ......................... ........... S ....... 0691 2.8253 173.90 60.61 34.78 

63001 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63003 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63005 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63011 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63012 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63015 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63016 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63017 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63020 ....... Neck spine disk surgery ................................. ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63030 ....... Low back disk surgery ................................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63035 ....... Spinal disk surgery add-on ............................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63040 ....... Laminotomy, single cervical ........................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63042 ....... Laminotomy, single lumbar ............................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63045 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63046 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63047 ....... Removal of spinal lamina ............................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63048 ....... Remove spinal lamina add-on ....................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63055 ....... Decompress spinal cord ................................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63056 ....... Decompress spinal cord ................................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63057 ....... Decompress spine cord add-on ..................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63064 ....... Decompress spinal cord ................................ ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63066 ....... Decompress spine cord add-on ..................... ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63075 ....... Neck spine disk surgery ................................. ........... T ....... 0208 43.9030 2,702.27 .................... 540.45 

63600 ....... Remove spinal cord lesion ............................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

63610 ....... Stimulation of spinal cord ............................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

63615 ....... Remove lesion of spinal cord ........................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

63650 ....... Implant neuroelectrodes ................................. ........... S ....... 0040 56.3855 3,470.58 .................... 694.12 

63655 ....... Implant neuroelectrodes ................................. ........... S ....... 0061 84.2373 5,184.89 .................... 1,036.98 

63660 ....... Revise/remove neuroelectrode ...................... ........... T ....... 0687 17.1830 1,057.63 423.05 211.53 

63685 ....... Insrt/redo spine n generator ........................... ........... T ....... 0222 178.1307 10,964.12 .................... 2,192.82 

63688 ....... Revise/remove neuroreceiver ........................ ........... T ....... 0688 33.9521 2,089.79 835.91 417.96 

63741 ....... Install spinal shunt ......................................... ........... T ....... 0228 36.1603 2,225.70 .................... 445.14 

63744 ....... Revision of spinal shunt ................................. ........... T ....... 0228 36.1603 2,225.70 .................... 445.14 

63746 ....... Removal of spinal shunt ................................ ........... T ....... 0109 10.9541 674.24 .................... 134.85 

64400 ....... N block inj, trigeminal ..................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64402 ....... N block inj, facial ............................................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64405 ....... N block inj, occipital ....................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64408 ....... N block inj, vagus ........................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64410 ....... N block inj, phrenic ........................................ ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64412 ....... N block inj, spinal accessor ........................... ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64413 ....... N block inj, cervical plexus ............................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64415 ....... N block inj, brachial plexus ............................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64416 ....... N block cont infuse, b plex ............................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64417 ....... N block inj, axillary ......................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64418 ....... N block inj, suprascapular .............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64420 ....... N block inj, intercost, sng ............................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64421 ....... N block inj, intercost, mlt ................................ ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64425 ....... N block inj, ilio-ing/hypogi .............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64430 ....... N block inj, pudendal ..................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64435 ....... N block inj, paracervical ................................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64445 ....... N block inj, sciatic, sng .................................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64446 ....... N blk inj, sciatic, cont inf ................................ ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64447 ....... N block inj fem, single .................................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64448 ....... N block inj fem, cont inf ................................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64449 ....... N block inj, lumbar plexus .............................. ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64450 ....... N block, other peripheral ................................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64470 ....... Inj paravertebral c/t ........................................ ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64472 ....... Inj paravertebral c/t add-on ............................ ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64475 ....... Inj paravertebral l/s ........................................ ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64476 ....... Inj paravertebral l/s add-on ............................ ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64479 ....... Inj foramen epidural c/t .................................. ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64480 ....... Inj foramen epidural add-on ........................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64483 ....... Inj foramen epidural l/s .................................. ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64484 ....... Inj foramen epidural add-on ........................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 


sroberts on PROD1PC70 with PROPOSALS
49804 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

64505 ....... N block, spenopalatine gangl ......................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64508 ....... N block, carotid sinus s/p ............................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64510 ....... N block, stellate ganglion ............................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64517 ....... N block inj, hypogas plxs ............................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64520 ....... N block, lumbar/thoracic ................................ ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64530 ....... N block inj, celiac pelus ................................. ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64553 ....... Implant neuroelectrodes ................................. ........... S ....... 0225 234.1628 14,412.95 .................... 2,882.59 

64555 ....... Implant neuroelectrodes ................................. ........... S ....... 0040 56.3855 3,470.58 .................... 694.12 

64560 ....... Implant neuroelectrodes ................................. ........... S ....... 0040 56.3855 3,470.58 .................... 694.12 

64561 ....... Implant neuroelectrodes ................................. ........... S ....... 0040 56.3855 3,470.58 .................... 694.12 

64565 ....... Implant neuroelectrodes ................................. ........... S ....... 0040 56.3855 3,470.58 .................... 694.12 

64573 ....... Implant neuroelectrodes ................................. ........... S ....... 0225 234.1628 14,412.95 .................... 2,882.59 

64575 ....... Implant neuroelectrodes ................................. ........... S ....... 0061 84.2373 5,184.89 .................... 1,036.98 

64577 ....... Implant neuroelectrodes ................................. ........... S ....... 0061 84.2373 5,184.89 .................... 1,036.98 

64580 ....... Implant neuroelectrodes ................................. ........... S ....... 0061 84.2373 5,184.89 .................... 1,036.98 

64581 ....... Implant neuroelectrodes ................................. ........... S ....... 0061 84.2373 5,184.89 .................... 1,036.98 

64585 ....... Revise/remove neuroelectrode ...................... ........... T ....... 0687 17.1830 1,057.63 423.05 211.53 

64590 ....... Insrt/redo perph n generator .......................... ........... T ....... 0222 178.1307 10,964.12 .................... 2,192.82 

64595 ....... Revise/remove neuroreceiver ........................ ........... T ....... 0688 33.9521 2,089.79 835.91 417.96 

64600 ....... Injection treatment of nerve ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

64605 ....... Injection treatment of nerve ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

64610 ....... Injection treatment of nerve ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

64612 ....... Destroy nerve, face muscle ........................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64613 ....... Destroy nerve, neck muscle .......................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64614 ....... Destroy nerve, extrem musc .......................... ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64620 ....... Injection treatment of nerve ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

64622 ....... Destr paravertebrl nerve l/s ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

64623 ....... Destr paravertebral n add-on ......................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64626 ....... Destr paravertebrl nerve c/t ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

64627 ....... Destr paravertebral n add-on ......................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64630 ....... Injection treatment of nerve ........................... ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64640 ....... Injection treatment of nerve ........................... ........... T ....... 0206 5.5439 341.23 75.55 68.25 

64650 ....... Chemodenerv eccrine glands ........................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64653 ....... Chemodenerv eccrine glands ........................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

64680 ....... Injection treatment of nerve ........................... ........... T ....... 0207 6.3788 392.62 86.92 78.52 

64681 ....... Injection treatment of nerve ........................... ........... T ....... 0203 12.4432 765.89 240.33 153.18 

64702 ....... Revise finger/toe nerve .................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64704 ....... Revise hand/foot nerve .................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64708 ....... Revise arm/leg nerve ..................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64712 ....... Revision of sciatic nerve ................................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64713 ....... Revision of arm nerve(s) ................................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64714 ....... Revise low back nerve(s) ............................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64716 ....... Revision of cranial nerve ............................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64718 ....... Revise ulnar nerve at elbow .......................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64719 ....... Revise ulnar nerve at wrist ............................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64721 ....... Carpal tunnel surgery ..................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64722 ....... Relieve pressure on nerve(s) ......................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64726 ....... Release foot/toe nerve ................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64727 ....... Internal nerve revision .................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64732 ....... Incision of brow nerve .................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64734 ....... Incision of cheek nerve .................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64736 ....... Incision of chin nerve ..................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64738 ....... Incision of jaw nerve ...................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64740 ....... Incision of tongue nerve ................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64742 ....... Incision of facial nerve ................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64744 ....... Incise nerve, back of head ............................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64746 ....... Incise diaphragm nerve .................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64761 ....... Incision of pelvis nerve .................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64763 ....... Incise hip/thigh nerve ..................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64766 ....... Incise hip/thigh nerve ..................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64771 ....... Sever cranial nerve ........................................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64772 ....... Incision of spinal nerve .................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64774 ....... Remove skin nerve lesion .............................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64776 ....... Remove digit nerve lesion ............................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64778 ....... Digit nerve surgery add-on ............................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64782 ....... Remove limb nerve lesion ............................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64783 ....... Limb nerve surgery add-on ............................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64784 ....... Remove nerve lesion ..................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64786 ....... Remove sciatic nerve lesion .......................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64787 ....... Implant nerve end .......................................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49805 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

64788 ....... Remove skin nerve lesion .............................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64790 ....... Removal of nerve lesion ................................ ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64792 ....... Removal of nerve lesion ................................ ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64795 ....... Biopsy of nerve .............................................. ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64802 ....... Remove sympathetic nerves .......................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64804 ....... Remove sympathetic nerves .......................... CH .... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64820 ....... Remove sympathetic nerves .......................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

64821 ....... Remove sympathetic nerves .......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

64822 ....... Remove sympathetic nerves .......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

64823 ....... Remove sympathetic nerves .......................... ........... T ....... 0054 25.8425 1,590.63 .................... 318.13 

64831 ....... Repair of digit nerve ....................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64832 ....... Repair nerve add-on ...................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64834 ....... Repair of hand or foot nerve .......................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64835 ....... Repair of hand or foot nerve .......................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64836 ....... Repair of hand or foot nerve .......................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64837 ....... Repair nerve add-on ...................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64840 ....... Repair of leg nerve ........................................ ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64856 ....... Repair/transpose nerve .................................. ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64857 ....... Repair arm/leg nerve ..................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64858 ....... Repair sciatic nerve ....................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64859 ....... Nerve surgery ................................................. ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64861 ....... Repair of arm nerves ..................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64862 ....... Repair of low back nerves ............................. ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64864 ....... Repair of facial nerve ..................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64865 ....... Repair of facial nerve ..................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64870 ....... Fusion of facial/other nerve ........................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64872 ....... Subsequent repair of nerve ........................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64874 ....... Repair&revise nerve add-on .......................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64876 ....... Repair nerve/shorten bone ............................ ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64885 ....... Nerve graft, head or neck .............................. ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64886 ....... Nerve graft, head or neck .............................. ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64890 ....... Nerve graft, hand or foot ................................ ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64891 ....... Nerve graft, hand or foot ................................ ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64892 ....... Nerve graft, arm or leg ................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64893 ....... Nerve graft, arm or leg ................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64895 ....... Nerve graft, hand or foot ................................ ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64896 ....... Nerve graft, hand or foot ................................ ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64897 ....... Nerve graft, arm or leg ................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64898 ....... Nerve graft, arm or leg ................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64901 ....... Nerve graft add-on ......................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64902 ....... Nerve graft add-on ......................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64905 ....... Nerve pedicle transfer .................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64907 ....... Nerve pedicle transfer .................................... ........... T ....... 0221 33.3035 2,049.86 463.62 409.97 

64999 ....... Nervous system surgery ................................ ........... T ....... 0204 2.2491 138.43 40.13 27.69 

65091 ....... Revise eye ..................................................... ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65093 ....... Revise eye with implant ................................. CH .... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65101 ....... Removal of eye .............................................. ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65103 ....... Remove eye/insert implant ............................ ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65105 ....... Remove eye/attach implant ........................... ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65110 ....... Removal of eye .............................................. ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65112 ....... Remove eye/revise socket ............................. ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65114 ....... Remove eye/revise socket ............................. ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65125 ....... Revise ocular implant ..................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

65130 ....... Insert ocular implant ....................................... ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

65135 ....... Insert ocular implant ....................................... ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

65140 ....... Attach ocular implant ..................................... ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65150 ....... Revise ocular implant ..................................... ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

65155 ....... Reinsert ocular implant .................................. ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

65175 ....... Removal of ocular implant ............................. ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

65205 ....... Remove foreign body from eye ..................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

65210 ....... Remove foreign body from eye ..................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

65220 ....... Remove foreign body from eye ..................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

65222 ....... Remove foreign body from eye ..................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

65235 ....... Remove foreign body from eye ..................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65260 ....... Remove foreign body from eye ..................... ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

65265 ....... Remove foreign body from eye ..................... ........... T ....... 0237 26.9305 1,657.60 .................... 331.52 

65270 ....... Repair of eye wound ...................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

65272 ....... Repair of eye wound ...................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

65275 ....... Repair of eye wound ...................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

65280 ....... Repair of eye wound ...................................... ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 


sroberts on PROD1PC70 with PROPOSALS
49806 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

65285 ....... Repair of eye wound ...................................... ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

65286 ....... Repair of eye wound ...................................... ........... T ....... 0232 5.9800 368.07 92.21 73.61 

65290 ....... Repair of eye socket wound .......................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

65400 ....... Removal of eye lesion ................................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65410 ....... Biopsy of cornea ............................................ ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65420 ....... Removal of eye lesion ................................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65426 ....... Removal of eye lesion ................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

65430 ....... Corneal smear ................................................ ........... S ....... 0698 1.2244 75.36 16.52 15.07 

65435 ....... Curette/treat cornea ....................................... ........... T ....... 0239 6.9354 426.88 .................... 85.38 

65436 ....... Curette/treat cornea ....................................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65450 ....... Treatment of corneal lesion ........................... ........... S ....... 0231 2.1934 135.01 .................... 27.00 

65600 ....... Revision of cornea ......................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

65710 ....... Corneal transplant .......................................... ........... T ....... 0244 37.9446 2,335.53 803.26 467.11 

65730 ....... Corneal transplant .......................................... ........... T ....... 0244 37.9446 2,335.53 803.26 467.11 

65750 ....... Corneal transplant .......................................... ........... T ....... 0244 37.9446 2,335.53 803.26 467.11 

65755 ....... Corneal transplant .......................................... ........... T ....... 0244 37.9446 2,335.53 803.26 467.11 

65770 ....... Revise cornea with implant ............................ CH .... T ....... 0293 50.6347 3,116.62 1,100.34 623.32 

65772 ....... Correction of astigmatism .............................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65775 ....... Correction of astigmatism .............................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65780 ....... Ocular reconst, transplant .............................. ........... T ....... 0244 37.9446 2,335.53 803.26 467.11 

65781 ....... Ocular reconst, transplant .............................. ........... T ....... 0244 37.9446 2,335.53 803.26 467.11 

65782 ....... Ocular reconst, transplant .............................. ........... T ....... 0244 37.9446 2,335.53 803.26 467.11 

65800 ....... Drainage of eye .............................................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65805 ....... Drainage of eye .............................................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65810 ....... Drainage of eye .............................................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49

65815 ....... Drainage of eye .............................................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49

65820 ....... Relieve inner eye pressure ............................ ........... T ....... 0232 5.9800 368.07 92.21 73.61 

65850 ....... Incision of eye ................................................ ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

65855 ....... Laser surgery of eye ...................................... ........... T ....... 0247 5.1266 315.55 104.31 63.11 

65860 ....... Incise inner eye adhesions ............................ ........... T ....... 0247 5.1266 315.55 104.31 63.11 

65865 ....... Incise inner eye adhesions ............................ ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65870 ....... Incise inner eye adhesions ............................ ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

65875 ....... Incise inner eye adhesions ............................ ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

65880 ....... Incise inner eye adhesions ............................ ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65900 ....... Remove eye lesion ........................................ ........... T ....... 0233 14.9969 923.07 266.33 184.61 

65920 ....... Remove implant of eye .................................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

65930 ....... Remove blood clot from eye .......................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66020 ....... Injection treatment of eye .............................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

66030 ....... Injection treatment of eye .............................. ........... T ....... 0232 5.9800 368.07 92.21 73.61 

66130 ....... Remove eye lesion ........................................ ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66150 ....... Glaucoma surgery .......................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66155 ....... Glaucoma surgery .......................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66160 ....... Glaucoma surgery .......................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66165 ....... Glaucoma surgery .......................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66170 ....... Glaucoma surgery .......................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66172 ....... Incision of eye ................................................ CH .... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66180 ....... Implant eye shunt ........................................... ........... T ....... 0673 37.3057 2,296.20 649.56 459.24 

66185 ....... Revise eye shunt ........................................... ........... T ....... 0673 37.3057 2,296.20 649.56 459.24 

66220 ....... Repair eye lesion ........................................... ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

66225 ....... Repair/graft eye lesion ................................... ........... T ....... 0673 37.3057 2,296.20 649.56 459.24 

66250 ....... Follow-up surgery of eye ............................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

66500 ....... Incision of iris ................................................. ........... T ....... 0232 5.9800 368.07 92.21 73.61 

66505 ....... Incision of iris ................................................. ........... T ....... 0232 5.9800 368.07 92.21 73.61 

66600 ....... Remove iris and lesion .................................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66605 ....... Removal of iris ............................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66625 ....... Removal of iris ............................................... ........... T ....... 0232 5.9800 368.07 92.21 73.61 

66630 ....... Removal of iris ............................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66635 ....... Removal of iris ............................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66680 ....... Repair iris&ciliary body .................................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66682 ....... Repair iris&ciliary body .................................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66700 ....... Destruction, ciliary body ................................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

66710 ....... Ciliary transsleral therapy .............................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

66711 ....... Ciliary endoscopic ablation ............................ ........... T ....... 0233 14.9969 923.07 266.33 184.61 

66720 ....... Destruction, ciliary body ................................. ........... T ....... 0233 14.9969 923.07 266.33 184.61 

66740 ....... Destruction, ciliary body ................................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66761 ....... Revision of iris ................................................ ........... T ....... 0247 5.1266 315.55 104.31 63.11 

66762 ....... Revision of iris ................................................ ........... T ....... 0247 5.1266 315.55 104.31 63.11 

66770 ....... Removal of inner eye lesion .......................... ........... T ....... 0247 5.1266 315.55 104.31 63.11 

66820 ....... Incision, secondary cataract .......................... ........... T ....... 0232 5.9800 368.07 92.21 73.61 

66821 ....... After cataract laser surgery ............................ ........... T ....... 0247 5.1266 315.55 104.31 63.11 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49807 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

66825 ....... Reposition intraocular lens ............................. ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

66830 ....... Removal of lens lesion ................................... ........... T ....... 0232 5.9800 368.07 92.21 73.61 

66840 ....... Removal of lens material ............................... ........... T ....... 0245 14.5427 895.12 217.05 179.02 

66850 ....... Removal of lens material ............................... ........... T ....... 0249 28.5043 1,754.47 524.67 350.89 

66852 ....... Removal of lens material ............................... ........... T ....... 0249 28.5043 1,754.47 524.67 350.89 

66920 ....... Extraction of lens ........................................... ........... T ....... 0249 28.5043 1,754.47 524.67 350.89

66930 ....... Extraction of lens ........................................... ........... T ....... 0249 28.5043 1,754.47 524.67 350.89

66940 ....... Extraction of lens ........................................... ........... T ....... 0245 14.5427 895.12 217.05 179.02 

66982 ....... Cataract surgery, complex ............................. ........... T ....... 0246 23.5664 1,450.54 495.96 290.11 

66983 ....... Cataract surg w/iol, 1 stage ........................... ........... T ....... 0246 23.5664 1,450.54 495.96 290.11 

66984 ....... Cataract surg w/iol, 1 stage ........................... ........... T ....... 0246 23.5664 1,450.54 495.96 290.11 

66985 ....... Insert lens prosthesis ..................................... ........... T ....... 0246 23.5664 1,450.54 495.96 290.11 

66986 ....... Exchange lens prosthesis .............................. ........... T ....... 0246 23.5664 1,450.54 495.96 290.11 

66990 ....... Ophthalmic endoscope add-on ...................... ........... N ....... .......... .................... .................... .................... ....................

66999 ....... Eye surgery procedure ................................... ........... T ....... 0232 5.9800 368.07 92.21 73.61 

67005 ....... Partial removal of eye fluid ............................ ........... T ....... 0237 26.9305 1,657.60 .................... 331.52 

67010 ....... Partial removal of eye fluid ............................ ........... T ....... 0237 26.9305 1,657.60 .................... 331.52 

67015 ....... Release of eye fluid ....................................... ........... T ....... 0237 26.9305 1,657.60 .................... 331.52 

67025 ....... Replace eye fluid ........................................... ........... T ....... 0237 26.9305 1,657.60 .................... 331.52 

67027 ....... Implant eye drug system ................................ ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67028 ....... Injection eye drug ........................................... ........... T ....... 0235 4.0750 250.82 61.14 50.16 

67030 ....... Incise inner eye strands ................................. ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

67031 ....... Laser surgery, eye strands ............................ ........... T ....... 0247 5.1266 315.55 104.31 63.11 

67036 ....... Removal of inner eye fluid ............................. ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67038 ....... Strip retinal membrane ................................... ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67039 ....... Laser treatment of retina ................................ ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67040 ....... Laser treatment of retina ................................ ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67101 ....... Repair detached retina ................................... ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

67105 ....... Repair detached retina ................................... ........... T ....... 0248 5.0285 309.51 95.08 61.90 

67107 ....... Repair detached retina ................................... ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67108 ....... Repair detached retina ................................... ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67110 ....... Repair detached retina ................................... ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

67112 ....... Rerepair detached retina ............................... ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

67115 ....... Release encircling material ............................ ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

67120 ....... Remove eye implant material ........................ ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

67121 ....... Remove eye implant material ........................ ........... T ....... 0237 26.9305 1,657.60 .................... 331.52 

67141 ....... Treatment of retina ......................................... ........... T ....... 0235 4.0750 250.82 61.14 50.16 

67145 ....... Treatment of retina ......................................... ........... T ....... 0248 5.0285 309.51 95.08 61.90 

67208 ....... Treatment of retinal lesion ............................. ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

67210 ....... Treatment of retinal lesion ............................. ........... T ....... 0248 5.0285 309.51 95.08 61.90 

67218 ....... Treatment of retinal lesion ............................. ........... T ....... 0236 16.3433 1,005.95 .................... 201.19 

67220 ....... Treatment of choroid lesion ........................... ........... T ....... 0235 4.0750 250.82 61.14 50.16 

67221 ....... Ocular photodynamic ther .............................. ........... T ....... 0235 4.0750 250.82 61.14 50.16 

67225 ....... Eye photodynamic ther add-on ...................... ........... T ....... 0235 4.0750 250.82 61.14 50.16 

67227 ....... Treatment of retinal lesion ............................. CH .... T ....... 0237 26.9305 1,657.60 .................... 331.52 

67228 ....... Treatment of retinal lesion ............................. ........... T ....... 0248 5.0285 309.51 95.08 61.90 

67250 ....... Reinforce eye wall .......................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67255 ....... Reinforce/graft eye wall ................................. ........... T ....... 0237 26.9305 1,657.60 .................... 331.52 

67299 ....... Eye surgery procedure ................................... ........... T ....... 0235 4.0750 250.82 61.14 50.16 

67311 ....... Revise eye muscle ......................................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67312 ....... Revise two eye muscles ................................ ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67314 ....... Revise eye muscle ......................................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67316 ....... Revise two eye muscles ................................ ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67318 ....... Revise eye muscle(s) ..................................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67320 ....... Revise eye muscle(s) add-on ........................ ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67331 ....... Eye surgery follow-up add-on ........................ ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67332 ....... Rerevise eye muscles add-on ....................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67334 ....... Revise eye muscle w/suture .......................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67335 ....... Eye suture during surgery .............................. ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67340 ....... Revise eye muscle add-on ............................ ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67343 ....... Release eye tissue ......................................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67345 ....... Destroy nerve of eye muscle ......................... ........... T ....... 0238 2.8099 172.95 .................... 34.59

67350 ....... Biopsy eye muscle ......................................... ........... T ....... 0699 13.9509 858.69 .................... 171.74 

67399 ....... Eye muscle surgery procedure ...................... ........... T ....... 0243 21.2885 1,310.33 431.09 262.07 

67400 ....... Explore/biopsy eye socket ............................. ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67405 ....... Explore/drain eye socket ................................ ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67412 ....... Explore/treat eye socket ................................ ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67413 ....... Explore/treat eye socket ................................ ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67414 ....... Explr/decompress eye socket ........................ ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67415 ....... Aspiration, orbital contents ............................. ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 


sroberts on PROD1PC70 with PROPOSALS
49808 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

67420 ....... Explore/treat eye socket ................................ ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67430 ....... Explore/treat eye socket ................................ ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67440 ....... Explore/drain eye socket ................................ ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67445 ....... Explr/decompress eye socket ........................ ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67450 ....... Explore/biopsy eye socket ............................. ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67500 ....... Inject/treat eye socket .................................... ........... S ....... 0231 2.1934 135.01 .................... 27.00 

67505 ....... Inject/treat eye socket .................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67515 ....... Inject/treat eye socket .................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67550 ....... Insert eye socket implant ............................... ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67560 ....... Revise eye socket implant ............................. ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67570 ....... Decompress optic nerve ................................ ........... T ....... 0242 35.5217 2,186.40 597.36 437.28 

67599 ....... Orbit surgery procedure ................................. ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67700 ....... Drainage of eyelid abscess ............................ ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67710 ....... Incision of eyelid ............................................ ........... T ....... 0239 6.9354 426.88 .................... 85.38 

67715 ....... Incision of eyelid fold ..................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67800 ....... Remove eyelid lesion ..................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67801 ....... Remove eyelid lesions ................................... ........... T ....... 0239 6.9354 426.88 .................... 85.38 

67805 ....... Remove eyelid lesions ................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67808 ....... Remove eyelid lesion(s) ................................. ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67810 ....... Biopsy of eyelid .............................................. ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67820 ....... Revise eyelashes ........................................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

67825 ....... Revise eyelashes ........................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

67830 ....... Revise eyelashes ........................................... ........... T ....... 0239 6.9354 426.88 .................... 85.38 

67835 ....... Revise eyelashes ........................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67840 ....... Remove eyelid lesion ..................................... ........... T ....... 0239 6.9354 426.88 .................... 85.38 

67850 ....... Treat eyelid lesion .......................................... ........... T ....... 0239 6.9354 426.88 .................... 85.38 

67875 ....... Closure of eyelid by suture ............................ ........... T ....... 0239 6.9354 426.88 .................... 85.38 

67880 ....... Revision of eyelid ........................................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

67882 ....... Revision of eyelid ........................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43

67900 ....... Repair brow defect ......................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67901 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67902 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67903 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67904 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67906 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67908 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67909 ....... Revise eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67911 ....... Revise eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67912 ....... Correction eyelid w/implant ............................ ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67914 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67915 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67916 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67917 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67921 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67922 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67923 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67924 ....... Repair eyelid defect ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67930 ....... Repair eyelid wound ...................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67935 ....... Repair eyelid wound ...................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67938 ....... Remove eyelid foreign body .......................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

67950 ....... Revision of eyelid ........................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43

67961 ....... Revision of eyelid ........................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43

67966 ....... Revision of eyelid ........................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43

67971 ....... Reconstruction of eyelid ................................. ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67973 ....... Reconstruction of eyelid ................................. ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67974 ....... Reconstruction of eyelid ................................. ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

67975 ....... Reconstruction of eyelid ................................. ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

67999 ....... Revision of eyelid ........................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

68020 ....... Incise/drain eyelid lining ................................. ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68040 ....... Treatment of eyelid lesions ............................ ........... S ....... 0698 1.2244 75.36 16.52 15.07 

68100 ....... Biopsy of eyelid lining .................................... ........... T ....... 0232 5.9800 368.07 92.21 73.61 

68110 ....... Remove eyelid lining lesion ........................... ........... T ....... 0699 13.9509 858.69 .................... 171.74 

68115 ....... Remove eyelid lining lesion ........................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68130 ....... Remove eyelid lining lesion ........................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

68135 ....... Remove eyelid lining lesion ........................... ........... T ....... 0239 6.9354 426.88 .................... 85.38 

68200 ....... Treat eyelid by injection ................................. ........... S ....... 0230 0.8126 50.02 14.97 10.00 

68320 ....... Revise/graft eyelid lining ................................ ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68325 ....... Revise/graft eyelid lining ................................ CH .... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68326 ....... Revise/graft eyelid lining ................................ ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68328 ....... Revise/graft eyelid lining ................................ ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49809 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

68330 ....... Revise eyelid lining ........................................ ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

68335 ....... Revise/graft eyelid lining ................................ ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68340 ....... Separate eyelid adhesions ............................. ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68360 ....... Revise eyelid lining ........................................ ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

68362 ....... Revise eyelid lining ........................................ ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

68371 ....... Harvest eye tissue, alograft ........................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

68399 ....... Eyelid lining surgery ....................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

68400 ....... Incise/drain tear gland .................................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

68420 ....... Incise/drain tear sac ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68440 ....... Incise tear duct opening ................................. ........... T ....... 0238 2.8099 172.95 .................... 34.59 

68500 ....... Removal of tear gland .................................... ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68505 ....... Partial removal, tear gland ............................. ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68510 ....... Biopsy of tear gland ....................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68520 ....... Removal of tear sac ....................................... ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68525 ....... Biopsy of tear sac .......................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68530 ....... Clearance of tear duct ................................... ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68540 ....... Remove tear gland lesion .............................. ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68550 ....... Remove tear gland lesion .............................. CH .... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68700 ....... Repair tear ducts ............................................ ........... T ....... 0241 24.8502 1,529.55 384.47 305.91

68705 ....... Revise tear duct opening ............................... ........... T ....... 0238 2.8099 172.95 .................... 34.59 

68720 ....... Create tear sac drain ..................................... CH .... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68745 ....... Create tear duct drain .................................... ........... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68750 ....... Create tear duct drain .................................... CH .... T ....... 0241 24.8502 1,529.55 384.47 305.91 

68760 ....... Close tear duct opening ................................. CH .... S ....... 0231 2.1934 135.01 .................... 27.00 

68761 ....... Close tear duct opening ................................. ........... S ....... 0231 2.1934 135.01 .................... 27.00 

68770 ....... Close tear system fistula ................................ ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68801 ....... Dilate tear duct opening ................................. ........... S ....... 0698 1.2244 75.36 16.52 15.07 

68810 ....... Probe nasolacrimal duct ................................ ........... S ....... 0231 2.1934 135.01 .................... 27.00 

68811 ....... Probe nasolacrimal duct ................................ ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68815 ....... Probe nasolacrimal duct ................................ ........... T ....... 0240 17.0126 1,047.14 307.90 209.43 

68840 ....... Explore/irrigate tear ducts .............................. CH .... S ....... 0698 1.2244 75.36 16.52 15.07 

68850 ....... Injection for tear sac x-ray ............................. ........... N ....... .......... .................... .................... .................... ....................

68899 ....... Tear duct system surgery .............................. CH .... T ....... 0238 2.8099 172.95 .................... 34.59 

69000 ....... Drain external ear lesion ................................ ........... T ....... 0006 1.4821 91.22 21.76 18.24 

69005 ....... Drain external ear lesion ................................ ........... T ....... 0008 17.4686 1,075.21 .................... 215.04 

69020 ....... Drain outer ear canal lesion ........................... ........... T ....... 0006 1.4821 91.22 21.76 18.24 

69100 ....... Biopsy of external ear .................................... ........... T ....... 0019 4.0123 246.96 71.87 49.39 

69105 ....... Biopsy of external ear canal .......................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

69110 ....... Remove external ear, partial .......................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

69120 ....... Removal of external ear ................................. ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69140 ....... Remove ear canal lesion(s) ........................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69145 ....... Remove ear canal lesion(s) ........................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

69150 ....... Extensive ear canal surgery .......................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

69200 ....... Clear outer ear canal ..................................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

69205 ....... Clear outer ear canal ..................................... ........... T ....... 0022 19.9760 1,229.54 354.45 245.91 

69210 ....... Remove impacted ear wax ............................ ........... X ....... 0340 0.6211 38.23 .................... 7.65 

69220 ....... Clean out mastoid cavity ................................ ........... T ....... 0012 0.8076 49.71 10.30 9.94 

69222 ....... Clean out mastoid cavity ................................ CH .... T ....... 0252 7.7261 475.55 111.84 95.11 

69300 ....... Revise external ear ........................................ ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69310 ....... Rebuild outer ear canal .................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69320 ....... Rebuild outer ear canal .................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69399 ....... Outer ear surgery procedure ......................... ........... T ....... 0251 2.3768 146.29 .................... 29.26

69400 ....... Inflate middle ear canal .................................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

69401 ....... Inflate middle ear canal .................................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

69405 ....... Catheterize middle ear canal ......................... ........... T ....... 0252 7.7261 475.55 111.84 95.11 

69420 ....... Incision of eardrum ........................................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

69421 ....... Incision of eardrum ........................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

69424 ....... Remove ventilating tube ................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

69433 ....... Create eardrum opening ................................ ........... T ....... 0252 7.7261 475.55 111.84 95.11 

69436 ....... Create eardrum opening ................................ ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

69440 ....... Exploration of middle ear ............................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69450 ....... Eardrum revision ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69501 ....... Mastoidectomy ............................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69502 ....... Mastoidectomy ............................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69505 ....... Remove mastoid structures ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69511 ....... Extensive mastoid surgery ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69530 ....... Extensive mastoid surgery ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69540 ....... Remove ear lesion ......................................... ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

69550 ....... Remove ear lesion ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69552 ....... Remove ear lesion ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 


sroberts on PROD1PC70 with PROPOSALS
49810 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

69601 ....... Mastoid surgery revision ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69602 ....... Mastoid surgery revision ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69603 ....... Mastoid surgery revision ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69604 ....... Mastoid surgery revision ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69605 ....... Mastoid surgery revision ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69610 ....... Repair of eardrum .......................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69620 ....... Repair of eardrum .......................................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69631 ....... Repair eardrum structures ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69632 ....... Rebuild eardrum structures ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69633 ....... Rebuild eardrum structures ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69635 ....... Repair eardrum structures ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69636 ....... Rebuild eardrum structures ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69637 ....... Rebuild eardrum structures ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69641 ....... Revise middle ear&mastoid ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69642 ....... Revise middle ear&mastoid ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69643 ....... Revise middle ear&mastoid ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69644 ....... Revise middle ear&mastoid ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69645 ....... Revise middle ear&mastoid ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69646 ....... Revise middle ear&mastoid ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69650 ....... Release middle ear bone ............................... ........... T ....... 0254 23.1564 1,425.30 321.35 285.06 

69660 ....... Revise middle ear bone ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69661 ....... Revise middle ear bone ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69662 ....... Revise middle ear bone ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69666 ....... Repair middle ear structures .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69667 ....... Repair middle ear structures .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69670 ....... Remove mastoid air cells ............................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69676 ....... Remove middle ear nerve .............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69700 ....... Close mastoid fistula ...................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69711 ....... Remove/repair hearing aid ............................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69714 ....... Implant temple bone w/stimul ........................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69715 ....... Temple bne implnt w/stimulat ........................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69717 ....... Temple bone implant revision ........................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69718 ....... Revise temple bone implant .......................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69720 ....... Release facial nerve ...................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69725 ....... Release facial nerve ...................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69740 ....... Repair facial nerve ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69745 ....... Repair facial nerve ......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69799 ....... Middle ear surgery procedure ........................ ........... T ....... 0251 2.3768 146.29 .................... 29.26

69801 ....... Incise inner ear .............................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69802 ....... Incise inner ear .............................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69805 ....... Explore inner ear ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69806 ....... Explore inner ear ............................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69820 ....... Establish inner ear window ............................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69840 ....... Revise inner ear window ................................ ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69905 ....... Remove inner ear .......................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69910 ....... Remove inner ear&mastoid ........................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69915 ....... Incise inner ear nerve .................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69930 ....... Implant cochlear device ................................. ........... T ....... 0259 406.8232 25,040.37 8,698.43 5,008.07 

69949 ....... Inner ear surgery procedure .......................... ........... T ....... 0251 2.3768 146.29 .................... 29.26 

69955 ....... Release facial nerve ...................................... ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69960 ....... Release inner ear canal ................................. ........... T ....... 0256 37.7719 2,324.90 .................... 464.98 

69979 ....... Temporal bone surgery .................................. ........... T ....... 0251 2.3768 146.29 .................... 29.26 

69990 ....... Microsurgery add-on ...................................... ........... N ....... .......... .................... .................... .................... ....................

70010 ....... Contrast x-ray of brain ................................... ........... S ....... 0274 2.6182 161.15 64.46 32.23 

70015 ....... Contrast x-ray of brain ................................... ........... S ....... 0274 2.6182 161.15 64.46 32.23 

70030 ....... X-ray eye for foreign body ............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70100 ....... X-ray exam of jaw .......................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70110 ....... X-ray exam of jaw .......................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70120 ....... X-ray exam of mastoids ................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70130 ....... X-ray exam of mastoids ................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70134 ....... X-ray exam of middle ear .............................. ........... X ....... 0261 1.2515 77.03 .................... 15.41 

70140 ....... X-ray exam of facial bones ............................ ........... X ....... 0260 0.7276 44.78 .................... 8.96

70150 ....... X-ray exam of facial bones ............................ ........... X ....... 0260 0.7276 44.78 .................... 8.96

70160 ....... X-ray exam of nasal bones ............................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70170 ....... X-ray exam of tear duct ................................. ........... X ....... 0264 2.9791 183.37 70.84 36.67 

70190 ....... X-ray exam of eye sockets ............................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70200 ....... X-ray exam of eye sockets ............................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70210 ....... X-ray exam of sinuses ................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70220 ....... X-ray exam of sinuses ................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70240 ....... X-ray exam, pituitary saddle .......................... ........... X ....... 0260 0.7276 44.78 .................... 8.96


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49811 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

70250 ....... X-ray exam of skull ........................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70260 ....... X-ray exam of skull ........................................ ........... X ....... 0261 1.2515 77.03 .................... 15.41 

70300 ....... X-ray exam of teeth ....................................... ........... X ....... 0262 0.5818 35.81 .................... 7.16 

70310 ....... X-ray exam of teeth ....................................... ........... X ....... 0262 0.5818 35.81 .................... 7.16 

70320 ....... Full mouth x-ray of teeth ................................ ........... X ....... 0262 0.5818 35.81 .................... 7.16 

70328 ....... X-ray exam of jaw joint .................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70330 ....... X-ray exam of jaw joints ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70332 ....... X-ray exam of jaw joint .................................. ........... S ....... 0275 3.7021 227.87 69.09 45.57 

70336 ....... Magnetic image, jaw joint .............................. ........... S ....... 0335 4.6629 287.01 114.80 57.40 

70350 ....... X-ray head for orthodontia ............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70355 ....... Panoramic x-ray of jaws ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70360 ....... X-ray exam of neck ........................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70370 ....... Throat x-ray&fluoroscopy ............................... ........... X ....... 0272 1.2985 79.92 31.64 15.98 

70371 ....... Speech evaluation, complex .......................... ........... X ....... 0272 1.2985 79.92 31.64 15.98 

70373 ....... Contrast x-ray of larynx .................................. ........... X ....... 0263 1.7120 105.38 23.77 21.08 

70380 ....... X-ray exam of salivary gland ......................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

70390 ....... X-ray exam of salivary duct ........................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

70450 ....... Ct head/brain w/o dye .................................... ........... S ....... 0332 3.1631 194.69 75.24 38.94 

70460 ....... Ct head/brain w/dye ....................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

70470 ....... Ct head/brain w/o&w/dye ............................... ........... S ....... 0333 5.0020 307.88 121.52 61.58 

70480 ....... Ct orbit/ear/fossa w/o dye .............................. ........... S ....... 0332 3.1631 194.69 75.24 38.94 

70481 ....... Ct orbit/ear/fossa w/dye ................................. ........... S ....... 0283 4.1858 257.64 102.17 51.53 

70482 ....... Ct orbit/ear/fossa w/o&w/dye ......................... ........... S ....... 0333 5.0020 307.88 121.52 61.58 

70486 ....... Ct maxillofacial w/o dye ................................. ........... S ....... 0332 3.1631 194.69 75.24 38.94 

70487 ....... Ct maxillofacial w/dye .................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

70488 ....... Ct maxillofacial w/o&w/dye ............................ ........... S ....... 0333 5.0020 307.88 121.52 61.58 

70490 ....... Ct soft tissue neck w/o dye ............................ ........... S ....... 0332 3.1631 194.69 75.24 38.94 

70491 ....... Ct soft tissue neck w/dye ............................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

70492 ....... Ct sft tsue nck w/o&w/dye ............................. ........... S ....... 0333 5.0020 307.88 121.52 61.58 

70496 ....... Ct angiography, head ..................................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

70498 ....... Ct angiography, neck ..................................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

70540 ....... Mri orbit/face/neck w/o dye ............................ ........... S ....... 0336 5.8500 360.07 139.68 72.01 

70542 ....... Mri orbit/face/neck w/dye ............................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

70543 ....... Mri orbt/fac/nck w/o&w/dye ............................ ........... S ....... 0337 8.3423 513.48 202.50 102.70 

70544 ....... Mr angiography head w/o dye ....................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

70545 ....... Mr angiography head w/dye .......................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

70546 ....... Mr angiograph head w/o&w/dye .................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

70547 ....... Mr angiography neck w/o dye ........................ ........... S ....... 0336 5.8500 360.07 139.68 72.01 

70548 ....... Mr angiography neck w/dye ........................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

70549 ....... Mr angiograph neck w/o&w/dye ..................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

70551 ....... Mri brain w/o dye ........................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

70552 ....... Mri brain w/dye ............................................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

70553 ....... Mri brain w/o&w/dye ....................................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

70557 ....... Mri brain w/o dye ........................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

70558 ....... Mri brain w/dye ............................................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

70559 ....... Mri brain w/o&w/dye ....................................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

71010 ....... Chest x-ray ..................................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71015 ....... Chest x-ray ..................................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71020 ....... Chest x-ray ..................................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71021 ....... Chest x-ray ..................................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71022 ....... Chest x-ray ..................................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71023 ....... Chest x-ray and fluoroscopy .......................... ........... X ....... 0272 1.2985 79.92 31.64 15.98 

71030 ....... Chest x-ray ..................................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71034 ....... Chest x-ray and fluoroscopy .......................... ........... X ....... 0272 1.2985 79.92 31.64 15.98 

71035 ....... Chest x-ray ..................................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71040 ....... Contrast x-ray of bronchi ............................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

71060 ....... Contrast x-ray of bronchi ............................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

71090 ....... X-ray&pacemaker insertion ............................ ........... X ....... 0272 1.2985 79.92 31.64 15.98 

71100 ....... X-ray exam of ribs .......................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71101 ....... X-ray exam of ribs/chest ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71110 ....... X-ray exam of ribs .......................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71111 ....... X-ray exam of ribs/chest ................................ ........... X ....... 0261 1.2515 77.03 .................... 15.41 

71120 ....... X-ray exam of breastbone ............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71130 ....... X-ray exam of breastbone ............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

71250 ....... Ct thorax w/o dye ........................................... ........... S ....... 0332 3.1631 194.69 75.24 38.94 

71260 ....... Ct thorax w/dye .............................................. ........... S ....... 0283 4.1858 257.64 102.17 51.53 

71270 ....... Ct thorax w/o&w/dye ...................................... ........... S ....... 0333 5.0020 307.88 121.52 61.58 

71275 ....... Ct angiography, chest .................................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

71550 ....... Mri chest w/o dye ........................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

71551 ....... Mri chest w/dye .............................................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 


sroberts on PROD1PC70 with PROPOSALS
49812 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

71552 ....... Mri chest w/o&w/dye ...................................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

72010 ....... X-ray exam of spine ....................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72020 ....... X-ray exam of spine ....................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72040 ....... X-ray exam of neck spine .............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96

72050 ....... X-ray exam of neck spine .............................. ........... X ....... 0261 1.2515 77.03 .................... 15.41 

72052 ....... X-ray exam of neck spine .............................. ........... X ....... 0261 1.2515 77.03 .................... 15.41 

72069 ....... X-ray exam of trunk spine .............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72070 ....... X-ray exam of thoracic spine ......................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72072 ....... X-ray exam of thoracic spine ......................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72074 ....... X-ray exam of thoracic spine ......................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72080 ....... X-ray exam of trunk spine .............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72090 ....... X-ray exam of trunk spine .............................. ........... X ....... 0261 1.2515 77.03 .................... 15.41 

72100 ....... X-ray exam of lower spine ............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96

72110 ....... X-ray exam of lower spine ............................. ........... X ....... 0261 1.2515 77.03 .................... 15.41 

72114 ....... X-ray exam of lower spine ............................. ........... X ....... 0261 1.2515 77.03 .................... 15.41 

72120 ....... X-ray exam of lower spine ............................. ........... X ....... 0261 1.2515 77.03 .................... 15.41 

72125 ....... Ct neck spine w/o dye ................................... ........... S ....... 0332 3.1631 194.69 75.24 38.94 

72126 ....... Ct neck spine w/dye ....................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

72127 ....... Ct neck spine w/o&w/dye ............................... ........... S ....... 0333 5.0020 307.88 121.52 61.58 

72128 ....... Ct chest spine w/o dye .................................. ........... S ....... 0332 3.1631 194.69 75.24 38.94 

72129 ....... Ct chest spine w/dye ...................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

72130 ....... Ct chest spine w/o&w/dye .............................. ........... S ....... 0333 5.0020 307.88 121.52 61.58 

72131 ....... Ct lumbar spine w/o dye ................................ ........... S ....... 0332 3.1631 194.69 75.24 38.94 

72132 ....... Ct lumbar spine w/dye ................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

72133 ....... Ct lumbar spine w/o&w/dye ........................... ........... S ....... 0333 5.0020 307.88 121.52 61.58 

72141 ....... Mri neck spine w/o dye .................................. ........... S ....... 0336 5.8500 360.07 139.68 72.01 

72142 ....... Mri neck spine w/dye ..................................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

72146 ....... Mri chest spine w/o dye ................................. ........... S ....... 0336 5.8500 360.07 139.68 72.01 

72147 ....... Mri chest spine w/dye .................................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

72148 ....... Mri lumbar spine w/o dye ............................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

72149 ....... Mri lumbar spine w/dye .................................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 

72156 ....... Mri neck spine w/o&w/dye ............................. ........... S ....... 0337 8.3423 513.48 202.50 102.70 

72157 ....... Mri chest spine w/o&w/dye ............................ ........... S ....... 0337 8.3423 513.48 202.50 102.70 

72158 ....... Mri lumbar spine w/o&w/dye .......................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

72170 ....... X-ray exam of pelvis ...................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72190 ....... X-ray exam of pelvis ...................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72191 ....... Ct angiograph pelv w/o&w/dye ...................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

72192 ....... Ct pelvis w/o dye ............................................ ........... S ....... 0332 3.1631 194.69 75.24 38.94 

72193 ....... Ct pelvis w/dye ............................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

72194 ....... Ct pelvis w/o&w/dye ....................................... ........... S ....... 0333 5.0020 307.88 121.52 61.58 

72195 ....... Mri pelvis w/o dye .......................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

72196 ....... Mri pelvis w/dye ............................................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 

72197 ....... Mri pelvis w/o&w/dye ..................................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

72200 ....... X-ray exam sacroiliac joints ........................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72202 ....... X-ray exam sacroiliac joints ........................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72220 ....... X-ray exam of tailbone ................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

72240 ....... Contrast x-ray of neck spine .......................... ........... S ....... 0274 2.6182 161.15 64.46 32.23 

72255 ....... Contrast x-ray, thorax spine ........................... ........... S ....... 0274 2.6182 161.15 64.46 32.23 

72265 ....... Contrast x-ray, lower spine ............................ ........... S ....... 0274 2.6182 161.15 64.46 32.23 

72270 ....... Contrast x-ray, spine ...................................... ........... S ....... 0274 2.6182 161.15 64.46 32.23 

72275 ....... Epidurography ................................................ ........... S ....... 0274 2.6182 161.15 64.46 32.23 

72285 ....... X-ray c/t spine disk ........................................ ........... S ....... 0388 14.2706 878.37 289.72 175.67 

72295 ....... X-ray of lower spine disk ............................... ........... S ....... 0388 14.2706 878.37 289.72 175.67 

73000 ....... X-ray exam of collar bone .............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73010 ....... X-ray exam of shoulder blade ........................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73020 ....... X-ray exam of shoulder .................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73030 ....... X-ray exam of shoulder .................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73040 ....... Contrast x-ray of shoulder ............................. ........... S ....... 0275 3.7021 227.87 69.09 45.57 

73050 ....... X-ray exam of shoulders ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73060 ....... X-ray exam of humerus ................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96

73070 ....... X-ray exam of elbow ...................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73080 ....... X-ray exam of elbow ...................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73085 ....... Contrast x-ray of elbow .................................. ........... S ....... 0275 3.7021 227.87 69.09 45.57 

73090 ....... X-ray exam of forearm ................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73092 ....... X-ray exam of arm, infant .............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73100 ....... X-ray exam of wrist ........................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73110 ....... X-ray exam of wrist ........................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73115 ....... Contrast x-ray of wrist .................................... ........... S ....... 0275 3.7021 227.87 69.09 45.57 

73120 ....... X-ray exam of hand ....................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73130 ....... X-ray exam of hand ....................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49813 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

73140 ....... X-ray exam of finger(s) .................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73200 ....... Ct upper extremity w/o dye ............................ ........... S ....... 0332 3.1631 194.69 75.24 38.94 

73201 ....... Ct upper extremity w/dye ............................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

73202 ....... Ct uppr extremity w/o&w/dye ......................... ........... S ....... 0333 5.0020 307.88 121.52 61.58 

73206 ....... Ct angio upr extrm w/o&w/dye ....................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

73218 ....... Mri upper extremity w/o dye .......................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

73219 ....... Mri upper extremity w/dye .............................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 

73220 ....... Mri uppr extremity w/o&w/dye ........................ ........... S ....... 0337 8.3423 513.48 202.50 102.70 

73221 ....... Mri joint upr extrem w/o dye .......................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

73222 ....... Mri joint upr extrem w/dye ............................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 

73223 ....... Mri joint upr extr w/o&w/dye .......................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

73500 ....... X-ray exam of hip ........................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73510 ....... X-ray exam of hip ........................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73520 ....... X-ray exam of hips ......................................... ........... X ....... 0261 1.2515 77.03 .................... 15.41 

73525 ....... Contrast x-ray of hip ...................................... ........... S ....... 0275 3.7021 227.87 69.09 45.57 

73530 ....... X-ray exam of hip ........................................... ........... X ....... 0261 1.2515 77.03 .................... 15.41 

73540 ....... X-ray exam of pelvis&hips ............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96

73542 ....... X-ray exam, sacroiliac joint ............................ ........... S ....... 0275 3.7021 227.87 69.09 45.57 

73550 ....... X-ray exam of thigh ........................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73560 ....... X-ray exam of knee, 1 or 2 ............................ ........... X ....... 0260 0.7276 44.78 .................... 8.96

73562 ....... X-ray exam of knee, 3 ................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73564 ....... X-ray exam, knee, 4 or more ......................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73565 ....... X-ray exam of knees ...................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73580 ....... Contrast x-ray of knee joint ............................ ........... S ....... 0275 3.7021 227.87 69.09 45.57 

73590 ....... X-ray exam of lower leg ................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73592 ....... X-ray exam of leg, infant ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73600 ....... X-ray exam of ankle ....................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73610 ....... X-ray exam of ankle ....................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73615 ....... Contrast x-ray of ankle ................................... ........... S ....... 0275 3.7021 227.87 69.09 45.57 

73620 ....... X-ray exam of foot ......................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73630 ....... X-ray exam of foot ......................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73650 ....... X-ray exam of heel ......................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73660 ....... X-ray exam of toe(s) ...................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

73700 ....... Ct lower extremity w/o dye ............................ ........... S ....... 0332 3.1631 194.69 75.24 38.94 

73701 ....... Ct lower extremity w/dye ................................ ........... S ....... 0283 4.1858 257.64 102.17 51.53 

73702 ....... Ct lwr extremity w/o&w/dye ............................ ........... S ....... 0333 5.0020 307.88 121.52 61.58 

73706 ....... Ct angio lwr extr w/o&w/dye .......................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

73718 ....... Mri lower extremity w/o dye ........................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

73719 ....... Mri lower extremity w/dye .............................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 

73720 ....... Mri lwr extremity w/o&w/dye .......................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

73721 ....... Mri jnt of lwr extre w/o dye ............................ ........... S ....... 0336 5.8500 360.07 139.68 72.01 

73722 ....... Mri joint of lwr extr w/dye ............................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

73723 ....... Mri joint lwr extr w/o&w/dye ........................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

74000 ....... X-ray exam of abdomen ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

74010 ....... X-ray exam of abdomen ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

74020 ....... X-ray exam of abdomen ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

74022 ....... X-ray exam series, abdomen ......................... ........... X ....... 0261 1.2515 77.03 .................... 15.41 

74150 ....... Ct abdomen w/o dye ...................................... ........... S ....... 0332 3.1631 194.69 75.24 38.94 

74160 ....... Ct abdomen w/dye ......................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

74170 ....... Ct abdomen w/o&w/dye ................................. ........... S ....... 0333 5.0020 307.88 121.52 61.58 

74175 ....... Ct angio abdom w/o&w/dye ........................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

74181 ....... Mri abdomen w/o dye .................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

74182 ....... Mri abdomen w/dye ........................................ ........... S ....... 0284 6.2589 385.24 148.40 77.05 

74183 ....... Mri abdomen w/o&w/dye ................................ ........... S ....... 0337 8.3423 513.48 202.50 102.70 

74190 ....... X-ray exam of peritoneum ............................. ........... X ....... 0264 2.9791 183.37 70.84 36.67 

74210 ....... Contrst x-ray exam of throat .......................... ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74220 ....... Contrast x-ray, esophagus ............................. ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74230 ....... Cine/vid x-ray, throat/esoph ........................... ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74235 ....... Remove esophagus obstruction .................... CH .... S ....... 0257 0.9770 60.14 .................... 12.03 

74240 ....... X-ray exam, upper gi tract ............................. ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74241 ....... X-ray exam, upper gi tract ............................. ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74245 ....... X-ray exam, upper gi tract ............................. ........... S ....... 0277 2.2764 140.11 54.63 28.02 

74246 ....... Contrst x-ray uppr gi tract .............................. ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74247 ....... Contrst x-ray uppr gi tract .............................. ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74249 ....... Contrst x-ray uppr gi tract .............................. ........... S ....... 0277 2.2764 140.11 54.63 28.02 

74250 ....... X-ray exam of small bowel ............................ ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74251 ....... X-ray exam of small bowel ............................ ........... S ....... 0277 2.2764 140.11 54.63 28.02 

74260 ....... X-ray exam of small bowel ............................ CH .... S ....... 0276 1.4519 89.37 34.97 17.87 

74270 ....... Contrast x-ray exam of colon ......................... ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74280 ....... Contrast x-ray exam of colon ......................... ........... S ....... 0277 2.2764 140.11 54.63 28.02 


sroberts on PROD1PC70 with PROPOSALS
49814 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

74283 ....... Contrast x-ray exam of colon ......................... ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74290 ....... Contrast x-ray, gallbladder ............................. ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74291 ....... Contrast x-rays, gallbladder ........................... ........... S ....... 0276 1.4519 89.37 34.97 17.87 

74300 ....... X-ray bile ducts/pancreas .............................. ........... X ....... 0263 1.7120 105.38 23.77 21.08 

74301 ....... X-rays at surgery add-on ............................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

74305 ....... X-ray bile ducts/pancreas .............................. ........... X ....... 0263 1.7120 105.38 23.77 21.08 

74320 ....... Contrast x-ray of bile ducts ............................ ........... X ....... 0264 2.9791 183.37 70.84 36.67 

74327 ....... X-ray bile stone removal ................................ ........... S ....... 0296 2.7106 166.84 53.99 33.37 

74328 ....... X-ray bile duct endoscopy ............................. ........... N ....... .......... .................... .................... .................... ....................

74329 ....... X-ray for pancreas endoscopy ....................... ........... N ....... .......... .................... .................... .................... ....................

74330 ....... X-ray bile/panc endoscopy ............................. ........... N ....... .......... .................... .................... .................... ....................

74340 ....... X-ray guide for GI tube .................................. ........... X ....... 0272 1.2985 79.92 31.64 15.98 

74350 ....... X-ray guide, stomach tube ............................. ........... X ....... 0263 1.7120 105.38 23.77 21.08 

74355 ....... X-ray guide, intestinal tube ............................ ........... X ....... 0263 1.7120 105.38 23.77 21.08 

74360 ....... X-ray guide, GI dilation .................................. CH .... S ....... 0257 0.9770 60.14 .................... 12.03

74363 ....... X-ray, bile duct dilation .................................. ........... S ....... 0297 3.6483 224.56 89.82 44.91 

74400 ....... Contrst x-ray, urinary tract ............................. ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74410 ....... Contrst x-ray, urinary tract ............................. ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74415 ....... Contrst x-ray, urinary tract ............................. ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74420 ....... Contrst x-ray, urinary tract ............................. ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74425 ....... Contrst x-ray, urinary tract ............................. ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74430 ....... Contrast x-ray, bladder .................................. ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74440 ....... X-ray, male genital tract ................................. ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74445 ....... X-ray exam of penis ....................................... ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74450 ....... X-ray, urethra/bladder .................................... ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74455 ....... X-ray, urethra/bladder .................................... ........... S ....... 0278 2.4721 152.16 60.84 30.43 

74470 ....... X-ray exam of kidney lesion .......................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

74475 ....... X-ray control, cath insert ................................ ........... S ....... 0297 3.6483 224.56 89.82 44.91 

74480 ....... X-ray control, cath insert ................................ ........... S ....... 0296 2.7106 166.84 53.99 33.37 

74485 ....... X-ray guide, GU dilation ................................. ........... S ....... 0296 2.7106 166.84 53.99 33.37 

74710 ....... X-ray measurement of pelvis ......................... ........... X ....... 0261 1.2515 77.03 .................... 15.41 

74740 ....... X-ray, female genital tract .............................. ........... X ....... 0264 2.9791 183.37 70.84 36.67 

74742 ....... X-ray, fallopian tube ....................................... ........... X ....... 0264 2.9791 183.37 70.84 36.67 

74775 ....... X-ray exam of perineum ................................ ........... S ....... 0278 2.4721 152.16 60.84 30.43 

75552 ....... Heart mri for morph w/o dye .......................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

75553 ....... Heart mri for morph w/dye ............................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 

75554 ....... Cardiac MRI/function ...................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

75555 ....... Cardiac MRI/limited study .............................. ........... S ....... 0336 5.8500 360.07 139.68 72.01 

75600 ....... Contrast x-ray exam of aorta ......................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75605 ....... Contrast x-ray exam of aorta ......................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75625 ....... Contrast x-ray exam of aorta ......................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75630 ....... X-ray aorta, leg arteries ................................. ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75635 ....... Ct angio abdominal arteries ........................... ........... S ....... 0662 4.9203 302.85 118.88 60.57 

75650 ....... Artery x-rays, head&neck ............................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75658 ....... Artery x-rays, arm .......................................... ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75660 ....... Artery x-rays, head&neck ............................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75662 ....... Artery x-rays, head&neck ............................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75665 ....... Artery x-rays, head&neck ............................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75671 ....... Artery x-rays, head&neck ............................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75676 ....... Artery x-rays, neck ......................................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75680 ....... Artery x-rays, neck ......................................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75685 ....... Artery x-rays, spine ........................................ ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75705 ....... Artery x-rays, spine ........................................ ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75710 ....... Artery x-rays, arm/leg ..................................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75716 ....... Artery x-rays, arms/legs ................................. ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75722 ....... Artery x-rays, kidney ...................................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75724 ....... Artery x-rays, kidneys .................................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75726 ....... Artery x-rays, abdomen .................................. ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75731 ....... Artery x-rays, adrenal gland ........................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75733 ....... Artery x-rays, adrenals ................................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75736 ....... Artery x-rays, pelvis ....................................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75741 ....... Artery x-rays, lung .......................................... ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75743 ....... Artery x-rays, lungs ........................................ ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75746 ....... Artery x-rays, lung .......................................... ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75756 ....... Artery x-rays, chest ........................................ ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75774 ....... Artery x-ray, each vessel ............................... ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75790 ....... Visualize A-V shunt ........................................ ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75801 ....... Lymph vessel x-ray, arm/leg .......................... ........... X ....... 0264 2.9791 183.37 70.84 36.67 

75803 ....... Lymph vessel x-ray,arms/legs ....................... ........... X ....... 0264 2.9791 183.37 70.84 36.67 

75805 ....... Lymph vessel x-ray, trunk .............................. ........... X ....... 0264 2.9791 183.37 70.84 36.67 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49815 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

75807 ....... Lymph vessel x-ray, trunk .............................. ........... X ....... 0264 2.9791 183.37 70.84 36.67 

75809 ....... Nonvascular shunt, x-ray ............................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

75810 ....... Vein x-ray, spleen/liver ................................... ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75820 ....... Vein x-ray, arm/leg ......................................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75822 ....... Vein x-ray, arms/legs ..................................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75825 ....... Vein x-ray, trunk ............................................. ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75827 ....... Vein x-ray, chest ............................................ ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75831 ....... Vein x-ray, kidney .......................................... ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75833 ....... Vein x-ray, kidneys ......................................... ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75840 ....... Vein x-ray, adrenal gland ............................... ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75842 ....... Vein x-ray, adrenal glands ............................. ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75860 ....... Vein x-ray, neck ............................................. ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75870 ....... Vein x-ray, skull .............................................. ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75872 ....... Vein x-ray, skull .............................................. ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75880 ....... Vein x-ray, eye socket ................................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75885 ....... Vein x-ray, liver .............................................. ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75887 ....... Vein x-ray, liver .............................................. ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75889 ....... Vein x-ray, liver .............................................. ........... S ....... 0280 20.9479 1,289.36 353.85 257.87 

75891 ....... Vein x-ray, liver .............................................. ........... S ....... 0279 9.6539 594.21 150.03 118.84 

75893 ....... Venous sampling by catheter ........................ CH .... Q ....... 0668 6.3684 391.98 88.26 78.40 

75894 ....... X-rays, transcath therapy ............................... CH .... S ....... 0298 8.4904 522.59 209.02 104.52 

75896 ....... X-rays, transcath therapy ............................... CH .... S ....... 0298 8.4904 522.59 209.02 104.52 

75898 ....... Follow-up angiography ................................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

75901 ....... Remove cva device obstruct .......................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

75902 ....... Remove cva lumen obstruct .......................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

75940 ....... X-ray placement, vein filter ............................ CH .... S ....... 0298 8.4904 522.59 209.02 104.52 

75945 ....... Intravascular us .............................................. ........... S ....... 0267 2.5166 154.90 60.80 30.98 

75946 ....... Intravascular us add-on ................................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

75960 ....... Transcath iv stent rs&i ................................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75961 ....... Retrieval, broken catheter .............................. ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75962 ....... Repair arterial blockage ................................. ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75964 ....... Repair artery blockage, each ......................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75966 ....... Repair arterial blockage ................................. ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75968 ....... Repair artery blockage, each ......................... ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75970 ....... Vascular biopsy .............................................. ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75978 ....... Repair venous blockage ................................ ........... S ....... 0668 6.3684 391.98 88.26 78.40 

75980 ....... Contrast xray exam bile duct ......................... ........... S ....... 0297 3.6483 224.56 89.82 44.91 

75982 ....... Contrast xray exam bile duct ......................... ........... S ....... 0297 3.6483 224.56 89.82 44.91 

75984 ....... Xray control catheter change ......................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

75989 ....... Abscess drainage under x-ray ....................... ........... N ....... .......... .................... .................... .................... ....................

75992 ....... Atherectomy, x-ray exam ............................... CH .... S ....... 0668 6.3684 391.98 88.26 78.40 

75993 ....... Atherectomy, x-ray exam ............................... CH .... S ....... 0668 6.3684 391.98 88.26 78.40 

75994 ....... Atherectomy, x-ray exam ............................... CH .... S ....... 0668 6.3684 391.98 88.26 78.40 

75995 ....... Atherectomy, x-ray exam ............................... CH .... S ....... 0668 6.3684 391.98 88.26 78.40 

75996 ....... Atherectomy, x-ray exam ............................... CH .... S ....... 0668 6.3684 391.98 88.26 78.40 

75998 ....... Fluoroguide for vein device ............................ ........... N ....... .......... .................... .................... .................... ....................

76000 ....... Fluoroscope examination ............................... ........... X ....... 0272 1.2985 79.92 31.64 15.98 

76001 ....... Fluoroscope exam, extensive ........................ ........... N ....... .......... .................... .................... .................... ....................

76003 ....... Needle localization by x-ray ........................... ........... N ....... .......... .................... .................... .................... ....................

76005 ....... Fluoroguide for spine inject ............................ ........... N ....... .......... .................... .................... .................... ....................

76006 ....... X-ray stress view ............................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76010 ....... X-ray, nose to rectum .................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76012 ....... Percut vertebroplasty fluor ............................. ........... S ....... 0274 2.6182 161.15 64.46 32.23 

76013 ....... Percut vertebroplasty, ct ................................ ........... S ....... 0274 2.6182 161.15 64.46 32.23 

76020 ....... X-rays for bone age ....................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76040 ....... X-rays, bone evaluation ................................. CH .... X ....... 0260 0.7276 44.78 .................... 8.96 

76061 ....... X-rays, bone survey ....................................... ........... X ....... 0261 1.2515 77.03 .................... 15.41 

76062 ....... X-rays, bone survey ....................................... ........... X ....... 0261 1.2515 77.03 .................... 15.41 

76065 ....... X-rays, bone evaluation ................................. CH .... X ....... 0260 0.7276 44.78 .................... 8.96 

76066 ....... Joint survey, single view ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76070 ....... Ct bone density, axial .................................... ........... S ....... 0288 1.2005 73.89 .................... 14.78 

76071 ....... Ct bone density, peripheral ............................ ........... S ....... 0282 1.5552 95.72 37.92 19.14 

76075 ....... Dxa bone density, axial .................................. ........... S ....... 0288 1.2005 73.89 .................... 14.78 

76076 ....... Dxa bone density/peripheral .......................... ........... S ....... 0665 0.5569 34.28 .................... 6.86 

76077 ....... Dxa bone density/v-fracture ........................... ........... X ....... 0260 0.7276 44.78 .................... 8.96

76078 ....... Radiographic absorptiometry ......................... CH .... X ....... 0261 1.2515 77.03 .................... 15.41 

76080 ....... X-ray exam of fistula ...................................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

76086 ....... X-ray of mammary duct ................................. ........... X ....... 0263 1.7120 105.38 23.77 21.08 

76088 ....... X-ray of mammary ducts ................................ ........... X ....... 0263 1.7120 105.38 23.77 21.08 

76095 ....... Stereotactic breast biopsy .............................. ........... X ....... 0264 2.9791 183.37 70.84 36.67 


sroberts on PROD1PC70 with PROPOSALS
49816 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

76096 ....... X-ray of needle wire, breast ........................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

76098 ....... X-ray exam, breast specimen ........................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76100 ....... X-ray exam of body section ........................... ........... X ....... 0261 1.2515 77.03 .................... 15.41

76101 ....... Complex body section x-ray .......................... ........... X ....... 0263 1.7120 105.38 23.77 21.08 

76102 ....... Complex body section x-rays ......................... ........... X ....... 0264 2.9791 183.37 70.84 36.67 

76120 ....... Cine/video x-rays ........................................... ........... X ....... 0272 1.2985 79.92 31.64 15.98 

76125 ....... Cine/video x-rays add-on ............................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76150 ....... X-ray exam, dry process ................................ ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76350 ....... Special x-ray contrast study ........................... ........... N ....... .......... .................... .................... .................... ....................

76355 ....... Ct scan for localization ................................... ........... S ....... 0283 4.1858 257.64 102.17 51.53 

76360 ....... Ct scan for needle biopsy .............................. ........... S ....... 0283 4.1858 257.64 102.17 51.53 

76362 ....... Ct guide for tissue ablation ............................ ........... S ....... 0333 5.0020 307.88 121.52 61.58 

76370 ....... Ct scan for therapy guide .............................. ........... S ....... 0282 1.5552 95.72 37.92 19.14 

76376 ....... 3d render w/o postprocess ............................ ........... X ....... 0340 0.6211 38.23 .................... 7.65 

76377 ....... 3d rendering w/postprocess ........................... ........... S ....... 0282 1.5552 95.72 37.92 19.14 

76380 ....... CAT scan follow-up study .............................. ........... S ....... 0282 1.5552 95.72 37.92 19.14 

76393 ....... Mr guidance for needle place ........................ ........... S ....... 0335 4.6629 287.01 114.80 57.40 

76394 ....... Mri for tissue ablation ..................................... ........... S ....... 0335 4.6629 287.01 114.80 57.40 

76400 ....... Magnetic image, bone marrow ...................... ........... S ....... 0335 4.6629 287.01 114.80 57.40 

76496 ....... Fluoroscopic procedure .................................. ........... X ....... 0272 1.2985 79.92 31.64 15.98 

76497 ....... Ct procedure .................................................. ........... S ....... 0282 1.5552 95.72 37.92 19.14 

76498 ....... Mri procedure ................................................. ........... S ....... 0335 4.6629 287.01 114.80 57.40 

76499 ....... Radiographic procedure ................................. ........... X ....... 0260 0.7276 44.78 .................... 8.96 

76506 ....... Echo exam of head ........................................ ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76510 ....... Ophth us, b&quant a ...................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76511 ....... Ophth us, quant a only .................................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76512 ....... Ophth us, b w/non-quant a ............................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76513 ....... Echo exam of eye, water bath ....................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76514 ....... Echo exam of eye, thickness ......................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

76516 ....... Echo exam of eye .......................................... ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76519 ....... Echo exam of eye .......................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76529 ....... Echo exam of eye .......................................... ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76536 ....... Us exam of head and neck ............................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76604 ....... Us exam, chest, b-scan ................................. CH .... S ....... 0265 1.0145 62.44 23.63 12.49 

76645 ....... Us exam, breast(s) ......................................... ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76700 ....... Us exam, abdom, complete ........................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76705 ....... Echo exam of abdomen ................................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76770 ....... Us exam abdo back wall, comp ..................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76775 ....... Us exam abdo back wall, lim ......................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76778 ....... Us exam kidney transplant ............................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76800 ....... Us exam, spinal canal .................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76801 ....... Ob us < 14 wks, single fetus ......................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76802 ....... Ob us < 14 wks, add’l fetus ........................... ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76805 ....... Ob us >/= 14 wks, sngl fetus ......................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76810 ....... Ob us >/= 14 wks, addl fetus ......................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76811 ....... Ob us, detailed, sngl fetus ............................. ........... S ....... 0267 2.5166 154.90 60.80 30.98 

76812 ....... Ob us, detailed, addl fetus ............................. CH .... S ....... 0265 1.0145 62.44 23.63 12.49 

76815 ....... Ob us, limited, fetus(s) ................................... ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76816 ....... Ob us, follow-up, per fetus ............................. ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76817 ....... Transvaginal us, obstetric .............................. CH .... S ....... 0265 1.0145 62.44 23.63 12.49 

76818 ....... Fetal biophys profile w/nst ............................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76819 ....... Fetal biophys profil w/o nst ............................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76820 ....... Umbilical artery echo ..................................... ........... S ....... 0096 1.5727 96.80 38.13 19.36 

76821 ....... Middle cerebral artery echo ........................... ........... S ....... 0096 1.5727 96.80 38.13 19.36 

76825 ....... Echo exam of fetal heart ................................ CH .... S ....... 0697 1.6002 98.49 35.99 19.70 

76826 ....... Echo exam of fetal heart ................................ ........... S ....... 0697 1.6002 98.49 35.99 19.70 

76827 ....... Echo exam of fetal heart ................................ CH .... S ....... 0697 1.6002 98.49 35.99 19.70 

76828 ....... Echo exam of fetal heart ................................ ........... S ....... 0697 1.6002 98.49 35.99 19.70 

76830 ....... Transvaginal us, non-ob ................................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76831 ....... Echo exam, uterus ......................................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

76856 ....... Us exam, pelvic, complete ............................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76857 ....... Us exam, pelvic, limited ................................. ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76870 ....... Us exam, scrotum .......................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76872 ....... Us, transrectal ................................................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76873 ....... Echograp trans r, pros study ......................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76880 ....... Us exam, extremity ........................................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76885 ....... Us exam infant hips, dynamic ........................ ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76886 ....... Us exam infant hips, static ............................. CH .... S ....... 0265 1.0145 62.44 23.63 12.49 

76930 ....... Echo guide, cardiocentesis ............................ ........... S ....... 0268 1.1967 73.66 .................... 14.73 

76932 ....... Echo guide for heart biopsy ........................... CH .... S ....... 0309 2.1284 131.01 .................... 26.20 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49817 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

76936 ....... Echo guide for artery repair ........................... CH .... S ....... 0309 2.1284 131.01 .................... 26.20 

76937 ....... Us guide, vascular access ............................. ........... N ....... .......... .................... .................... .................... ....................

76940 ....... Us guide, tissue ablation ................................ ........... S ....... 0268 1.1967 73.66 .................... 14.73 

76941 ....... Echo guide for transfusion ............................. ........... S ....... 0268 1.1967 73.66 .................... 14.73 

76942 ....... Echo guide for biopsy .................................... ........... S ....... 0268 1.1967 73.66 .................... 14.73 

76945 ....... Echo guide, villus sampling ........................... ........... S ....... 0268 1.1967 73.66 .................... 14.73 

76946 ....... Echo guide for amniocentesis ........................ ........... S ....... 0268 1.1967 73.66 .................... 14.73 

76948 ....... Echo guide, ova aspiration ............................ CH .... S ....... 0309 2.1284 131.01 .................... 26.20 

76950 ....... Echo guidance radiotherapy .......................... ........... S ....... 0268 1.1967 73.66 .................... 14.73 

76965 ....... Echo guidance radiotherapy .......................... CH .... S ....... 0309 2.1284 131.01 .................... 26.20 

76970 ....... Ultrasound exam follow-up ............................ ........... S ....... 0265 1.0145 62.44 23.63 12.49 

76975 ....... GI endoscopic ultrasound .............................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76977 ....... Us bone density measure .............................. ........... X ....... 0340 0.6211 38.23 .................... 7.65 

76986 ....... Ultrasound guide intraoper ............................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

76999 ....... Echo examination procedure ......................... ........... S ....... 0265 1.0145 62.44 23.63 12.49 

77280 ....... Set radiation therapy field .............................. ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77285 ....... Set radiation therapy field .............................. ........... X ....... 0305 4.0232 247.63 91.38 49.53 

77290 ....... Set radiation therapy field .............................. ........... X ....... 0305 4.0232 247.63 91.38 49.53 

77295 ....... Set radiation therapy field .............................. ........... X ....... 0310 14.0578 865.27 325.27 173.05 

77299 ....... Radiation therapy planning ............................ ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77300 ....... Radiation therapy dose plan .......................... ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77301 ....... Radiotherapy dose plan, imrt ......................... ........... X ....... 0310 14.0578 865.27 325.27 173.05 

77305 ....... Teletx isodose plan simple ............................ ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77310 ....... Teletx isodose plan intermed ......................... ........... X ....... 0305 4.0232 247.63 91.38 49.53 

77315 ....... Teletx isodose plan complex ......................... ........... X ....... 0305 4.0232 247.63 91.38 49.53 

77321 ....... Special teletx port plan .................................. ........... X ....... 0305 4.0232 247.63 91.38 49.53 

77326 ....... Brachytx isodose calc simp ........................... ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77327 ....... Brachytx isodose calc interm ......................... ........... X ....... 0305 4.0232 247.63 91.38 49.53 

77328 ....... Brachytx isodose plan compl ......................... ........... X ....... 0305 4.0232 247.63 91.38 49.53 

77331 ....... Special radiation dosimetry ............................ ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77332 ....... Radiation treatment aid(s) .............................. ........... X ....... 0303 2.9637 182.42 66.95 36.48 

77333 ....... Radiation treatment aid(s) .............................. ........... X ....... 0303 2.9637 182.42 66.95 36.48 

77334 ....... Radiation treatment aid(s) .............................. ........... X ....... 0303 2.9637 182.42 66.95 36.48 

77336 ....... Radiation physics consult .............................. ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77370 ....... Radiation physics consult .............................. ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77399 ....... External radiation dosimetry .......................... ........... X ....... 0304 1.6062 98.86 39.54 19.77 

77401 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77402 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77403 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77404 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77406 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77407 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77408 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77409 ....... Radiation treatment delivery .......................... ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77411 ....... Radiation treatment delivery .......................... ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77412 ....... Radiation treatment delivery .......................... ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77413 ....... Radiation treatment delivery .......................... ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77414 ....... Radiation treatment delivery .......................... ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77416 ....... Radiation treatment delivery .......................... ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77417 ....... Radiology port film(s) ..................................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

77418 ....... Radiation tx delivery, imrt .............................. ........... S ....... 0412 5.5021 338.66 .................... 67.73 

77421 ....... Stereoscopic x-ray guidance .......................... CH .... S ....... 0257 0.9770 60.14 .................... 12.03 

77422 ....... Neutron beam tx, simple ................................ ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77423 ....... Neutron beam tx, complex ............................. ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77470 ....... Special radiation treatment ............................ ........... S ....... 0299 6.0322 371.29 .................... 74.26 

77520 ....... Proton trmt, simple w/o comp ........................ ........... S ....... 0664 18.4698 1,136.83 .................... 227.37 

77522 ....... Proton trmt, simple w/comp ........................... ........... S ....... 0664 18.4698 1,136.83 .................... 227.37 

77523 ....... Proton trmt, intermediate ............................... ........... S ....... 0667 22.0972 1,360.10 .................... 272.02 

77525 ....... Proton treatment, complex ............................. ........... S ....... 0667 22.0972 1,360.10 .................... 272.02 

77600 ....... Hyperthermia treatment ................................. ........... S ....... 0314 3.6583 225.17 66.65 45.03 

77605 ....... Hyperthermia treatment ................................. ........... S ....... 0314 3.6583 225.17 66.65 45.03 

77610 ....... Hyperthermia treatment ................................. ........... S ....... 0314 3.6583 225.17 66.65 45.03 

77615 ....... Hyperthermia treatment ................................. ........... S ....... 0314 3.6583 225.17 66.65 45.03 

77620 ....... Hyperthermia treatment ................................. ........... S ....... 0314 3.6583 225.17 66.65 45.03 

77750 ....... Infuse radioactive materials ........................... ........... S ....... 0301 2.2670 139.54 .................... 27.91 

77761 ....... Apply intrcav radiat simple ............................. ........... S ....... 0312 5.0185 308.89 .................... 61.78 

77762 ....... Apply intrcav radiat interm ............................. ........... S ....... 0312 5.0185 308.89 .................... 61.78 

77763 ....... Apply intrcav radiat compl .............................. ........... S ....... 0312 5.0185 308.89 .................... 61.78 

77776 ....... Apply interstit radiat simpl .............................. ........... S ....... 0312 5.0185 308.89 .................... 61.78 

77777 ....... Apply interstit radiat inter ............................... ........... S ....... 0312 5.0185 308.89 .................... 61.78 


sroberts on PROD1PC70 with PROPOSALS
49818 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

77778 ....... Apply interstit radiat compl ............................. ........... S ....... 0651 16.6585 1,025.35 .................... 205.07 

77781 ....... High intensity brachytherapy .......................... ........... S ....... 0313 13.3939 824.41 .................... 164.88 

77782 ....... High intensity brachytherapy .......................... ........... S ....... 0313 13.3939 824.41 .................... 164.88 

77783 ....... High intensity brachytherapy .......................... ........... S ....... 0313 13.3939 824.41 .................... 164.88 

77784 ....... High intensity brachytherapy .......................... ........... S ....... 0313 13.3939 824.41 .................... 164.88 

77789 ....... Apply surface radiation .................................. ........... S ....... 0300 1.5004 92.35 .................... 18.47 

77790 ....... Radiation handling ......................................... ........... N ....... .......... .................... .................... .................... ....................

77799 ....... Radium/radioisotope therapy ......................... CH .... S ....... 0312 5.0185 308.89 .................... 61.78 

78000 ....... Thyroid, single uptake .................................... ........... S ....... 0389 1.4072 86.61 33.98 17.32 

78001 ....... Thyroid, multiple uptakes ............................... ........... S ....... 0389 1.4072 86.61 33.98 17.32 

78003 ....... Thyroid suppress/stimul ................................. ........... S ....... 0392 2.0849 128.33 51.33 25.67 

78006 ....... Thyroid imaging with uptake .......................... ........... S ....... 0390 2.3732 146.07 58.42 29.21 

78007 ....... Thyroid image, mult uptakes .......................... ........... S ....... 0391 2.7556 169.61 66.18 33.92 

78010 ....... Thyroid imaging .............................................. ........... S ....... 0390 2.3732 146.07 58.42 29.21 

78011 ....... Thyroid imaging with flow .............................. ........... S ....... 0390 2.3732 146.07 58.42 29.21 

78015 ....... Thyroid met imaging ...................................... ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78016 ....... Thyroid met imaging/studies .......................... ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78018 ....... Thyroid met imaging, body ............................ ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78020 ....... Thyroid met uptake ........................................ ........... S ....... 0399 1.5282 94.06 35.80 18.81 

78070 ....... Parathyroid nuclear imaging .......................... ........... S ....... 0391 2.7556 169.61 66.18 33.92 

78075 ....... Adrenal nuclear imaging ................................ ........... S ....... 0391 2.7556 169.61 66.18 33.92 

78099 ....... Endocrine nuclear procedure ......................... ........... S ....... 0390 2.3732 146.07 58.42 29.21 

78102 ....... Bone marrow imaging, ltd .............................. ........... S ....... 0400 3.9304 241.92 93.22 48.38 

78103 ....... Bone marrow imaging, mult ........................... ........... S ....... 0400 3.9304 241.92 93.22 48.38 

78104 ....... Bone marrow imaging, body .......................... ........... S ....... 0400 3.9304 241.92 93.22 48.38 

78110 ....... Plasma volume, single ................................... ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78111 ....... Plasma volume, multiple ................................ ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78120 ....... Red cell mass, single ..................................... ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78121 ....... Red cell mass, multiple .................................. ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78122 ....... Blood volume ................................................. ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78130 ....... Red cell survival study ................................... ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78135 ....... Red cell survival kinetics ................................ ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78140 ....... Red cell sequestration ................................... ........... S ....... 0393 3.5902 220.98 82.04 44.20 

78185 ....... Spleen imaging .............................................. ........... S ....... 0400 3.9304 241.92 93.22 48.38 

78190 ....... Platelet survival, kinetics ................................ ........... S ....... 0392 2.0849 128.33 51.33 25.67 

78191 ....... Platelet survival .............................................. ........... S ....... 0392 2.0849 128.33 51.33 25.67 

78195 ....... Lymph system imaging .................................. ........... S ....... 0400 3.9304 241.92 93.22 48.38 

78199 ....... Blood/lymph nuclear exam ............................. ........... S ....... 0400 3.9304 241.92 93.22 48.38 

78201 ....... Liver imaging .................................................. ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78202 ....... Liver imaging with flow ................................... ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78205 ....... Liver imaging (3D) .......................................... ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78206 ....... Liver image (3d) with flow .............................. ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78215 ....... Liver and spleen imaging ............................... ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78216 ....... Liver&spleen image/flow ................................ ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78220 ....... Liver function study ........................................ ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78223 ....... Hepatobiliary imaging ..................................... ........... S ....... 0394 4.4705 275.16 102.61 55.03 

78230 ....... Salivary gland imaging ................................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78231 ....... Serial salivary imaging ................................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78232 ....... Salivary gland function exam ......................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78258 ....... Esophageal motility study .............................. ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78261 ....... Gastric mucosa imaging ................................ ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78262 ....... Gastroesophageal reflux exam ...................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78264 ....... Gastric emptying study .................................. ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78270 ....... Vit B-12 absorption exam .............................. ........... S ....... 0392 2.0849 128.33 51.33 25.67 

78271 ....... Vit b-12 absrp exam, int fac ........................... ........... S ....... 0392 2.0849 128.33 51.33 25.67 

78272 ....... Vit B-12 absorp, combined ............................ ........... S ....... 0392 2.0849 128.33 51.33 25.67 

78278 ....... Acute GI blood loss imaging .......................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78282 ....... GI protein loss exam ...................................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78290 ....... Meckel’s divert exam ..................................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78291 ....... Leveen/shunt patency exam .......................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78299 ....... GI nuclear procedure ..................................... ........... S ....... 0395 3.6937 227.35 89.73 45.47 

78300 ....... Bone imaging, limited area ............................ ........... S ....... 0396 4.0166 247.23 95.02 49.45 

78305 ....... Bone imaging, multiple areas ........................ ........... S ....... 0396 4.0166 247.23 95.02 49.45 

78306 ....... Bone imaging, whole body ............................. ........... S ....... 0396 4.0166 247.23 95.02 49.45 

78315 ....... Bone imaging, 3 phase .................................. ........... S ....... 0396 4.0166 247.23 95.02 49.45 

78320 ....... Bone imaging (3D) ......................................... ........... S ....... 0396 4.0166 247.23 95.02 49.45 

78350 ....... Bone mineral, single photon .......................... ........... X ....... 0260 0.7276 44.78 .................... 8.96 

78399 ....... Musculoskeletal nuclear exam ....................... ........... S ....... 0396 4.0166 247.23 95.02 49.45 

78414 ....... Non-imaging heart function ............................ ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78428 ....... Cardiac shunt imaging ................................... ........... S ....... 0398 4.2511 261.66 100.06 52.33 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49819 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

78445 ....... Vascular flow imaging .................................... ........... S ....... 0397 2.2521 138.62 49.58 27.72 

78456 ....... Acute venous thrombus image ...................... ........... S ....... 0397 2.2521 138.62 49.58 27.72 

78457 ....... Venous thrombosis imaging ........................... ........... S ....... 0397 2.2521 138.62 49.58 27.72 

78458 ....... Ven thrombosis images, bilat ......................... ........... S ....... 0397 2.2521 138.62 49.58 27.72 

78459 ....... Heart muscle imaging (PET) .......................... CH .... S ....... 0307 11.6773 718.75 287.49 143.75 

78460 ....... Heart muscle blood, single ............................ ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78461 ....... Heart muscle blood, multiple ......................... ........... S ....... 0377 6.7443 415.12 158.84 83.02 

78464 ....... Heart image (3d), single ................................ ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78465 ....... Heart image (3d), multiple ............................. ........... S ....... 0377 6.7443 415.12 158.84 83.02 

78466 ....... Heart infarct image ......................................... ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78468 ....... Heart infarct image (ef) .................................. ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78469 ....... Heart infarct image (3D) ................................ ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78472 ....... Gated heart, planar, single ............................ ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78473 ....... Gated heart, multiple ...................................... ........... S ....... 0376 4.9770 306.34 119.77 61.27 

78478 ....... Heart wall motion add-on ............................... ........... S ....... 0399 1.5282 94.06 35.80 18.81 

78480 ....... Heart function add-on .................................... ........... S ....... 0399 1.5282 94.06 35.80 18.81 

78481 ....... Heart first pass, single ................................... ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78483 ....... Heart first pass, multiple ................................ ........... S ....... 0376 4.9770 306.34 119.77 61.27 

78491 ....... Heart image (pet), single ............................... CH .... S ....... 0307 11.6773 718.75 287.49 143.75 

78492 ....... Heart image (pet), multiple ............................ ........... S ....... 0307 11.6773 718.75 287.49 143.75 

78494 ....... Heart image, spect ......................................... ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78496 ....... Heart first pass add-on .................................. ........... S ....... 0399 1.5282 94.06 35.80 18.81 

78499 ....... Cardiovascular nuclear exam ........................ ........... S ....... 0398 4.2511 261.66 100.06 52.33 

78580 ....... Lung perfusion imaging .................................. ........... S ....... 0401 3.2013 197.04 78.81 39.41 

78584 ....... Lung V/Q image single breath ....................... ........... S ....... 0378 5.2084 320.58 128.23 64.12 

78585 ....... Lung V/Q imaging .......................................... ........... S ....... 0378 5.2084 320.58 128.23 64.12 

78586 ....... Aerosol lung image, single ............................. ........... S ....... 0401 3.2013 197.04 78.81 39.41 

78587 ....... Aerosol lung image, multiple .......................... ........... S ....... 0401 3.2013 197.04 78.81 39.41 

78588 ....... Perfusion lung image ..................................... ........... S ....... 0378 5.2084 320.58 128.23 64.12 

78591 ....... Vent image, 1 breath, 1 proj .......................... ........... S ....... 0401 3.2013 197.04 78.81 39.41 

78593 ....... Vent image, 1 proj, gas .................................. ........... S ....... 0401 3.2013 197.04 78.81 39.41 

78594 ....... Vent image, mult proj, gas ............................. ........... S ....... 0401 3.2013 197.04 78.81 39.41 

78596 ....... Lung differential function ................................ ........... S ....... 0378 5.2084 320.58 128.23 64.12 

78599 ....... Respiratory nuclear exam .............................. ........... S ....... 0401 3.2013 197.04 78.81 39.41 

78600 ....... Brain imaging, ltd static .................................. ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78601 ....... Brain imaging, ltd w/flow ................................ ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78605 ....... Brain imaging, complete ................................ ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78606 ....... Brain imaging, compl w/flow .......................... ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78607 ....... Brain imaging (3D) ......................................... ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78608 ....... Brain imaging (PET) ....................................... CH .... S ....... 0308 14.0093 862.29 .................... 172.46 

78610 ....... Brain flow imaging only .................................. ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78615 ....... Cerebral vascular flow image ........................ ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78630 ....... Cerebrospinal fluid scan ................................ ........... S ....... 0403 3.4867 214.61 83.35 42.92 

78635 ....... CSF ventriculography ..................................... ........... S ....... 0403 3.4867 214.61 83.35 42.92 

78645 ....... CSF shunt evaluation ..................................... ........... S ....... 0403 3.4867 214.61 83.35 42.92 

78647 ....... Cerebrospinal fluid scan ................................ ........... S ....... 0403 3.4867 214.61 83.35 42.92 

78650 ....... CSF leakage imaging ..................................... ........... S ....... 0403 3.4867 214.61 83.35 42.92 

78660 ....... Nuclear exam of tear flow .............................. ........... S ....... 0403 3.4867 214.61 83.35 42.92 

78699 ....... Nervous system nuclear exam ...................... ........... S ....... 0402 4.8596 299.11 119.64 59.82 

78700 ....... Kidney imaging, static .................................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78701 ....... Kidney imaging with flow ............................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78704 ....... Imaging renogram .......................................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78707 ....... Kidney flow/function image ............................ ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78708 ....... Kidney flow/function image ............................ ........... S ....... 0405 4.1056 252.70 98.77 50.54 

78709 ....... Kidney flow/function image ............................ ........... S ....... 0405 4.1056 252.70 98.77 50.54 

78710 ....... Kidney imaging (3D) ...................................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78715 ....... Renal vascular flow exam .............................. ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78725 ....... Kidney function study ..................................... ........... S ....... 0389 1.4072 86.61 33.98 17.32 

78730 ....... Urinary bladder retention ............................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

78740 ....... Ureteral reflux study ....................................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78760 ....... Testicular imaging .......................................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78761 ....... Testicular imaging/flow ................................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78799 ....... Genitourinary nuclear exam ........................... ........... S ....... 0404 3.4235 210.72 84.28 42.14 

78800 ....... Tumor imaging, limited area .......................... ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78801 ....... Tumor imaging, mult areas ............................ ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78802 ....... Tumor imaging, whole body ........................... ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78803 ....... Tumor imaging (3D) ....................................... ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78804 ....... Tumor imaging, whole body ........................... CH .... S ....... 0408 4.9998 307.74 .................... 61.55 

78805 ....... Abscess imaging, ltd area .............................. ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78806 ....... Abscess imaging, whole body ....................... CH .... S ....... 0408 4.9998 307.74 .................... 61.55 


sroberts on PROD1PC70 with PROPOSALS
49820 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

78807 ....... Nuclear localization/abscess .......................... ........... S ....... 0406 3.9386 242.42 96.96 48.48 

78811 ....... Tumor imaging (pet), limited .......................... CH .... S ....... 0308 14.0093 862.29 .................... 172.46 

78812 ....... Tumor image (pet)/skul-thigh ......................... CH .... S ....... 0308 14.0093 862.29 .................... 172.46 

78813 ....... Tumor image (pet) full body ........................... CH .... S ....... 0308 14.0093 862.29 .................... 172.46 

78814 ....... Tumor image pet/ct, limited ........................... CH .... S ....... 0308 14.0093 862.29 .................... 172.46 

78815 ....... Tumorimage pet/ct skul-thigh ......................... CH .... S ....... 0308 14.0093 862.29 .................... 172.46 

78816 ....... Tumor image pet/ct full body ......................... CH .... S ....... 0308 14.0093 862.29 .................... 172.46 

78890 ....... Nuclear medicine data proc ........................... ........... N ....... .......... .................... .................... .................... ....................

78891 ....... Nuclear med data proc .................................. ........... N ....... .......... .................... .................... .................... ....................

78999 ....... Nuclear diagnostic exam ................................ ........... S ....... 0389 1.4072 86.61 33.98 17.32 

79005 ....... Nuclear rx, oral admin .................................... ........... S ....... 0407 3.1506 193.92 77.56 38.78 

79101 ....... Nuclear rx, iv admin ....................................... ........... S ....... 0407 3.1506 193.92 77.56 38.78 

79200 ....... Nuclear rx, intracav admin ............................. CH .... S ....... 0413 5.1026 314.07 .................... 62.81 

79300 ....... Nuclr rx, interstit colloid .................................. ........... S ....... 0407 3.1506 193.92 77.56 38.78 

79403 ....... Hematopoietic nuclear tx ............................... CH .... S ....... 0413 5.1026 314.07 .................... 62.81 

79440 ....... Nuclear rx, intra-articular ................................ CH .... S ....... 0413 5.1026 314.07 .................... 62.81 

79445 ....... Nuclear rx, intra-arterial ................................. ........... S ....... 0407 3.1506 193.92 77.56 38.78 

79999 ....... Nuclear medicine therapy .............................. ........... S ....... 0407 3.1506 193.92 77.56 38.78 

80103 ....... Drug analysis, tissue prep ............................. ........... N ....... .......... .................... .................... .................... ....................

80500 ....... Lab pathology consultation ............................ ........... X ....... 0433 0.2571 15.82 5.93 3.16 

80502 ....... Lab pathology consultation ............................ ........... X ....... 0342 0.0813 5.00 2.00 1.00 

85097 ....... Bone marrow interpretation ............................ ........... X ....... 0343 0.5309 32.68 10.84 6.54 

85396 ....... Clotting assay, whole blood ........................... ........... N ....... .......... .................... .................... .................... ....................

86077 ....... Physician blood bank service ........................ ........... X ....... 0433 0.2571 15.82 5.93 3.16 

86078 ....... Physician blood bank service ........................ ........... X ....... 0343 0.5309 32.68 10.84 6.54 

86079 ....... Physician blood bank service ........................ ........... X ....... 0433 0.2571 15.82 5.93 3.16 

86485 ....... Skin test, candida ........................................... ........... X ....... 0341 0.0914 5.63 2.25 1.13 

86490 ....... Coccidioidomycosis skin test ......................... ........... X ....... 0341 0.0914 5.63 2.25 1.13 

86510 ....... Histoplasmosis skin test ................................. ........... X ....... 0341 0.0914 5.63 2.25 1.13 

86580 ....... TB intradermal test ......................................... ........... X ....... 0341 0.0914 5.63 2.25 1.13 

86850 ....... RBC antibody screen ..................................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86860 ....... RBC antibody elution ..................................... ........... X ....... 0346 0.3494 21.51 4.39 4.30 

86870 ....... RBC antibody identification ............................ ........... X ....... 0346 0.3494 21.51 4.39 4.30 

86880 ....... Coombs test, direct ........................................ ........... X ....... 0409 0.1237 7.61 2.20 1.52 

86885 ....... Coombs test, indirect, qual ............................ ........... X ....... 0409 0.1237 7.61 2.20 1.52 

86886 ....... Coombs test, indirect, titer ............................. ........... X ....... 0409 0.1237 7.61 2.20 1.52 

86890 ....... Autologous blood process .............................. ........... X ....... 0347 0.7394 45.51 11.24 9.10 

86891 ....... Autologous blood, op salvage ........................ ........... X ....... 0346 0.3494 21.51 4.39 4.30 

86900 ....... Blood typing, ABO .......................................... ........... X ....... 0409 0.1237 7.61 2.20 1.52 

86901 ....... Blood typing, Rh (D) ...................................... ........... X ....... 0409 0.1237 7.61 2.20 1.52 

86903 ....... Blood typing, antigen screen ......................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86904 ....... Blood typing, patient serum ........................... ........... X ....... 0346 0.3494 21.51 4.39 4.30 

86905 ....... Blood typing, RBC antigens ........................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86906 ....... Blood typing, Rh phenotype ........................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86920 ....... Compatibility test, spin ................................... ........... X ....... 0346 0.3494 21.51 4.39 4.30 

86921 ....... Compatibility test, incubate ............................ ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86922 ....... Compatibility test, antiglob ............................. ........... X ....... 0346 0.3494 21.51 4.39 4.30 

86923 ....... Compatibility test, electric .............................. ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86927 ....... Plasma, fresh frozen ...................................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86930 ....... Frozen blood prep .......................................... ........... X ....... 0347 0.7394 45.51 11.24 9.10 

86931 ....... Frozen blood thaw ......................................... ........... X ....... 0347 0.7394 45.51 11.24 9.10 

86932 ....... Frozen blood freeze/thaw .............................. ........... X ....... 0347 0.7394 45.51 11.24 9.10 

86945 ....... Blood product/irradiation ................................ ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86950 ....... Leukacyte transfusion .................................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86960 ....... Vol reduction of blood/prod ............................ ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86965 ....... Pooling blood platelets ................................... CH .... X ....... 0346 0.3494 21.51 4.39 4.30 

86970 ....... RBC pretreatment .......................................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86971 ....... RBC pretreatment .......................................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86972 ....... RBC pretreatment .......................................... ........... X ....... 0346 0.3494 21.51 4.39 4.30 

86975 ....... RBC pretreatment, serum .............................. CH .... X ....... 0346 0.3494 21.51 4.39 4.30 

86976 ....... RBC pretreatment, serum .............................. ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86977 ....... RBC pretreatment, serum .............................. CH .... X ....... 0346 0.3494 21.51 4.39 4.30 

86978 ....... RBC pretreatment, serum .............................. CH .... X ....... 0346 0.3494 21.51 4.39 4.30 

86985 ....... Split blood or products ................................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

86999 ....... Transfusion procedure ................................... ........... X ....... 0345 0.2218 13.65 2.87 2.73 

88104 ....... Cytopathology, fluids ...................................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88106 ....... Cytopathology, fluids ...................................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88107 ....... Cytopathology, fluids ...................................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88108 ....... Cytopath, concentrate tech ............................ ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88112 ....... Cytopath, cell enhance tech .......................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49821 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

88125 ....... Forensic cytopathology .................................. CH .... X ....... 0433 0.2571 15.82 5.93 3.16 

88141 ....... Cytopath, c/v, interpret ................................... ........... N ....... .......... .................... .................... .................... ....................

88160 ....... Cytopath smear, other source ....................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88161 ....... Cytopath smear, other source ....................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88162 ....... Cytopath smear, other source ....................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88172 ....... Cytopathology eval of fna .............................. ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88173 ....... Cytopath eval, fna, report .............................. ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88182 ....... Cell marker study ........................................... CH .... X ....... 0343 0.5309 32.68 10.84 6.54 

88184 ....... Flowcytometry/tc, 1 marker ............................ CH .... X ....... 0433 0.2571 15.82 5.93 3.16 

88185 ....... Flowcytometry/tc, add-on ............................... CH .... X ....... 0433 0.2571 15.82 5.93 3.16 

88187 ....... Flowcytometry/read, 2–8 ................................ ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88188 ....... Flowcytometry/read, 9–15 .............................. ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88189 ....... Flowcytometry/read, 16&> ............................. ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88299 ....... Cytogenetic study ........................................... ........... X ....... 0342 0.0813 5.00 2.00 1.00 

88300 ....... Surgical path, gross ....................................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88302 ....... Tissue exam by pathologist ........................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88304 ....... Tissue exam by pathologist ........................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88305 ....... Tissue exam by pathologist ........................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88307 ....... Tissue exam by pathologist ........................... ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88309 ....... Tissue exam by pathologist ........................... ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88311 ....... Decalcify tissue .............................................. CH .... X ....... 0433 0.2571 15.82 5.93 3.16 

88312 ....... Special stains ................................................. ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88313 ....... Special stains ................................................. ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88314 ....... Histochemical stain ........................................ ........... X ....... 0342 0.0813 5.00 2.00 1.00 

88318 ....... Chemical histochemistry ................................ ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88319 ....... Enzyme histochemistry .................................. ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88321 ....... Microslide consultation ................................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88323 ....... Microslide consultation ................................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88325 ....... Comprehensive review of data ...................... ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88329 ....... Path consult introp ......................................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88331 ....... Path consult intraop, 1 bloc ........................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88332 ....... Path consult intraop, add’l ............................. ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88333 ....... Intraop cyto path consult, 1 ........................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88334 ....... Intraop cyto path consult, 2 ........................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88342 ....... Immunohistochemistry ................................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88346 ....... Immunofluorescent study ............................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88347 ....... Immunofluorescent study ............................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88348 ....... Electron microscopy ....................................... ........... X ....... 0661 2.6066 160.44 64.17 32.09 

88349 ....... Scanning electron microscopy ....................... ........... X ....... 0661 2.6066 160.44 64.17 32.09 

88355 ....... Analysis, skeletal muscle ............................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88356 ....... Analysis, nerve ............................................... ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88358 ....... Analysis, tumor ............................................... ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88360 ....... Tumor immunohistochem/manual .................. CH .... X ....... 0343 0.5309 32.68 10.84 6.54 

88361 ....... Tumor immunohistochem/comput .................. ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88362 ....... Nerve teasing preparations ............................ ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88365 ....... Insitu hybridization (fish) ................................ ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88367 ....... Insitu hybridization, auto ................................ ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88368 ....... Insitu hybridization, manual ........................... ........... X ....... 0344 0.8107 49.90 15.66 9.98 

88380 ....... Microdissection ............................................... ........... N ....... .......... .................... .................... .................... ....................

88384 ....... Eval molecular probes, 11–50 ....................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

88385 ....... Eval molecul probes, 51–250 ........................ ........... X ....... 0343 0.5309 32.68 10.84 6.54 

88386 ....... Eval molecul probes, 251–500 ...................... ........... X ....... 0344 0.8107 49.90 15.66 9.98 

89049 ....... Chct for mal hyperthermia ............................. ........... X ....... 0343 0.5309 32.68 10.84 6.54 

89100 ....... Sample intestinal contents ............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89105 ....... Sample intestinal contents ............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89130 ....... Sample stomach contents .............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89132 ....... Sample stomach contents .............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89135 ....... Sample stomach contents .............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89136 ....... Sample stomach contents .............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89140 ....... Sample stomach contents .............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89141 ....... Sample stomach contents .............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

89220 ....... Sputum specimen collection .......................... ........... X ....... 0343 0.5309 32.68 10.84 6.54 

89230 ....... Collect sweat for test ..................................... ........... X ....... 0433 0.2571 15.82 5.93 3.16 

89250 ....... Cultr oocyte/embryo <4 days ......................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89251 ....... Cultr oocyte/embryo <4 days ......................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89253 ....... Embryo hatching ............................................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89254 ....... Oocyte identification ....................................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89255 ....... Prepare embryo for transfer ........................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89257 ....... Sperm identification ........................................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89258 ....... Cryopreservation; embryo(s) .......................... ........... X ....... 0348 0.8928 54.95 .................... 10.99


sroberts on PROD1PC70 with PROPOSALS
49822 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

89259 ....... Cryopreservation, sperm ................................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89260 ....... Sperm isolation, simple .................................. ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89261 ....... Sperm isolation, complex ............................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89264 ....... Identify sperm tissue ...................................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89268 ....... Insemination of oocytes ................................. ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89272 ....... Extended culture of oocytes .......................... ........... X ....... 0348 0.8928 54.95 .................... 10.99

89280 ....... Assist oocyte fertilization ................................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89281 ....... Assist oocyte fertilization ................................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89290 ....... Biopsy, oocyte polar body .............................. ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89291 ....... Biopsy, oocyte polar body .............................. ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89335 ....... Cryopreserve testicular tiss ............................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89342 ....... Storage/year; embryo(s) ................................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89343 ....... Storage/year; sperm/semen ........................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89344 ....... Storage/year; reprod tissue ............................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89346 ....... Storage/year; oocyte(s) .................................. ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89352 ....... Thawing cryopresrved; embryo ...................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89353 ....... Thawing cryopresrved; sperm ........................ ........... X ....... 0348 0.8928 54.95 .................... 10.99 

89354 ....... Thaw cryoprsvrd; reprod tiss ......................... ........... X ....... 0348 0.8928 54.95 .................... 10.99

89356 ....... Thawing cryopresrved; oocyte ....................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

90296 ....... Diphtheria antitoxin ........................................ ........... N ....... .......... .................... .................... .................... ....................

90371 ....... Hep b ig, im .................................................... ........... K ....... 1630 .................... 118.61 .................... 23.72 

90375 ....... Rabies ig, im/sc .............................................. ........... K ....... 9133 .................... 63.98 .................... 12.80 

90376 ....... Rabies ig, heat treated ................................... ........... K ....... 9134 .................... 68.58 .................... 13.72 

90385 ....... Rh ig, minidose, im ........................................ ........... N ....... .......... .................... .................... .................... ....................

90393 ....... Vaccina ig, im ................................................. ........... N ....... .......... .................... .................... .................... ....................

90396 ....... Varicella-zoster ig, im ..................................... ........... K ....... 9135 .................... 149.08 .................... 29.82 

90471 ....... Immunization admin ....................................... CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

90472 ....... Immunization admin, each add ...................... CH .... S ....... 0436 0.1769 10.89 .................... 2.18 

90473 ....... Immune admin oral/nasal ............................... CH .... S ....... 0436 0.1769 10.89 .................... 2.18 

90474 ....... Immune admin oral/nasal addl ....................... CH .... S ....... 0436 0.1769 10.89 .................... 2.18 

90476 ....... Adenovirus vaccine, type 4 ............................ CH .... N ....... .......... .................... .................... .................... ....................

90477 ....... Adenovirus vaccine, type 7 ............................ ........... N ....... .......... .................... .................... .................... ....................

90581 ....... Anthrax vaccine, sc ........................................ CH .... N ....... .......... .................... .................... .................... ....................

90585 ....... Bcg vaccine, percut ........................................ ........... K ....... 9137 .................... 115.46 .................... 23.09 

90632 ....... Hep a vaccine, adult im ................................. ........... N ....... .......... .................... .................... .................... ....................

90633 ....... Hep a vacc, ped/adol, 2 dose ........................ ........... N ....... .......... .................... .................... .................... ....................

90634 ....... Hep a vacc, ped/adol, 3 dose ........................ ........... N ....... .......... .................... .................... .................... ....................

90636 ....... Hep a/hep b vacc, adult im ............................ CH .... N ....... .......... .................... .................... .................... ....................

90645 ....... Hib vaccine, hboc, im ..................................... ........... N ....... .......... .................... .................... .................... ....................

90646 ....... Hib vaccine, prp-d, im .................................... ........... N ....... .......... .................... .................... .................... ....................

90647 ....... Hib vaccine, prp-omp, im ............................... ........... N ....... .......... .................... .................... .................... ....................

90648 ....... Hib vaccine, prp-t, im ..................................... ........... N ....... .......... .................... .................... .................... ....................

90665 ....... Lyme disease vaccine, im .............................. CH .... N ....... .......... .................... .................... .................... ....................

90675 ....... Rabies vaccine, im ......................................... ........... K ....... 9139 .................... 155.25 .................... 31.05 

90676 ....... Rabies vaccine, id .......................................... ........... K ....... 9140 .................... 118.49 .................... 23.70 

90680 ....... Rotovirus vacc 3 dose, oral ........................... ........... N ....... .......... .................... .................... .................... ....................

90690 ....... Typhoid vaccine, oral ..................................... ........... N ....... .......... .................... .................... .................... ....................

90691 ....... Typhoid vaccine, im ....................................... ........... N ....... .......... .................... .................... .................... ....................

90692 ....... Typhoid vaccine, h-p, sc/id ............................ ........... N ....... .......... .................... .................... .................... ....................

90693 ....... Typhoid vaccine, akd, sc ............................... ........... N ....... .......... .................... .................... .................... ....................

90698 ....... Dtap-hib-ip vaccine, im .................................. ........... N ....... .......... .................... .................... .................... ....................

90700 ....... Dtap vaccine, < 7 yrs, im ............................... ........... N ....... .......... .................... .................... .................... ....................

90701 ....... Dtp vaccine, im .............................................. ........... N ....... .......... .................... .................... .................... ....................

90702 ....... Dt vaccine < 7, im .......................................... ........... N ....... .......... .................... .................... .................... ....................

90703 ....... Tetanus vaccine, im ....................................... ........... N ....... .......... .................... .................... .................... ....................

90704 ....... Mumps vaccine, sc ........................................ ........... N ....... .......... .................... .................... .................... ....................

90705 ....... Measles vaccine, sc ....................................... ........... N ....... .......... .................... .................... .................... ....................

90706 ....... Rubella vaccine, sc ........................................ ........... N ....... .......... .................... .................... .................... ....................

90707 ....... Mmr vaccine, sc ............................................. ........... N ....... .......... .................... .................... .................... ....................

90708 ....... Measles-rubella vaccine, sc ........................... ........... K ....... 9141 .................... 44.62 .................... 8.92 

90710 ....... Mmrv vaccine, sc ........................................... ........... N ....... .......... .................... .................... .................... ....................

90712 ....... Oral poliovirus vaccine ................................... ........... N ....... .......... .................... .................... .................... ....................

90713 ....... Poliovirus, ipv, sc/im ...................................... ........... N ....... .......... .................... .................... .................... ....................

90714 ....... Td vaccine no prsrv >/= 7 im ......................... CH .... N ....... .......... .................... .................... .................... ....................

90715 ....... Tdap vaccine >7 im ....................................... ........... N ....... .......... .................... .................... .................... ....................

90716 ....... Chicken pox vaccine, sc ................................ ........... K ....... 9142 .................... 66.84 .................... 13.37 

90717 ....... Yellow fever vaccine, sc ................................ CH .... N ....... .......... .................... .................... .................... ....................

90718 ....... Td vaccine > 7, im ......................................... ........... N ....... .......... .................... .................... .................... ....................

90719 ....... Diphtheria vaccine, im .................................... ........... N ....... .......... .................... .................... .................... ....................

90720 ....... Dtp/hib vaccine, im ......................................... CH .... K ....... 3032 .................... 68.91 .................... 13.78 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49823 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

90721 ....... Dtap/hib vaccine, im ....................................... ........... N ....... .......... .................... .................... .................... ....................

90725 ....... Cholera vaccine, injectable ............................ ........... N ....... .......... .................... .................... .................... ....................

90727 ....... Plague vaccine, im ......................................... CH .... K ....... 0744 .................... 150.00 .................... 30.00 

90733 ....... Meningococcal vaccine, sc ............................ ........... K ....... 9143 .................... 84.46 .................... 16.89 

90734 ....... Meningococcal vaccine, im ............................ ........... K ....... 9145 .................... 143.12 .................... 28.62 

90735 ....... Encephalitis vaccine, sc ................................. ........... K ....... 9144 .................... 99.15 .................... 19.83 

90749 ....... Vaccine toxoid ................................................ ........... N ....... .......... .................... .................... .................... ....................

90772 ....... Ther/proph/diag inj, sc/im ............................... CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

90773 ....... Ther/proph/diag inj, ia .................................... CH .... S ....... 0438 0.7892 48.58 .................... 9.72

90779 ....... Ther/prop/diag inj/inf proc .............................. CH .... S ....... 0436 0.1769 10.89 .................... 2.18 

90801 ....... Psy dx interview ............................................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90802 ....... Intac psy dx interview .................................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90804 ....... Psytx, office, 20–30 min ................................. ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90805 ....... Psytx, off, 20–30 min w/e&m ......................... ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90806 ....... Psytx, off, 45–50 min ..................................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90807 ....... Psytx, off, 45–50 min w/e&m ......................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90808 ....... Psytx, office, 75–80 min ................................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90809 ....... Psytx, off, 75-80, w/e&m ................................ ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90810 ....... Intac psytx, off, 20–30 min ............................. ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90811 ....... Intac psytx, 20–30, w/e&m ............................. ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90812 ....... Intac psytx, off, 45–50 min ............................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90813 ....... Intac psytx, 45–50 min w/e&m ....................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90814 ....... Intac psytx, off, 75–80 min ............................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90815 ....... Intac psytx, 75–80 w/e&m .............................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90816 ....... Psytx, hosp, 20–30 min ................................. ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90817 ....... Psytx, hosp, 20–30 min w/e&m ..................... ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90818 ....... Psytx, hosp, 45–50 min ................................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90819 ....... Psytx, hosp, 45–50 min w/e&m ..................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90821 ....... Psytx, hosp, 75–80 min ................................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90822 ....... Psytx, hosp, 75–80 min w/e&m ..................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90823 ....... Intac psytx, hosp, 20–30 min ......................... ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90824 ....... Intac psytx, hsp 20–30 w/e&m ....................... ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90826 ....... Intac psytx, hosp, 45–50 min ......................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90827 ....... Intac psytx, hsp 45–50 w/e&m ....................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90828 ....... Intac psytx, hosp, 75–80 min ......................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90829 ....... Intac psytx, hsp 75–80 w/e&m ....................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90845 ....... Psychoanalysis ............................................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90846 ....... Family psytx w/o patient ................................ ........... S ....... 0324 2.2087 135.95 .................... 27.19 

90847 ....... Family psytx w/patient .................................... ........... S ....... 0324 2.2087 135.95 .................... 27.19 

90849 ....... Multiple family group psytx ............................ ........... S ....... 0325 1.0787 66.40 14.51 13.28 

90853 ....... Group psychotherapy ..................................... ........... S ....... 0325 1.0787 66.40 14.51 13.28 

90857 ....... Intac group psytx ............................................ ........... S ....... 0325 1.0787 66.40 14.51 13.28 

90862 ....... Medication management ................................ ........... X ....... 0374 1.1509 70.84 .................... 14.17

90865 ....... Narcosynthesis ............................................... ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90870 ....... Electroconvulsive therapy .............................. ........... S ....... 0320 5.5017 338.64 80.06 67.73 

90880 ....... Hypnotherapy ................................................. ........... S ....... 0323 1.7170 105.68 .................... 21.14 

90885 ....... Psy evaluation of records .............................. ........... N ....... .......... .................... .................... .................... ....................

90887 ....... Consultation with family ................................. ........... N ....... .......... .................... .................... .................... ....................

90889 ....... Preparation of report ...................................... ........... N ....... .......... .................... .................... .................... ....................

90899 ....... Psychiatric service/therapy ............................ ........... S ....... 0322 1.1749 72.32 .................... 14.46 

90911 ....... Biofeedback peri/uro/rectal ............................ ........... S ....... 0321 1.3693 84.28 21.72 16.86 

90935 ....... Hemodialysis, one evaluation ........................ ........... S ....... 0170 6.8096 419.14 .................... 83.83

90940 ....... Hemodialysis access study ............................ ........... N ....... .......... .................... .................... .................... ....................

90945 ....... Dialysis, one evaluation ................................. ........... S ....... 0170 6.8096 419.14 .................... 83.83 

91000 ....... Esophageal intubation .................................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91010 ....... Esophagus motility study ............................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91011 ....... Esophagus motility study ............................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91012 ....... Esophagus motility study ............................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91020 ....... Gastric motility studies ................................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91022 ....... Duodenal motility study .................................. ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91030 ....... Acid perfusion of esophagus ......................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91034 ....... Gastroesophageal reflux test ......................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91035 ....... G-esoph reflx tst w/electrod ........................... CH .... X ....... 0361 3.9319 242.01 83.23 48.40 

91037 ....... Esoph imped function test ............................. ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91038 ....... Esoph imped funct test > 1h .......................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91040 ....... Esoph balloon distension tst .......................... ........... X ....... 0360 1.3789 84.87 33.88 16.97 

91052 ....... Gastric analysis test ....................................... ........... X ....... 0361 3.9319 242.01 83.23 48.40 

91055 ....... Gastric intubation for smear ........................... ........... X ....... 0360 1.3789 84.87 33.88 16.97 

91060 ....... Gastric saline load test .................................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

91065 ....... Breath hydrogen test ...................................... ........... X ....... 0360 1.3789 84.87 33.88 16.97 


sroberts on PROD1PC70 with PROPOSALS
49824 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

91100 ....... Pass intestine bleeding tube .......................... ........... X ....... 0360 1.3789 84.87 33.88 16.97 

91105 ....... Gastric intubation treatment ........................... ........... X ....... 0360 1.3789 84.87 33.88 16.97 

91110 ....... Gi tract capsule endoscopy ........................... ........... T ....... 0142 9.3878 577.83 152.78 115.57 

91120 ....... Rectal sensation test ...................................... CH .... T ....... 0126 1.0844 66.75 16.40 13.35 

91122 ....... Anal pressure record ...................................... CH .... T ....... 0164 2.1159 130.24 .................... 26.05 

91123 ....... Irrigate fecal impaction ................................... ........... N ....... .......... .................... .................... .................... ....................

91132 ....... Electrogastrography ....................................... ........... X ....... 0360 1.3789 84.87 33.88 16.97 

91133 ....... Electrogastrography w/test ............................. ........... X ....... 0360 1.3789 84.87 33.88 16.97 

91299 ....... Gastroenterology procedure .......................... ........... X ....... 0360 1.3789 84.87 33.88 16.97 

92002 ....... Eye exam, new patient .................................. CH .... V ....... 0605 1.0057 61.90 .................... 12.38 

92004 ....... Eye exam, new patient .................................. CH .... V ....... 0606 1.3546 83.38 .................... 16.68 

92012 ....... Eye exam established pat .............................. CH .... V ....... 0604 0.8083 49.75 .................... 9.95 

92014 ....... Eye exam&treatment ...................................... CH .... V ....... 0605 1.0057 61.90 .................... 12.38 

92018 ....... New eye exam&treatment .............................. ........... T ....... 0699 13.9509 858.69 .................... 171.74 

92019 ....... Eye exam&treatment ...................................... ........... T ....... 0699 13.9509 858.69 .................... 171.74 

92020 ....... Special eye evaluation ................................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92060 ....... Special eye evaluation ................................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92065 ....... Orthoptic/pleoptic training .............................. CH .... S ....... 0230 0.8126 50.02 14.97 10.00 

92070 ....... Fitting of contact lens ..................................... ........... N ....... .......... .................... .................... .................... ....................

92081 ....... Visual field examination(s) ............................. ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92082 ....... Visual field examination(s) ............................. ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92083 ....... Visual field examination(s) ............................. ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92100 ....... Serial tonometry exam(s) ............................... ........... N ....... .......... .................... .................... .................... ....................

92120 ....... Tonography&eye evaluation .......................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92130 ....... Water provocation tonography ....................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92135 ....... Opthalmic dx imaging .................................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92136 ....... Ophthalmic biometry ...................................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

92140 ....... Glaucoma provocative tests ........................... CH .... S ....... 0230 0.8126 50.02 14.97 10.00 

92225 ....... Special eye exam, initial ................................ CH .... S ....... 0230 0.8126 50.02 14.97 10.00 

92226 ....... Special eye exam, subsequent ...................... CH .... S ....... 0230 0.8126 50.02 14.97 10.00 

92230 ....... Eye exam with photos .................................... CH .... S ....... 0231 2.1934 135.01 .................... 27.00 

92235 ....... Eye exam with photos .................................... ........... S ....... 0231 2.1934 135.01 .................... 27.00 

92240 ....... Icg angiography .............................................. ........... S ....... 0231 2.1934 135.01 .................... 27.00 

92250 ....... Eye exam with photos .................................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92260 ....... Ophthalmoscopy/dynamometry ...................... CH .... S ....... 0230 0.8126 50.02 14.97 10.00 

92265 ....... Eye muscle evaluation ................................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92270 ....... Electro-oculography ....................................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92275 ....... Electroretinography ........................................ ........... S ....... 0231 2.1934 135.01 .................... 27.00 

92283 ....... Color vision examination ................................ ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92284 ....... Dark adaptation eye exam ............................. ........... S ....... 0698 1.2244 75.36 16.52 15.07 

92285 ....... Eye photography ............................................ ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92286 ....... Internal eye photography ............................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

92287 ....... Internal eye photography ............................... ........... S ....... 0698 1.2244 75.36 16.52 15.07 

92311 ....... Contact lens fitting ......................................... ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92312 ....... Contact lens fitting ......................................... ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92313 ....... Contact lens fitting ......................................... ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92315 ....... Prescription of contact lens ............................ ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92316 ....... Prescription of contact lens ............................ ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92317 ....... Prescription of contact lens ............................ ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92325 ....... Modification of contact lens ........................... ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92326 ....... Replacement of contact lens ......................... ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92352 ....... Special spectacles fitting ................................ ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92353 ....... Special spectacles fitting ................................ ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92354 ....... Special spectacles fitting ................................ ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92355 ....... Special spectacles fitting ................................ ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92358 ....... Eye prosthesis service ................................... ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92371 ....... Repair&adjust spectacles ............................... ........... X ....... 0362 0.5328 32.79 .................... 6.56 

92499 ....... Eye service or procedure ............................... ........... S ....... 0230 0.8126 50.02 14.97 10.00 

92502 ....... Ear and throat examination ............................ ........... T ....... 0251 2.3768 146.29 .................... 29.26 

92504 ....... Ear microscopy examination .......................... ........... N ....... .......... .................... .................... .................... ....................

92511 ....... Nasopharyngoscopy ....................................... ........... T ....... 0071 0.7572 46.61 11.03 9.32 

92512 ....... Nasal function studies .................................... ........... X ....... 0363 0.8534 52.53 17.44 10.51 

92516 ....... Facial nerve function test ............................... ........... X ....... 0660 1.4988 92.25 29.07 18.45 

92520 ....... Laryngeal function studies ............................. ........... X ....... 0660 1.4988 92.25 29.07 18.45 

92531 ....... Spontaneous nystagmus study ...................... ........... N ....... .......... .................... .................... .................... ....................

92532 ....... Positional nystagmus test .............................. ........... N ....... .......... .................... .................... .................... ....................

92533 ....... Caloric vestibular test ..................................... ........... N ....... .......... .................... .................... .................... ....................

92534 ....... Optokinetic nystagmus test ............................ ........... N ....... .......... .................... .................... .................... ....................

92541 ....... Spontaneous nystagmus test ......................... ........... X ....... 0363 0.8534 52.53 17.44 10.51 

92542 ....... Positional nystagmus test .............................. ........... X ....... 0363 0.8534 52.53 17.44 10.51 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49825 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

92543 ....... Caloric vestibular test ..................................... ........... X ....... 0660 1.4988 92.25 29.07 18.45 

92544 ....... Optokinetic nystagmus test ............................ ........... X ....... 0363 0.8534 52.53 17.44 10.51 

92545 ....... Oscillating tracking test .................................. ........... X ....... 0363 0.8534 52.53 17.44 10.51 

92546 ....... Sinusoidal rotational test ................................ ........... X ....... 0660 1.4988 92.25 29.07 18.45 

92547 ....... Supplemental electrical test ........................... ........... X ....... 0363 0.8534 52.53 17.44 10.51 

92548 ....... Posturography ................................................ ........... X ....... 0660 1.4988 92.25 29.07 18.45 

92552 ....... Pure tone audiometry, air .............................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92553 ....... Audiometry, air&bone ..................................... ........... X ....... 0365 1.2467 76.74 18.52 15.35 

92555 ....... Speech threshold audiometry ........................ ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92556 ....... Speech audiometry, complete ....................... ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92557 ....... Comprehensive hearing test .......................... ........... X ....... 0365 1.2467 76.74 18.52 15.35 

92561 ....... Bekesy audiometry, diagnosis ....................... ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92562 ....... Loudness balance test ................................... ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92563 ....... Tone decay hearing test ................................ ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92564 ....... Sisi hearing test ............................................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92565 ....... Stenger test, pure tone .................................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92567 ....... Tympanometry ............................................... ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92568 ....... Acoustic refl threshold tst ............................... ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92569 ....... Acoustic reflex decay test .............................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92571 ....... Filtered speech hearing test .......................... ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92572 ....... Staggered spondaic word test ....................... ........... X ....... 0366 1.8175 111.87 26.14 22.37 

92573 ....... Lombard test .................................................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92575 ....... Sensorineural acuity test ................................ ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92576 ....... Synthetic sentence test .................................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92577 ....... Stenger test, speech ...................................... ........... X ....... 0366 1.8175 111.87 26.14 22.37 

92579 ....... Visual audiometry (vra) .................................. ........... X ....... 0365 1.2467 76.74 18.52 15.35 

92582 ....... Conditioning play audiometry ......................... ........... X ....... 0365 1.2467 76.74 18.52 15.35 

92583 ....... Select picture audiometry .............................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92584 ....... Electrocochleography ..................................... ........... X ....... 0660 1.4988 92.25 29.07 18.45 

92585 ....... Auditor evoke potent, compre ........................ ........... S ....... 0216 2.6729 164.52 .................... 32.90

92586 ....... Auditor evoke potent, limit ............................. ........... S ....... 0218 1.1993 73.82 .................... 14.76 

92587 ....... Evoked auditory test ...................................... ........... X ....... 0363 0.8534 52.53 17.44 10.51 

92588 ....... Evoked auditory test ...................................... ........... X ....... 0660 1.4988 92.25 29.07 18.45 

92596 ....... Ear protector evaluation ................................. ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92601 ....... Cochlear implt f/up exam < 7 ........................ ........... X ....... 0366 1.8175 111.87 26.14 22.37 

92602 ....... Reprogram cochlear implt < 7 ....................... ........... X ....... 0366 1.8175 111.87 26.14 22.37 

92603 ....... Cochlear implt f/up exam 7 > ........................ ........... X ....... 0366 1.8175 111.87 26.14 22.37 

92604 ....... Reprogram cochlear implt 7 > ....................... ........... X ....... 0366 1.8175 111.87 26.14 22.37 

92620 ....... Auditory function, 60 min ............................... ........... X ....... 0365 1.2467 76.74 18.52 15.35 

92621 ....... Auditory function, + 15 min ............................ ........... N ....... .......... .................... .................... .................... ....................

92625 ....... Tinnitus assessment ...................................... ........... X ....... 0365 1.2467 76.74 18.52 15.35 

92626 ....... Eval aud rehab status .................................... ........... X ....... 0365 1.2467 76.74 18.52 15.35 

92627 ....... Eval aud status rehab add-on ........................ ........... N ....... .......... .................... .................... .................... ....................

92700 ....... Ent procedure/service .................................... ........... X ....... 0364 0.4637 28.54 7.06 5.71 

92950 ....... Heart/lung resuscitation cpr ........................... ........... S ....... 0094 2.4630 151.60 46.29 30.32 

92953 ....... Temporary external pacing ............................ ........... S ....... 0094 2.4630 151.60 46.29 30.32 

92960 ....... Cardioversion electric, ext .............................. ........... S ....... 0679 5.5435 341.21 95.30 68.24 

92961 ....... Cardioversion, electric, int .............................. ........... S ....... 0679 5.5435 341.21 95.30 68.24 

92973 ....... Percut coronary thrombectomy ...................... ........... T ....... 0088 37.9652 2,336.80 655.22 467.36 

92974 ....... Cath place, cardio brachytx ........................... ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

92977 ....... Dissolve clot, heart vessel ............................. ........... T ....... 0676 2.0612 126.87 .................... 25.37 

92978 ....... Intravasc us, heart add-on ............................. ........... S ....... 0670 29.7322 1,830.05 536.10 366.01 

92979 ....... Intravasc us, heart add-on ............................. ........... S ....... 0416 32.2182 1,983.06 .................... 396.61 

92980 ....... Insert intracoronary stent ............................... ........... T ....... 0104 87.9808 5,415.31 .................... 1,083.06 

92981 ....... Insert intracoronary stent ............................... ........... T ....... 0104 87.9808 5,415.31 .................... 1,083.06 

92982 ....... Coronary artery dilation .................................. ........... T ....... 0083 57.4937 3,538.79 .................... 707.76 

92984 ....... Coronary artery dilation .................................. ........... T ....... 0083 57.4937 3,538.79 .................... 707.76 

92986 ....... Revision of aortic valve .................................. ........... T ....... 0083 57.4937 3,538.79 .................... 707.76 

92987 ....... Revision of mitral valve .................................. ........... T ....... 0083 57.4937 3,538.79 .................... 707.76 

92990 ....... Revision of pulmonary valve .......................... ........... T ....... 0083 57.4937 3,538.79 .................... 707.76 

92995 ....... Coronary atherectomy .................................... ........... T ....... 0082 76.2006 4,690.22 1,008.90 938.04 

92996 ....... Coronary atherectomy add-on ....................... ........... T ....... 0082 76.2006 4,690.22 1,008.90 938.04 

92997 ....... Pul art balloon repr, percut ............................ ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

92998 ....... Pul art balloon repr, percut ............................ ........... T ....... 0081 42.8894 2,639.89 .................... 527.98 

93005 ....... Electrocardiogram, tracing ............................. ........... S ....... 0099 0.3835 23.60 .................... 4.72 

93012 ....... Transmission of ecg ....................................... ........... N ....... .......... .................... .................... .................... ....................

93017 ....... Cardiovascular stress test .............................. ........... X ....... 0100 2.5352 156.04 41.44 31.21 

93024 ....... Cardiac drug stress test ................................. ........... X ....... 0100 2.5352 156.04 41.44 31.21 

93025 ....... Microvolt t-wave assess ................................. ........... X ....... 0100 2.5352 156.04 41.44 31.21 

93041 ....... Rhythm ECG, tracing ..................................... ........... S ....... 0099 0.3835 23.60 .................... 4.72 


sroberts on PROD1PC70 with PROPOSALS
49826 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

93225 ....... ECG monitor/record, 24 hrs ........................... ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93226 ....... ECG monitor/report, 24 hrs ............................ ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93231 ....... Ecg monitor/record, 24 hrs ............................ ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93232 ....... ECG monitor/report, 24 hrs ............................ ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93236 ....... ECG monitor/report, 24 hrs ............................ ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93270 ....... ECG recording ............................................... ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93271 ....... Ecg/monitoring and analysis .......................... ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93278 ....... ECG/signal-averaged ..................................... ........... S ....... 0099 0.3835 23.60 .................... 4.72 

93303 ....... Echo transthoracic ......................................... ........... S ....... 0269 3.2432 199.62 75.60 39.92 

93304 ....... Echo transthoracic ......................................... ........... S ....... 0697 1.6002 98.49 35.99 19.70 

93307 ....... Echo exam of heart ........................................ ........... S ....... 0269 3.2432 199.62 75.60 39.92 

93308 ....... Echo exam of heart ........................................ ........... S ....... 0697 1.6002 98.49 35.99 19.70 

93312 ....... Echo transesophageal ................................... ........... S ....... 0270 6.2689 385.86 141.32 77.17 

93313 ....... Echo transesophageal ................................... ........... S ....... 0270 6.2689 385.86 141.32 77.17 

93314 ....... Echo transesophageal ................................... ........... N ....... .......... .................... .................... .................... ....................

93315 ....... Echo transesophageal ................................... ........... S ....... 0270 6.2689 385.86 141.32 77.17 

93316 ....... Echo transesophageal ................................... ........... S ....... 0270 6.2689 385.86 141.32 77.17 

93317 ....... Echo transesophageal ................................... ........... N ....... .......... .................... .................... .................... ....................

93318 ....... Echo transesophageal intraop ....................... ........... S ....... 0270 6.2689 385.86 141.32 77.17 

93320 ....... Doppler echo exam, heart ............................. CH .... S ....... 0697 1.6002 98.49 35.99 19.70 

93321 ....... Doppler echo exam, heart ............................. ........... S ....... 0697 1.6002 98.49 35.99 19.70 

93325 ....... Doppler color flow add-on .............................. ........... S ....... 0697 1.6002 98.49 35.99 19.70 

93350 ....... Echo transthoracic ......................................... ........... S ....... 0269 3.2432 199.62 75.60 39.92 

93501 ....... Right heart catheterization ............................. ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93503 ....... Insert/place heart catheter ............................. ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

93505 ....... Biopsy of heart lining ..................................... ........... T ....... 0103 17.0436 1,049.05 223.63 209.81 

93508 ....... Cath placement, angiography ........................ ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93510 ....... Left heart catheterization ............................... ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93511 ....... Left heart catheterization ............................... ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93514 ....... Left heart catheterization ............................... ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93524 ....... Left heart catheterization ............................... ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93526 ....... Rt&Lt heart catheters ..................................... ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93527 ....... Rt&Lt heart catheters ..................................... ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93528 ....... Rt&Lt heart catheters ..................................... ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93529 ....... Rt, lt heart catheterization .............................. ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93530 ....... Rt heart cath, congenital ................................ ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93531 ....... R&l heart cath, congenital .............................. ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93532 ....... R&l heart cath, congenital .............................. ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93533 ....... R&l heart cath, congenital .............................. ........... T ....... 0080 37.1008 2,283.59 838.92 456.72 

93539 ....... Injection, cardiac cath .................................... ........... N ....... .......... .................... .................... .................... ....................

93540 ....... Injection, cardiac cath .................................... ........... N ....... .......... .................... .................... .................... ....................

93541 ....... Injection for lung angiogram .......................... ........... N ....... .......... .................... .................... .................... ....................

93542 ....... Injection for heart x-rays ................................ ........... N ....... .......... .................... .................... .................... ....................

93543 ....... Injection for heart x-rays ................................ ........... N ....... .......... .................... .................... .................... ....................

93544 ....... Injection for aortography ................................ ........... N ....... .......... .................... .................... .................... ....................

93545 ....... Inject for coronary x-rays ............................... ........... N ....... .......... .................... .................... .................... ....................

93555 ....... Imaging, cardiac cath ..................................... ........... N ....... .......... .................... .................... .................... ....................

93556 ....... Imaging, cardiac cath ..................................... ........... N ....... .......... .................... .................... .................... ....................

93561 ....... Cardiac output measurement ......................... ........... N ....... .......... .................... .................... .................... ....................

93562 ....... Cardiac output measurement ......................... ........... N ....... .......... .................... .................... .................... ....................

93571 ....... Heart flow reserve measure ........................... ........... S ....... 0670 29.7322 1,830.05 536.10 366.01 

93572 ....... Heart flow reserve measure ........................... ........... S ....... 0416 32.2182 1,983.06 .................... 396.61 

93580 ....... Transcath closure of asd ............................... ........... T ....... 0434 87.3424 5,376.01 .................... 1,075.20 

93581 ....... Transcath closure of vsd ................................ ........... T ....... 0434 87.3424 5,376.01 .................... 1,075.20 

93600 ....... Bundle of His recording ................................. ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93602 ....... Intra-atrial recording ....................................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93603 ....... Right ventricular recording ............................. ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93609 ....... Map tachycardia, add-on ............................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93610 ....... Intra-atrial pacing ........................................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93612 ....... Intraventricular pacing .................................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93613 ....... Electrophys map 3d, add-on .......................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93615 ....... Esophageal recording .................................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93616 ....... Esophageal recording .................................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93618 ....... Heart rhythm pacing ....................................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93619 ....... Electrophysiology evaluation .......................... ........... T ....... 0085 34.7086 2,136.35 .................... 427.27 

93620 ....... Electrophysiology evaluation .......................... ........... T ....... 0085 34.7086 2,136.35 .................... 427.27 

93621 ....... Electrophysiology evaluation .......................... ........... T ....... 0085 34.7086 2,136.35 .................... 427.27 

93622 ....... Electrophysiology evaluation .......................... ........... T ....... 0085 34.7086 2,136.35 .................... 427.27 

93623 ....... Stimulation, pacing heart ............................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93624 ....... Electrophysiologic study ................................. ........... T ....... 0085 34.7086 2,136.35 .................... 427.27 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49827 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

93631 ....... Heart pacing, mapping ................................... ........... T ....... 0087 32.8298 2,020.71 .................... 404.14 

93640 ....... Evaluation heart device .................................. CH .... N ....... .......... .................... .................... .................... ....................

93641 ....... Electrophysiology evaluation .......................... CH .... N ....... .......... .................... .................... .................... ....................

93642 ....... Electrophysiology evaluation .......................... ........... S ....... 0084 9.9197 610.57 .................... 122.11 

93650 ....... Ablate heart dysrhythm focus ........................ ........... T ....... 0086 47.1472 2,901.96 812.36 580.39 

93651 ....... Ablate heart dysrhythm focus ........................ ........... T ....... 0086 47.1472 2,901.96 812.36 580.39 

93652 ....... Ablate heart dysrhythm focus ........................ ........... T ....... 0086 47.1472 2,901.96 812.36 580.39 

93660 ....... Tilt table evaluation ........................................ ........... S ....... 0101 4.3122 265.42 100.24 53.08 

93662 ....... Intracardiac ecg (ice) ..................................... ........... S ....... 0670 29.7322 1,830.05 536.10 366.01 

93701 ....... Bioimpedance, thoracic .................................. ........... S ....... 0099 0.3835 23.60 .................... 4.72 

93721 ....... Plethysmography tracing ................................ ........... X ....... 0368 0.9568 58.89 22.77 11.78 

93724 ....... Analyze pacemaker system ........................... ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93727 ....... Analyze ilr system .......................................... ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93731 ....... Analyze pacemaker system ........................... ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93732 ....... Analyze pacemaker system ........................... ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93733 ....... Telephone analy, pacemaker ......................... ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93734 ....... Analyze pacemaker system ........................... ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93735 ....... Analyze pacemaker system ........................... ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93736 ....... Telephonic analy, pacemaker ........................ ........... S ....... 0690 0.3628 22.33 8.67 4.47 

93740 ....... Temperature gradient studies ........................ ........... X ....... 0368 0.9568 58.89 22.77 11.78 

93741 ....... Analyze ht pace device sngl .......................... ........... S ....... 0689 0.5400 33.24 .................... 6.65 

93742 ....... Analyze ht pace device sngl .......................... ........... S ....... 0689 0.5400 33.24 .................... 6.65 

93743 ....... Analyze ht pace device dual .......................... ........... S ....... 0689 0.5400 33.24 .................... 6.65 

93744 ....... Analyze ht pace device dual .......................... ........... S ....... 0689 0.5400 33.24 .................... 6.65 

93745 ....... Set-up cardiovert-defibrill ............................... ........... S ....... 0689 0.5400 33.24 .................... 6.65 

93770 ....... Measure venous pressure ............................. ........... N ....... .......... .................... .................... .................... ....................

93786 ....... Ambulatory BP recording ............................... ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93788 ....... Ambulatory BP analysis ................................. ........... X ....... 0097 1.0245 63.06 23.79 12.61 

93797 ....... Cardiac rehab ................................................. ........... S ....... 0095 0.5792 35.65 13.86 7.13 

93798 ....... Cardiac rehab/monitor .................................... ........... S ....... 0095 0.5792 35.65 13.86 7.13 

93799 ....... Cardiovascular procedure .............................. CH .... X ....... 0097 1.0245 63.06 23.79 12.61 

93875 ....... Extracranial study ........................................... ........... S ....... 0096 1.5727 96.80 38.13 19.36 

93880 ....... Extracranial study ........................................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93882 ....... Extracranial study ........................................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93886 ....... Intracranial study ............................................ ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93888 ....... Intracranial study ............................................ CH .... S ....... 0265 1.0145 62.44 23.63 12.49 

93890 ....... Tcd, vasoreactivity study ................................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93892 ....... Tcd, emboli detect w/o inj .............................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93893 ....... Tcd, emboli detect w/inj ................................. ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93922 ....... Extremity study ............................................... ........... S ....... 0096 1.5727 96.80 38.13 19.36 

93923 ....... Extremity study ............................................... ........... S ....... 0096 1.5727 96.80 38.13 19.36 

93924 ....... Extremity study ............................................... ........... S ....... 0096 1.5727 96.80 38.13 19.36 

93925 ....... Lower extremity study .................................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93926 ....... Lower extremity study .................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93930 ....... Upper extremity study .................................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93931 ....... Upper extremity study .................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93965 ....... Extremity study ............................................... ........... S ....... 0096 1.5727 96.80 38.13 19.36 

93970 ....... Extremity study ............................................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93971 ....... Extremity study ............................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93975 ....... Vascular study ................................................ ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93976 ....... Vascular study ................................................ ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93978 ....... Vascular study ................................................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93979 ....... Vascular study ................................................ ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93980 ....... Penile vascular study ..................................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

93981 ....... Penile vascular study ..................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

93990 ....... Doppler flow testing ....................................... ........... S ....... 0266 1.5947 98.16 37.80 19.63 

94010 ....... Breathing capacity test ................................... ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94014 ....... Patient recorded spirometry ........................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94015 ....... Patient recorded spirometry ........................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94060 ....... Evaluation of wheezing .................................. ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94070 ....... Evaluation of wheezing .................................. ........... X ....... 0369 2.8329 174.37 44.18 34.87 

94150 ....... Vital capacity test ........................................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94200 ....... Lung function test (MBC/MVV) ...................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94240 ....... Residual lung capacity ................................... ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94250 ....... Expired gas collection .................................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94260 ....... Thoracic gas volume ...................................... CH .... X ....... 0368 0.9568 58.89 22.77 11.78 

94350 ....... Lung nitrogen washout curve ......................... CH .... X ....... 0368 0.9568 58.89 22.77 11.78 

94360 ....... Measure airflow resistance ............................ ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94370 ....... Breath airway closing volume ........................ ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94375 ....... Respiratory flow volume loop ......................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 


sroberts on PROD1PC70 with PROPOSALS
49828 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

94400 ....... CO2 breathing response curve ...................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94450 ....... Hypoxia response curve ................................ ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94452 ....... Hast w/report .................................................. ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94453 ....... Hast w/oxygen titrate ..................................... CH .... X ....... 0367 0.6253 38.49 14.64 7.70 

94620 ....... Pulmonary stress test/simple ......................... ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94621 ....... Pulm stress test/complex ............................... ........... X ....... 0369 2.8329 174.37 44.18 34.87 

94640 ....... Airway inhalation treatment ............................ ........... S ....... 0077 0.3383 20.82 7.74 4.16 

94642 ....... Aerosol inhalation treatment .......................... ........... S ....... 0078 1.0381 63.90 14.55 12.78 

94656 ....... Initial ventilator mgmt ..................................... ........... S ....... 0079 2.7732 170.69 .................... 34.14 

94657 ....... Continued ventilator mgmt ............................. ........... S ....... 0079 2.7732 170.69 .................... 34.14 

94660 ....... Pos airway pressure, CPAP .......................... ........... S ....... 0068 1.3718 84.44 29.48 16.89 

94662 ....... Neg press ventilation, cnp ............................. ........... S ....... 0079 2.7732 170.69 .................... 34.14 

94664 ....... Evaluate pt use of inhaler .............................. ........... S ....... 0077 0.3383 20.82 7.74 4.16 

94667 ....... Chest wall manipulation ................................. ........... S ....... 0077 0.3383 20.82 7.74 4.16 

94668 ....... Chest wall manipulation ................................. ........... S ....... 0077 0.3383 20.82 7.74 4.16 

94680 ....... Exhaled air analysis, o2 ................................. ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94681 ....... Exhaled air analysis, o2/co2 .......................... ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94690 ....... Exhaled air analysis ....................................... CH .... X ....... 0367 0.6253 38.49 14.64 7.70 

94720 ....... Monoxide diffusing capacity ........................... ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94725 ....... Membrane diffusion capacity ......................... ........... X ....... 0368 0.9568 58.89 22.77 11.78 

94750 ....... Pulmonary compliance study ......................... CH .... X ....... 0367 0.6253 38.49 14.64 7.70 

94760 ....... Measure blood oxygen level .......................... ........... N ....... .......... .................... .................... .................... ....................

94761 ....... Measure blood oxygen level .......................... ........... N ....... .......... .................... .................... .................... ....................

94762 ....... Measure blood oxygen level .......................... CH .... Q ....... 0443 0.9939 61.18 24.47 12.24 

94770 ....... Exhaled carbon dioxide test ........................... ........... X ....... 0367 0.6253 38.49 14.64 7.70 

94772 ....... Breath recording, infant .................................. ........... X ....... 0369 2.8329 174.37 44.18 34.87 

94799 ....... Pulmonary service/procedure ........................ ........... X ....... 0367 0.6253 38.49 14.64 7.70 

95004 ....... Percut allergy skin tests ................................. ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95010 ....... Percut allergy titrate test ................................ ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95015 ....... Id allergy titrate-drug/bug ............................... ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95024 ....... Id allergy test, drug/bug ................................. ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95027 ....... Id allergy titrate-airborne ................................ ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95028 ....... Id allergy test-delayed type ............................ ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95044 ....... Allergy patch tests .......................................... ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95052 ....... Photo patch test ............................................. ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95056 ....... Photosensitivity tests ...................................... ........... X ....... 0370 1.0769 66.28 .................... 13.26 

95060 ....... Eye allergy tests ............................................. ........... X ....... 0370 1.0769 66.28 .................... 13.26 

95065 ....... Nose allergy test ............................................ ........... X ....... 0381 0.2151 13.24 .................... 2.65 

95070 ....... Bronchial allergy tests .................................... ........... X ....... 0369 2.8329 174.37 44.18 34.87 

95071 ....... Bronchial allergy tests .................................... ........... X ....... 0369 2.8329 174.37 44.18 34.87 

95075 ....... Ingestion challenge test ................................. ........... X ....... 0361 3.9319 242.01 83.23 48.40 

95078 ....... Provocative testing ......................................... ........... X ....... 0370 1.0769 66.28 .................... 13.26 

95115 ....... Immunotherapy, one injection ........................ CH .... S ....... 0436 0.1769 10.89 .................... 2.18 

95117 ....... Immunotherapy injections .............................. CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95144 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95145 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95146 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95147 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95148 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95149 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95165 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95170 ....... Antigen therapy services ................................ CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

95180 ....... Rapid desensitization ..................................... ........... X ....... 0370 1.0769 66.28 .................... 13.26 

95199 ....... Allergy immunology services ......................... CH .... X ....... 0381 0.2151 13.24 .................... 2.65 

95250 ....... Glucose monitoring, cont ............................... ........... X ....... 0421 1.6486 101.47 .................... 20.29 

95805 ....... Multiple sleep latency test .............................. ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95806 ....... Sleep study, unattended ................................ ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95807 ....... Sleep study, attended .................................... ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95808 ....... Polysomnography, 1-3 ................................... ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95810 ....... Polysomnography, 4 or more ......................... ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95811 ....... Polysomnography w/cpap .............................. ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95812 ....... Eeg, 41-60 minutes ........................................ ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95813 ....... Eeg, over 1 hour ............................................ ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95816 ....... Eeg, awake and drowsy ................................. ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95819 ....... Eeg, awake and asleep ................................. ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95822 ....... Eeg, coma or sleep only ................................ ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95824 ....... Eeg, cerebral death only ................................ ........... S ....... 0214 1.2353 76.03 28.24 15.21 

95827 ....... Eeg, all night recording .................................. ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95829 ....... Surgery electrocorticogram ............................ ........... S ....... 0214 1.2353 76.03 28.24 15.21 

95857 ....... Tensilon test ................................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49829 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

95860 ....... Muscle test, one limb ..................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95861 ....... Muscle test, 2 limbs ....................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95863 ....... Muscle test, 3 limbs ....................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95864 ....... Muscle test, 4 limbs ....................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95865 ....... Muscle test, larynx ......................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95866 ....... Muscle test, hemidiaphragm .......................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95867 ....... Muscle test cran nerv unilat ........................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95868 ....... Muscle test cran nerve bilat ........................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95869 ....... Muscle test, thor paraspinal ........................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95870 ....... Muscle test, nonparaspinal ............................ ........... S ....... 0215 0.5760 35.45 .................... 7.09

95872 ....... Muscle test, one fiber ..................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95873 ....... Guide nerv destr, elec stim ............................ ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95874 ....... Guide nerv destr, needle emg ....................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95875 ....... Limb exercise test .......................................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95900 ....... Motor nerve conduction test .......................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95903 ....... Motor nerve conduction test .......................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95904 ....... Sense nerve conduction test ......................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95920 ....... Intraop nerve test add-on ............................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

95921 ....... Autonomic nerv function test ......................... CH .... S ....... 0215 0.5760 35.45 .................... 7.09 

95922 ....... Autonomic nerv function test ......................... CH .... S ....... 0215 0.5760 35.45 .................... 7.09 

95923 ....... Autonomic nerv function test ......................... CH .... S ....... 0215 0.5760 35.45 .................... 7.09 

95925 ....... Somatosensory testing ................................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

95926 ....... Somatosensory testing ................................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

95927 ....... Somatosensory testing ................................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

95928 ....... C motor evoked, uppr limbs ........................... ........... S ....... 0218 1.1993 73.82 .................... 14.76

95929 ....... C motor evoked, lwr limbs ............................. ........... S ....... 0218 1.1993 73.82 .................... 14.76 

95930 ....... Visual evoked potential test ........................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

95933 ....... Blink reflex test ............................................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95934 ....... H-reflex test .................................................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95936 ....... H-reflex test .................................................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

95937 ....... Neuromuscular junction test .......................... CH .... S ....... 0215 0.5760 35.45 .................... 7.09 

95950 ....... Ambulatory eeg monitoring ............................ ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95951 ....... EEG monitoring/videorecord .......................... ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95953 ....... EEG monitoring/computer .............................. ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95954 ....... EEG monitoring/giving drugs ......................... ........... S ....... 0214 1.2353 76.03 28.24 15.21 

95955 ....... EEG during surgery ....................................... ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95956 ....... Eeg monitoring, cable/radio ........................... ........... S ....... 0209 11.4847 706.89 268.73 141.38 

95957 ....... EEG digital analysis ....................................... ........... S ....... 0214 1.2353 76.03 28.24 15.21 

95958 ....... EEG monitoring/function test ......................... ........... S ....... 0213 2.3133 142.39 53.58 28.48 

95961 ....... Electrode stimulation, brain ............................ ........... S ....... 0216 2.6729 164.52 .................... 32.90 

95962 ....... Electrode stim, brain add-on .......................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

95965 ....... Meg, spontaneous .......................................... CH .... S ....... 0038 51.2627 3,155.27 .................... 631.05 

95966 ....... Meg, evoked, single ....................................... CH .... S ....... 0209 11.4847 706.89 268.73 141.38 

95967 ....... Meg, evoked, each add’l ................................ CH .... S ....... 0209 11.4847 706.89 268.73 141.38 

95970 ....... Analyze neurostim, no prog ........................... ........... S ....... 0218 1.1993 73.82 .................... 14.76

95971 ....... Analyze neurostim, simple ............................. ........... S ....... 0692 1.9519 120.14 30.16 24.03 

95972 ....... Analyze neurostim, complex .......................... ........... S ....... 0692 1.9519 120.14 30.16 24.03 

95973 ....... Analyze neurostim, complex .......................... CH .... S ....... 0663 1.0752 66.18 16.96 13.24 

95974 ....... Cranial neurostim, complex ........................... ........... S ....... 0692 1.9519 120.14 30.16 24.03 

95975 ....... Cranial neurostim, complex ........................... ........... S ....... 0692 1.9519 120.14 30.16 24.03 

95978 ....... Analyze neurostim brain/1h ........................... ........... S ....... 0692 1.9519 120.14 30.16 24.03 

95979 ....... Analyz neurostim brain addon ....................... CH .... S ....... 0663 1.0752 66.18 16.96 13.24 

95990 ....... Spin/brain pump refil&main ............................ ........... T ....... 0125 2.2200 136.64 .................... 27.33 

95991 ....... Spin/brain pump refil&main ............................ ........... T ....... 0125 2.2200 136.64 .................... 27.33 

95999 ....... Neurological procedure .................................. ........... S ....... 0215 0.5760 35.45 .................... 7.09 

96000 ....... Motion analysis, video/3d ............................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

96001 ....... Motion test w/ft press meas ........................... ........... S ....... 0216 2.6729 164.52 .................... 32.90 

96002 ....... Dynamic surface emg .................................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

96003 ....... Dynamic fine wire emg .................................. ........... S ....... 0215 0.5760 35.45 .................... 7.09 

96101 ....... Psycho testing by psych/phys ........................ ........... X ....... 0373 1.6262 100.09 .................... 20.02

96102 ....... Psycho testing by technician ......................... ........... X ....... 0382 2.7541 169.52 67.80 33.90 

96103 ....... Psycho testing admin by comp ...................... ........... X ....... 0373 1.6262 100.09 .................... 20.02 

96110 ....... Developmental test, lim .................................. ........... X ....... 0373 1.6262 100.09 .................... 20.02 

96111 ....... Developmental test, extend ........................... ........... X ....... 0373 1.6262 100.09 .................... 20.02 

96116 ....... Neurobehavioral status exam ........................ ........... X ....... 0373 1.6262 100.09 .................... 20.02 

96118 ....... Neuropsych tst by psych/phys ....................... ........... X ....... 0373 1.6262 100.09 .................... 20.02 

96119 ....... Neuropsych testing by tech ........................... ........... X ....... 0382 2.7541 169.52 67.80 33.90 

96120 ....... Neuropsych tst admin w/comp ....................... ........... X ....... 0373 1.6262 100.09 .................... 20.02 

96150 ....... Assess hlth/behave, init ................................. ........... S ....... 0432 0.6006 36.97 .................... 7.39 

96151 ....... Assess hlth/behave, subseq .......................... ........... S ....... 0432 0.6006 36.97 .................... 7.39 


sroberts on PROD1PC70 with PROPOSALS
49830 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

96152 ....... Intervene hlth/behave, indiv ........................... ........... S ....... 0432 0.6006 36.97 .................... 7.39 

96153 ....... Intervene hlth/behave, group ......................... ........... S ....... 0432 0.6006 36.97 .................... 7.39 

96154 ....... Interv hlth/behav, fam w/pt ............................. ........... S ....... 0432 0.6006 36.97 .................... 7.39 

96401 ....... Chemo, anti-neopl, sq/im ............................... CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

96402 ....... Chemo hormon antineopl sq/im ..................... CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

96405 ....... Chemo intralesional, up to 7 .......................... CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

96406 ....... Chemo intralesional over 7 ............................ CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

96416 ....... Chemo prolong infuse w/pump ...................... CH .... S ....... 0441 2.5071 154.31 .................... 30.86 

96420 ....... Chemo, ia, push tecnique .............................. CH .... S ....... 0439 1.5841 97.50 .................... 19.50 

96422 ....... Chemo ia infusion up to 1 hr ......................... CH .... S ....... 0441 2.5071 154.31 .................... 30.86 

96423 ....... Chemo ia infuse each addl hr ........................ CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

96425 ....... Chemotherapy,infusion method ..................... CH .... S ....... 0441 2.5071 154.31 .................... 30.86 

96440 ....... Chemotherapy, intracavitary .......................... CH .... S ....... 0439 1.5841 97.50 .................... 19.50 

96445 ....... Chemotherapy, intracavitary .......................... CH .... S ....... 0439 1.5841 97.50 .................... 19.50 

96450 ....... Chemotherapy, into CNS ............................... CH .... S ....... 0441 2.5071 154.31 .................... 30.86 

96521 ....... Refill/maint, portable pump ............................ CH .... S ....... 0440 1.8285 112.55 .................... 22.51 

96522 ....... Refill/maint pump/resvr syst ........................... CH .... S ....... 0440 1.8285 112.55 .................... 22.51 

96523 ....... Irrig drug delivery device ................................ CH .... Q ....... 0624 0.5336 32.84 13.13 6.57 

96542 ....... Chemotherapy injection ................................. CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

96549 ....... Chemotherapy, unspecified ........................... CH .... S ....... 0436 0.1769 10.89 .................... 2.18 

96567 ....... Photodynamic tx, skin .................................... ........... T ....... 0016 2.6253 161.59 32.68 32.32 

96570 ....... Photodynamic tx, 30 min ............................... ........... T ....... 0015 1.6062 98.86 20.13 19.77 

96571 ....... Photodynamic tx, addl 15 min ....................... ........... T ....... 0015 1.6062 98.86 20.13 19.77 

96900 ....... Ultraviolet light therapy .................................. ........... S ....... 0001 0.4896 30.14 7.00 6.03 

96902 ....... Trichogram ..................................................... ........... N ....... .......... .................... .................... .................... ....................

96910 ....... Photochemotherapy with UV–B ..................... ........... S ....... 0001 0.4896 30.14 7.00 6.03 

96912 ....... Photochemotherapy with UV–A ..................... ........... S ....... 0001 0.4896 30.14 7.00 6.03 

96913 ....... Photochemotherapy, UV–A or B .................... ........... S ....... 0683 2.6902 165.58 .................... 33.12 

96920 ....... Laser tx, skin < 250 sq cm ............................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 

96921 ....... Laser tx, skin 250–500 sq cm ........................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 

96922 ....... Laser tx, skin > 500 sq cm ............................ ........... T ....... 0013 1.0876 66.94 .................... 13.39 

96999 ....... Dermatological procedure .............................. ........... T ....... 0010 0.4829 29.72 8.14 5.94 

97597 ....... Active wound care/20 cm or < ....................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 

97598 ....... Active wound care > 20 cm ........................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

97602 ....... Wound(s) care non-selective ......................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

97605 ....... Neg press wound tx, < 50 cm ....................... ........... T ....... 0012 0.8076 49.71 10.30 9.94 

97606 ....... Neg press wound tx, > 50 cm ....................... ........... T ....... 0013 1.0876 66.94 .................... 13.39 

98925 ....... Osteopathic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

98926 ....... Osteopathic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

98927 ....... Osteopathic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

98928 ....... Osteopathic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

98929 ....... Osteopathic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

98940 ....... Chiropractic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

98941 ....... Chiropractic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

98942 ....... Chiropractic manipulation ............................... ........... S ....... 0060 0.4904 30.18 .................... 6.04 

99078 ....... Group health education .................................. ........... N ....... .......... .................... .................... .................... ....................

99091 ....... Collect/review data from pt ............................ ........... N ....... .......... .................... .................... .................... ....................

99143 ....... Mod cs by same phys, < 5 yrs ...................... ........... N ....... .......... .................... .................... .................... ....................

99144 ....... Mod cs by same phys, 5 yrs + ...................... ........... N ....... .......... .................... .................... .................... ....................

99145 ....... Mod cs by same phys add-on ....................... ........... N ....... .......... .................... .................... .................... ....................

99148 ....... Mod cs diff phys < 5 yrs ................................ ........... N ....... .......... .................... .................... .................... ....................

99149 ....... Mod cs diff phys 5 yrs + ................................ ........... N ....... .......... .................... .................... .................... ....................

99150 ....... Mod cs diff phys add-on ................................ ........... N ....... .......... .................... .................... .................... ....................

99170 ....... Anogenital exam, child ................................... ........... T ....... 0191 0.1501 9.24 .................... 1.85 

99175 ....... Induction of vomiting ...................................... ........... N ....... .......... .................... .................... .................... ....................

99185 ....... Regional hypothermia .................................... ........... N ....... .......... .................... .................... .................... ....................

99186 ....... Total body hypothermia ................................. ........... N ....... .......... .................... .................... .................... ....................

99195 ....... Phlebotomy .................................................... ........... X ....... 0372 0.5814 35.79 10.09 7.16 

99201 ....... Office/outpatient visit, new ............................. CH .... B ....... .......... .................... .................... .................... ....................

99202 ....... Office/outpatient visit, new ............................. CH .... B ....... .......... .................... .................... .................... ....................

99203 ....... Office/outpatient visit, new ............................. CH .... B ....... .......... .................... .................... .................... ....................

99204 ....... Office/outpatient visit, new ............................. CH .... B ....... .......... .................... .................... .................... ....................

99205 ....... Office/outpatient visit, new ............................. CH .... B ....... .......... .................... .................... .................... ....................

99211 ....... Office/outpatient visit, est ............................... CH .... B ....... .......... .................... .................... .................... ....................

99212 ....... Office/outpatient visit, est ............................... CH .... B ....... .......... .................... .................... .................... ....................

99213 ....... Office/outpatient visit, est ............................... CH .... B ....... .......... .................... .................... .................... ....................

99214 ....... Office/outpatient visit, est ............................... CH .... B ....... .......... .................... .................... .................... ....................

99215 ....... Office/outpatient visit, est ............................... CH .... B ....... .......... .................... .................... .................... ....................

99241 ....... Office consultation .......................................... CH .... B ....... .......... .................... .................... .................... ....................

99242 ....... Office consultation .......................................... CH .... B ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49831 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

99243 ....... Office consultation .......................................... CH .... B ....... .......... .................... .................... .................... ....................

99244 ....... Office consultation .......................................... CH .... B ....... .......... .................... .................... .................... ....................

99245 ....... Office consultation .......................................... CH .... B ....... .......... .................... .................... .................... ....................

99281 ....... Emergency dept visit ...................................... CH .... B ....... .......... .................... .................... .................... ....................

99282 ....... Emergency dept visit ...................................... CH .... B ....... .......... .................... .................... .................... ....................

99283 ....... Emergency dept visit ...................................... CH .... B ....... .......... .................... .................... .................... ....................

99284 ....... Emergency dept visit ...................................... CH .... B ....... .......... .................... .................... .................... ....................

99285 ....... Emergency dept visit ...................................... CH .... B ....... .......... .................... .................... .................... ....................

99289 ....... Ped crit care transport ................................... ........... N ....... .......... .................... .................... .................... ....................

99290 ....... Ped crit care transport addl ........................... ........... N ....... .......... .................... .................... .................... ....................

99291 ....... Critical care, first hour .................................... CH .... B ....... .......... .................... .................... .................... ....................

99292 ....... Critical care, add’l 30 min .............................. CH .... B ....... .......... .................... .................... .................... ....................

99300 ....... Ic, infant pbw 2501-5000 gm ......................... ........... N ....... .......... .................... .................... .................... ....................

99354 ....... Prolonged service, office ................................ ........... N ....... .......... .................... .................... .................... ....................

99355 ....... Prolonged service, office ................................ ........... N ....... .......... .................... .................... .................... ....................

99358 ....... Prolonged serv, w/o contact .......................... ........... N ....... .......... .................... .................... .................... ....................

99359 ....... Prolonged serv, w/o contact .......................... ........... N ....... .......... .................... .................... .................... ....................

99361 ....... Physician/team conference ............................ ........... N ....... .......... .................... .................... .................... ....................

99362 ....... Physician/team conference ............................ ........... N ....... .......... .................... .................... .................... ....................

99431 ....... Initial care, normal newborn ........................... CH .... V ....... 0605 1.0057 61.90 .................... 12.38 

99432 ....... Newborn care, not in hosp ............................. ........... N ....... .......... .................... .................... .................... ....................

99436 ....... Attendance, birth ............................................ ........... N ....... .......... .................... .................... .................... ....................

99440 ....... Newborn resuscitation .................................... ........... S ....... 0094 2.4630 151.60 46.29 30.32 

0003T ....... Cervicography ................................................ CH .... T ....... 0191 0.1501 9.24 .................... 1.85 

0008T ....... Upper gi endoscopy w/suture ........................ ........... T ....... 0422 27.5493 1,695.69 448.81 339.14 

0016T ....... Thermotx choroid vasc lesion ........................ ........... T ....... 0235 4.0750 250.82 61.14 50.16 

0017T ....... Photocoagulat macular drusen ...................... ........... T ....... 0235 4.0750 250.82 61.14 50.16 

0018T ....... Transcranial magnetic stimul ......................... ........... S ....... 0215 0.5760 35.45 .................... 7.09 

0027T ....... Endoscopic epidural lysis ............................... ........... T ....... 0220 17.7609 1,093.20 .................... 218.64 

0028T ....... Dexa body composition study ........................ ........... N ....... .......... .................... .................... .................... ....................

0031T ....... Speculoscopy ................................................. ........... N ....... .......... .................... .................... .................... ....................

0032T ....... Speculoscopy w/direct sample ....................... ........... N ....... .......... .................... .................... .................... ....................

0042T ....... Ct perfusion w/contrast, cbf ........................... ........... N ....... .......... .................... .................... .................... ....................

0044T ....... Whole body photography ............................... ........... N ....... .......... .................... .................... .................... ....................

0045T ....... Whole body photography ............................... ........... N ....... .......... .................... .................... .................... ....................

0046T ....... Cath lavage, mammary duct(s ....................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

0047T ....... Cath lavage, mammary duct(s) ...................... ........... T ....... 0021 14.9563 920.58 219.48 184.12 

0054T ....... Bone surgery using computer ........................ ........... S ....... 0302 5.5005 338.56 105.94 67.71 

0055T ....... Bone surgery using computer ........................ ........... S ....... 0302 5.5005 338.56 105.94 67.71 

0056T ....... Bone surgery using computer ........................ ........... S ....... 0302 5.5005 338.56 105.94 67.71 

0058T ....... Cryopreservation, ovary tiss .......................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

0059T ....... Cryopreservation, oocyte ............................... ........... X ....... 0348 0.8928 54.95 .................... 10.99 

0062T ....... Rep intradisc annulus;1 lev ............................ ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

0063T ....... Rep intradisc annulus;>1lev ........................... ........... T ....... 0050 25.0600 1,542.47 .................... 308.49 

0064T ....... Spectroscop eval expired gas ........................ ........... X ....... 0367 0.6253 38.49 14.64 7.70 

0067T ....... Ct colonography;dx ........................................ ........... S ....... 0333 5.0020 307.88 121.52 61.58 

0069T ....... Analysis only heart sound .............................. ........... N ....... .......... .................... .................... .................... ....................

0070T ....... Interp only heart sound .................................. ........... N ....... .......... .................... .................... .................... ....................

0071T ....... U/s leiomyomata ablate <200 ........................ ........... T ....... 0195 28.7410 1,769.04 483.80 353.81 

0072T ....... U/s leiomyomata ablate >200 ........................ ........... T ....... 0202 42.8756 2,639.04 981.50 527.81 

0073T ....... Delivery, comp imrt ........................................ ........... S ....... 0412 5.5021 338.66 .................... 67.73 

0083T ....... Stereotactic rad tx mngmt .............................. ........... N ....... .......... .................... .................... .................... ....................

0084T ....... Temp prostate urethral stent .......................... ........... T ....... 0164 2.1159 130.24 .................... 26.05 

0085T ....... Breath test heart reject .................................. ........... X ....... 0340 0.6211 38.23 .................... 7.65 

0086T ....... L ventricle fill pressure ................................... ........... N ....... .......... .................... .................... .................... ....................

0087T ....... Sperm eval hyaluronan .................................. ........... X ....... 0348 0.8928 54.95 .................... 10.99 

0088T ....... Rf tongue base vol reduxn ............................. ........... T ....... 0253 16.4494 1,012.48 282.29 202.50 

0089T ....... Actigraphy testing, 3-day ............................... ........... S ....... 0218 1.1993 73.82 .................... 14.76 

0099T ....... Implant corneal ring ....................................... ........... T ....... 0233 14.9969 923.07 266.33 184.61 

0100T ....... Prosth retina receive&gen .............................. ........... T ....... 0672 36.8820 2,270.12 .................... 454.02 

0101T ....... Extracorp shockwv tx,hi enrg ......................... CH .... T ....... 0050 25.0600 1,542.47 .................... 308.49

0102T ....... Extracorp shockwv tx,anesth ......................... CH .... T ....... 0050 25.0600 1,542.47 .................... 308.49 

0106T ....... Touch quant sensory test .............................. ........... X ....... 0341 0.0914 5.63 2.25 1.13 

0107T ....... Vibrate quant sensory test ............................. ........... X ....... 0341 0.0914 5.63 2.25 1.13 

0108T ....... Cool quant sensory test ................................. ........... X ....... 0341 0.0914 5.63 2.25 1.13 

0109T ....... Heat quant sensory test ................................. ........... X ....... 0341 0.0914 5.63 2.25 1.13 

0110T ....... Nos quant sensory test .................................. ........... X ....... 0341 0.0914 5.63 2.25 1.13 

0120T ....... Fibroadenoma cryoablate, ea ........................ ........... T ....... 0029 28.1505 1,732.69 .................... 346.54 

0123T ....... Scleral fistulization ......................................... ........... T ....... 0234 22.9479 1,412.47 511.31 282.49 

0124T ....... Conjunctival drug placement .......................... ........... T ....... 0232 5.9800 368.07 92.21 73.61 


sroberts on PROD1PC70 with PROPOSALS
49832 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

0126T ....... Chd risk imt study .......................................... ........... N ....... .......... .................... .................... .................... ....................

0133T ....... Esophageal implant injexn ............................. CH .... T ....... 0422 27.5493 1,695.69 448.81 339.14 

0135T ....... Perq cryoablate renal tumor .......................... CH .... T ....... 0423 39.0235 2,401.94 .................... 480.39

0137T ....... Prostate saturation sampling ......................... ........... T ....... 0184 5.9892 368.64 96.27 73.73 

0144T ....... CT heart wo dye; qual calc ............................ ........... S ....... 0398 4.2511 261.66 100.06 52.33 

0145T ....... CT heart w/wo dye funct ................................ ........... S ....... 0376 4.9770 306.34 119.77 61.27 

0146T ....... CCTA w/wo dye ............................................. ........... S ....... 0376 4.9770 306.34 119.77 61.27 

0147T ....... CCTA w/wo, quan calcium ............................. ........... S ....... 0376 4.9770 306.34 119.77 61.27 

0148T ....... CCTA w/wo, strxr ........................................... ........... S ....... 0377 6.7443 415.12 158.84 83.02 

0149T ....... CCTA w/wo, strxr quan calc .......................... ........... S ....... 0377 6.7443 415.12 158.84 83.02 

0150T ....... CCTA w/wo, disease strxr ............................. ........... S ....... 0398 4.2511 261.66 100.06 52.33 

0151T ....... CT heart funct add-on .................................... ........... S ....... 0282 1.5552 95.72 37.92 19.14 

0152T ....... Computer chest add-on ................................. ........... N ....... .......... .................... .................... .................... ....................

0154T ....... Implant aneur sensor study ........................... ........... X ....... 0097 1.0245 63.06 23.79 12.61 

A0800 ...... Amb trans 7pm-7am ...................................... CH .... E ....... .......... .................... .................... .................... ....................

A4218 ...... Sterile saline or water .................................... ........... N ....... .......... .................... .................... .................... ....................

A4220 ...... Infusion pump refill kit .................................... ........... N ....... .......... .................... .................... .................... ....................

A4248 ...... Chlorhexidine antisept .................................... ........... N ....... .......... .................... .................... .................... ....................

A4262 ...... Temporary tear duct plug ............................... ........... N ....... .......... .................... .................... .................... ....................

A4263 ...... Permanent tear duct plug .............................. ........... N ....... .......... .................... .................... .................... ....................

A4270 ...... Disposable endoscope sheath ....................... ........... N ....... .......... .................... .................... .................... ....................

A4300 ...... Cath impl vasc access portal ......................... ........... N ....... .......... .................... .................... .................... ....................

A4301 ...... Implantable access syst perc ......................... ........... N ....... .......... .................... .................... .................... ....................

A4561 ...... Pessary rubber, any type ............................... ........... N ....... .......... .................... .................... .................... ....................

A4562 ...... Pessary, non rubber,any type ........................ ........... N ....... .......... .................... .................... .................... ....................

A4641 ...... Radiopharm dx agent noc .............................. ........... N ....... .......... .................... .................... .................... ....................

A4642 ...... In111 satumomab .......................................... CH .... K ....... 0704 .................... 192.12 .................... 38.42 

A9500 ...... Tc99m sestamibi ............................................ CH .... K ....... 1600 .................... 82.58 .................... 16.52 

A9502 ...... Tc99m tetrofosmin ......................................... CH .... K ....... 0705 .................... 73.81 .................... 14.76 

A9503 ...... Tc99m medronate .......................................... ........... N ....... .......... .................... .................... .................... ....................

A9504 ...... Tc99m apcitide ............................................... CH .... N ....... .......... .................... .................... .................... ....................

A9505 ...... TL201 thallium ................................................ CH .... K ....... 1603 .................... 27.18 .................... 5.44 

A9507 ...... In111 capromab ............................................. CH .... K ....... 1604 .................... 928.19 .................... 185.64 

A9508 ...... I131 iodobenguate, dx ................................... CH .... K ....... 1045 .................... 429.55 .................... 85.91 

A9510 ...... Tc99m disofenin ............................................. CH .... N ....... .......... .................... .................... .................... ....................

A9512 ...... Tc99m pertechnetate ..................................... ........... N ....... .......... .................... .................... .................... ....................

A9516 ...... I123 iodide cap, dx ......................................... CH .... K ....... 9148 .................... 27.44 .................... 5.49 

A9517 ...... I131 iodide cap, rx ......................................... CH .... K ....... 1064 .................... 14.54 .................... 2.91 

A9521 ...... Tc99m exametazime ...................................... CH .... K ....... 1096 .................... 317.07 .................... 63.41 

A9524 ...... I131 serum albumin, dx ................................. CH .... K ....... 9100 .................... 36.78 .................... 7.36 

A9526 ...... Nitrogen N-13 ammonia ................................. CH .... K ....... 0737 .................... 230.77 .................... 46.15 

A9528 ...... Iodine I-131 iodide cap, dx ............................ CH .... K ....... 1088 .................... 24.86 .................... 4.97 

A9529 ...... I131 iodide sol, dx .......................................... CH .... N ....... .......... .................... .................... .................... ....................

A9530 ...... I131 iodide sol, rx ........................................... CH .... K ....... 1150 .................... 12.60 .................... 2.52 

A9531 ...... I131 max 100uCi ............................................ CH .... N ....... .......... .................... .................... .................... ....................

A9532 ...... I125 serum albumin, dx ................................. CH .... N ....... .......... .................... .................... .................... ....................

A9535 ...... Injection, methylene blue ............................... CH .... N ....... .......... .................... .................... .................... ....................

A9536 ...... Tc99m depreotide .......................................... CH .... K ....... 0739 .................... 67.91 .................... 13.58 

A9537 ...... Tc99m mebrofenin ......................................... ........... N ....... .......... .................... .................... .................... ....................

A9538 ...... Tc99m pyrophosphate ................................... ........... N ....... .......... .................... .................... .................... ....................

A9539 ...... Tc99m pentetate ............................................ CH .... K ....... 0722 .................... 56.77 .................... 11.35 

A9540 ...... Tc99m MAA ................................................... ........... N ....... .......... .................... .................... .................... ....................

A9541 ...... Tc99m sulfur colloid ....................................... ........... N ....... .......... .................... .................... .................... ....................

A9542 ...... In111 ibritumomab, dx ................................... CH .... K ....... 1642 .................... 1,344.34 .................... 268.87 

A9543 ...... Y90 ibritumomab, rx ....................................... CH .... K ....... 1643 .................... 12,130.20 .................... 2,426.04 

A9544 ...... I131 tositumomab, dx ..................................... CH .... K ....... 1644 .................... 1,368.17 .................... 273.63 

A9545 ...... I131 tositumomab, rx ..................................... CH .... K ....... 1645 .................... 11,868.78 .................... 2,373.76 

A9546 ...... Co57/58 .......................................................... CH .... K ....... 0723 .................... 149.44 .................... 29.89 

A9547 ...... In111 oxyquinoline ......................................... CH .... K ....... 1646 .................... 306.51 .................... 61.30 

A9548 ...... In111 pentetate .............................................. CH .... K ....... 1647 .................... 262.81 .................... 52.56 

A9549 ...... Tc99m arcitumomab ...................................... CH .... K ....... 1648 .................... 255.95 .................... 51.19 

A9550 ...... Tc99m gluceptate ........................................... CH .... K ....... 0740 .................... 236.53 .................... 47.31 

A9551 ...... Tc99m succimer ............................................. CH .... K ....... 1650 .................... 84.79 .................... 16.96 

A9552 ...... F18 fdg ........................................................... CH .... K ....... 1651 .................... 235.56 .................... 47.11 

A9553 ...... Cr51 chromate ............................................... CH .... K ....... 0741 .................... 167.62 .................... 33.52 

A9554 ...... I125 iothalamate, dx ....................................... CH .... N ....... .......... .................... .................... .................... ....................

A9555 ...... Rb82 rubidium ................................................ CH .... K ....... 1654 .................... 239.83 .................... 47.97 

A9556 ...... Ga67 gallium .................................................. CH .... K ....... 1671 .................... 22.73 .................... 4.55 

A9557 ...... Tc99m bicisate ............................................... CH .... K ....... 1672 .................... 254.46 .................... 50.89 

A9558 ...... Xe133 xenon 10mci ....................................... ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49833 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

A9559 ...... Co57 cyano .................................................... CH .... K ....... 0724 .................... 63.74 .................... 12.75 

A9560 ...... Tc99m labeled rbc ......................................... CH .... K ....... 0742 .................... 132.95 .................... 26.59 

A9561 ...... Tc99m oxidronate .......................................... ........... N ....... .......... .................... .................... .................... ....................

A9562 ...... Tc99m mertiatide ........................................... CH .... K ....... 0743 .................... 180.08 .................... 36.02 

A9563 ...... P32 Na phosphate ......................................... CH .... K ....... 1675 .................... 117.11 .................... 23.42 

A9564 ...... P32 chromic phosphate ................................. CH .... K ....... 1676 .................... 222.35 .................... 44.47 

A9565 ...... In111 pentetreotide ........................................ CH .... K ....... 1677 .................... 185.60 .................... 37.12 

A9566 ...... Tc99m fanolesomab ....................................... CH .... K ....... 1678 .................... 527.31 .................... 105.46 

A9567 ...... Technetium TC-99m aerosol ......................... CH .... N ....... .......... .................... .................... .................... ....................

A9600 ...... Sr89 strontium ................................................ CH .... K ....... 0701 .................... 533.58 .................... 106.72 

A9605 ...... Sm 153 lexidronm .......................................... CH .... K ....... 0702 .................... 1,316.41 .................... 263.28 

A9698 ...... Non-rad contrast materialNOC ...................... ........... N ....... .......... .................... .................... .................... ....................

A9699 ...... Radiopharm rx agent noc .............................. ........... N ....... .......... .................... .................... .................... ....................

C1178 ...... BUSULFAN IV, 6 Mg ..................................... ........... K ....... 1178 .................... 24.87 .................... 4.97 

C1300 ...... HYPERBARIC Oxygen .................................. ........... S ....... 0659 1.5925 98.02 .................... 19.60 

C1713 ...... Anchor/screw bn/bn,tis/bn .............................. ........... N ....... .......... .................... .................... .................... ....................

C1714 ...... Cath, trans atherectomy, dir .......................... ........... N ....... .......... .................... .................... .................... ....................

C1715 ...... Brachytherapy needle .................................... ........... N ....... .......... .................... .................... .................... ....................

C1716 ...... Brachytx source, Gold 198 ............................ CH .... K ....... 1716 0.4493 27.65 .................... 5.53 

C1717 ...... Brachytx source, HDR Ir-192 ......................... CH .... K ....... 1717 2.1922 134.93 .................... 26.99 

C1718 ...... Brachytx source, Iodine 125 .......................... CH .... K ....... 1718 0.5754 35.42 .................... 7.08 

C1719 ...... Brachytx sour,Non-HDR Ir-192 ...................... CH .... K ....... 1719 0.5108 31.44 .................... 6.29 

C1720 ...... Brachytx sour, Palladium 103 ........................ CH .... K ....... 1720 0.7945 48.90 .................... 9.78 

C1721 ...... AICD, dual chamber ....................................... ........... N ....... .......... .................... .................... .................... ....................

C1722 ...... AICD, single chamber .................................... ........... N ....... .......... .................... .................... .................... ....................

C1724 ...... Cath, trans atherec,rotation ........................... ........... N ....... .......... .................... .................... .................... ....................

C1725 ...... Cath, translumin non-laser ............................. ........... N ....... .......... .................... .................... .................... ....................

C1726 ...... Cath, bal dil, non-vascular ............................. ........... N ....... .......... .................... .................... .................... ....................

C1727 ...... Cath, bal tis dis, non-vas ............................... ........... N ....... .......... .................... .................... .................... ....................

C1728 ...... Cath, brachytx seed adm ............................... ........... N ....... .......... .................... .................... .................... ....................

C1729 ...... Cath, drainage ................................................ ........... N ....... .......... .................... .................... .................... ....................

C1730 ...... Cath, EP, 19 or few elect ............................... ........... N ....... .......... .................... .................... .................... ....................

C1731 ...... Cath, EP, 20 or more elec ............................. ........... N ....... .......... .................... .................... .................... ....................

C1732 ...... Cath, EP, diag/abl, 3D/vect ............................ ........... N ....... .......... .................... .................... .................... ....................

C1733 ...... Cath, EP, othr than cool-tip ........................... ........... N ....... .......... .................... .................... .................... ....................

C1750 ...... Cath, hemodialysis,long-term ......................... ........... N ....... .......... .................... .................... .................... ....................

C1751 ...... Cath, inf, per/cent/midline .............................. ........... N ....... .......... .................... .................... .................... ....................

C1752 ...... Cath,hemodialysis,short-term ......................... ........... N ....... .......... .................... .................... .................... ....................

C1753 ...... Cath, intravas ultrasound ............................... ........... N ....... .......... .................... .................... .................... ....................

C1754 ...... Catheter, intradiscal ....................................... ........... N ....... .......... .................... .................... .................... ....................

C1755 ...... Catheter, intraspinal ....................................... ........... N ....... .......... .................... .................... .................... ....................

C1756 ...... Cath, pacing, transesoph ............................... ........... N ....... .......... .................... .................... .................... ....................

C1757 ...... Cath, thrombectomy/embolect ....................... ........... N ....... .......... .................... .................... .................... ....................

C1758 ...... Catheter, ureteral ........................................... ........... N ....... .......... .................... .................... .................... ....................

C1759 ...... Cath, intra echocardiography ......................... ........... N ....... .......... .................... .................... .................... ....................

C1760 ...... Closure dev, vasc .......................................... ........... N ....... .......... .................... .................... .................... ....................

C1762 ...... Conn tiss, human(inc fascia) ......................... ........... N ....... .......... .................... .................... .................... ....................

C1763 ...... Conn tiss, non-human .................................... ........... N ....... .......... .................... .................... .................... ....................

C1764 ...... Event recorder, cardiac .................................. ........... N ....... .......... .................... .................... .................... ....................

C1765 ...... Adhesion barrier ............................................. ........... N ....... .......... .................... .................... .................... ....................

C1766 ...... Intro/sheath,strble,non-peel ............................ ........... N ....... .......... .................... .................... .................... ....................

C1767 ...... Generator, neuro non-recharg ....................... ........... N ....... .......... .................... .................... .................... ....................

C1768 ...... Graft, vascular ................................................ ........... N ....... .......... .................... .................... .................... ....................

C1769 ...... Guide wire ...................................................... ........... N ....... .......... .................... .................... .................... ....................

C1770 ...... Imaging coil, MR, insertable .......................... ........... N ....... .......... .................... .................... .................... ....................

C1771 ...... Rep dev, urinary, w/sling ............................... ........... N ....... .......... .................... .................... .................... ....................

C1772 ...... Infusion pump, programmable ....................... ........... N ....... .......... .................... .................... .................... ....................

C1773 ...... Ret dev, insertable ......................................... ........... N ....... .......... .................... .................... .................... ....................

C1776 ...... Joint device (implantable) .............................. ........... N ....... .......... .................... .................... .................... ....................

C1777 ...... Lead, AICD, endo single coil ......................... ........... N ....... .......... .................... .................... .................... ....................

C1778 ...... Lead, neurostimulator .................................... ........... N ....... .......... .................... .................... .................... ....................

C1779 ...... Lead, pmkr, transvenous VDD ....................... ........... N ....... .......... .................... .................... .................... ....................

C1780 ...... Lens, intraocular (new tech) .......................... ........... N ....... .......... .................... .................... .................... ....................

C1781 ...... Mesh (implantable) ......................................... ........... N ....... .......... .................... .................... .................... ....................

C1782 ...... Morcellator ...................................................... ........... N ....... .......... .................... .................... .................... ....................

C1783 ...... Ocular imp, aqueous drain de ....................... ........... N ....... .......... .................... .................... .................... ....................

C1784 ...... Ocular dev, intraop, det ret ............................ ........... N ....... .......... .................... .................... .................... ....................

C1785 ...... Pmkr, dual, rate-resp ..................................... ........... N ....... .......... .................... .................... .................... ....................

C1786 ...... Pmkr, single, rate-resp ................................... ........... N ....... .......... .................... .................... .................... ....................

C1787 ...... Patient progr, neurostim ................................. ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
49834 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

C1788 ...... Port, indwelling, imp ....................................... ........... N ....... .......... .................... .................... .................... ....................

C1789 ...... Prosthesis, breast, imp .................................. ........... N ....... .......... .................... .................... .................... ....................

C1813 ...... Prosthesis, penile, inflatab ............................. ........... N ....... .......... .................... .................... .................... ....................

C1814 ...... Retinal tamp, silicone oil ................................ ........... N ....... .......... .................... .................... .................... ....................

C1815 ...... Pros, urinary sph, imp .................................... ........... N ....... .......... .................... .................... .................... ....................

C1816 ...... Receiver/transmitter, neuro ............................ ........... N ....... .......... .................... .................... .................... ....................

C1817 ...... Septal defect imp sys ..................................... ........... N ....... .......... .................... .................... .................... ....................

C1818 ...... Integrated keratoprosthesis ............................ ........... N ....... .......... .................... .................... .................... ....................

C1819 ...... Tissue localization-excision ............................ ........... N ....... .......... .................... .................... .................... ....................

C1820 ...... Generator neuro rechg bat sy ........................ ........... H ....... 1820 .................... .................... .................... ....................

C1874 ...... Stent, coated/cov w/del sys ........................... ........... N ....... .......... .................... .................... .................... ....................

C1875 ...... Stent, coated/cov w/o del sy .......................... ........... N ....... .......... .................... .................... .................... ....................

C1876 ...... Stent, non-coa/non-cov w/del ........................ ........... N ....... .......... .................... .................... .................... ....................

C1877 ...... Stent, non-coat/cov w/o del ........................... ........... N ....... .......... .................... .................... .................... ....................

C1878 ...... Matrl for vocal cord ........................................ ........... N ....... .......... .................... .................... .................... ....................

C1879 ...... Tissue marker, implantable ............................ ........... N ....... .......... .................... .................... .................... ....................

C1880 ...... Vena cava filter .............................................. ........... N ....... .......... .................... .................... .................... ....................

C1881 ...... Dialysis access system .................................. ........... N ....... .......... .................... .................... .................... ....................

C1882 ...... AICD, other than sing/dual ............................. ........... N ....... .......... .................... .................... .................... ....................

C1883 ...... Adapt/ext, pacing/neuro lead ......................... ........... N ....... .......... .................... .................... .................... ....................

C1884 ...... Embolization Protect syst ............................... ........... N ....... .......... .................... .................... .................... ....................

C1885 ...... Cath, translumin angio laser .......................... ........... N ....... .......... .................... .................... .................... ....................

C1887 ...... Catheter, guiding ............................................ ........... N ....... .......... .................... .................... .................... ....................

C1888 ...... Endovas non-cardiac abl cath ....................... ........... N ....... .......... .................... .................... .................... ....................

C1891 ...... Infusion pump,non-prog, perm ....................... ........... N ....... .......... .................... .................... .................... ....................

C1892 ...... Intro/sheath,fixed,peel-away .......................... ........... N ....... .......... .................... .................... .................... ....................

C1893 ...... Intro/sheath, fixed,non-peel ............................ ........... N ....... .......... .................... .................... .................... ....................

C1894 ...... Intro/sheath, non-laser ................................... ........... N ....... .......... .................... .................... .................... ....................

C1895 ...... Lead, AICD, endo dual coil ............................ ........... N ....... .......... .................... .................... .................... ....................

C1896 ...... Lead, AICD, non sing/dual ............................. ........... N ....... .......... .................... .................... .................... ....................

C1897 ...... Lead, neurostim test kit .................................. ........... N ....... .......... .................... .................... .................... ....................

C1898 ...... Lead, pmkr, other than trans ......................... ........... N ....... .......... .................... .................... .................... ....................

C1899 ...... Lead, pmkr/AICD combination ....................... ........... N ....... .......... .................... .................... .................... ....................

C1900 ...... Lead, coronary venous .................................. ........... N ....... .......... .................... .................... .................... ....................

C2614 ...... Probe, perc lumb disc .................................... ........... N ....... .......... .................... .................... .................... ....................

C2615 ...... Sealant, pulmonary, liquid .............................. ........... N ....... .......... .................... .................... .................... ....................

C2616 ...... Brachytx source, Yttrium-90 ........................... CH .... K ....... 2616 272.7710 16,789.33 .................... 3,357.87 

C2617 ...... Stent, non-cor, tem w/o del ............................ ........... N ....... .......... .................... .................... .................... ....................

C2618 ...... Probe, cryoablation ........................................ ........... N ....... .......... .................... .................... .................... ....................

C2619 ...... Pmkr, dual, non rate-resp .............................. ........... N ....... .......... .................... .................... .................... ....................

C2620 ...... Pmkr, single, non rate-resp ............................ ........... N ....... .......... .................... .................... .................... ....................

C2621 ...... Pmkr, other than sing/dual ............................. ........... N ....... .......... .................... .................... .................... ....................

C2622 ...... Prosthesis, penile, non-inf .............................. ........... N ....... .......... .................... .................... .................... ....................

C2625 ...... Stent, non-cor, tem w/del sy .......................... ........... N ....... .......... .................... .................... .................... ....................

C2626 ...... Infusion pump, non-prog,temp ....................... ........... N ....... .......... .................... .................... .................... ....................

C2627 ...... Cath, suprapubic/cystoscopic ........................ ........... N ....... .......... .................... .................... .................... ....................

C2628 ...... Catheter, occlusion ........................................ ........... N ....... .......... .................... .................... .................... ....................

C2629 ...... Intro/sheath, laser .......................................... ........... N ....... .......... .................... .................... .................... ....................

C2630 ...... Cath, EP, cool-tip ........................................... ........... N ....... .......... .................... .................... .................... ....................

C2631 ...... Rep dev, urinary, w/o sling ............................ ........... N ....... .......... .................... .................... .................... ....................

C2632 ...... Brachytx sol, I-125, per mCi .......................... CH .... K ....... 2632 0.3139 19.32 .................... 3.86 

C2633 ...... Brachytx source, Cesium-131 ........................ CH .... K ....... 2633 1.4622 90.00 .................... 18.00 

C2634 ...... Brachytx source, HA, I-125 ............................ CH .... K ....... 2634 0.4172 25.68 .................... 5.14 

C2635 ...... Brachytx source, HA, P-103 .......................... CH .... K ....... 2635 0.8820 54.29 .................... 10.86 

C2636 ...... Brachytx linear source,P-103 ......................... CH .... K ....... 2636 0.6360 39.15 .................... 7.83 

C2637 ...... Brachytx, Ytterbium-169 ................................. CH .... K ....... 2637 0.4172 25.68 .................... 5.14 

C8900 ...... MRA w/cont, abd ............................................ ........... S ....... 0284 6.2589 385.24 148.40 77.05 

C8901 ...... MRA w/o cont, abd ........................................ ........... S ....... 0336 5.8500 360.07 139.68 72.01 

C8902 ...... MRA w/o fol w/cont, abd ................................ ........... S ....... 0337 8.3423 513.48 202.50 102.70 

C8903 ...... MRI w/cont, breast, uni .................................. ........... S ....... 0284 6.2589 385.24 148.40 77.05 

C8904 ...... MRI w/o cont, breast, uni ............................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

C8905 ...... MRI w/o fol w/cont, brst, un ........................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

C8906 ...... MRI w/cont, breast, bi .................................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

C8907 ...... MRI w/o cont, breast, bi ................................. ........... S ....... 0336 5.8500 360.07 139.68 72.01 

C8908 ...... MRI w/o fol w/cont, breast, ............................ ........... S ....... 0337 8.3423 513.48 202.50 102.70 

C8909 ...... MRA w/cont, chest ......................................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

C8910 ...... MRA w/o cont, chest ...................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

C8911 ...... MRA w/o fol w/cont, chest ............................. ........... S ....... 0337 8.3423 513.48 202.50 102.70 

C8912 ...... MRA w/cont, lwr ext ....................................... ........... S ....... 0284 6.2589 385.24 148.40 77.05 

C8913 ...... MRA w/o cont, lwr ext .................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49835 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

C8914 ...... MRA w/o fol w/cont, lwr ext ........................... ........... S ....... 0337 8.3423 513.48 202.50 102.70 

C8918 ...... MRA w/cont, pelvis ........................................ ........... S ....... 0284 6.2589 385.24 148.40 77.05 

C8919 ...... MRA w/o cont, pelvis ..................................... ........... S ....... 0336 5.8500 360.07 139.68 72.01 

C8920 ...... MRA w/o fol w/cont, pelvis ............................. ........... S ....... 0337 8.3423 513.48 202.50 102.70 

C8950 ...... IV inf, tx/dx, up to 1 hr ................................... CH .... S ....... 0440 1.8285 112.55 .................... 22.51 

C8951 ...... IV inf, tx/dx, each addl hr ............................... CH .... S ....... 0437 0.4107 25.28 .................... 5.06 

C8952 ...... Tx, prophy, dx IV push ................................... CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

C8953 ...... Chemotx adm, IV push .................................. CH .... S ....... 0439 1.5841 97.50 .................... 19.50 

C8954 ...... Chemotx adm, IV inf up to 1h ........................ CH .... S ....... 0441 2.5071 154.31 .................... 30.86 

C8955 ...... Chemotx adm, IV inf, addl hr ......................... CH .... S ....... 0438 0.7892 48.58 .................... 9.72 

C8957 ...... Prolonged IV inf, req pump ............................ CH .... S ....... 0441 2.5071 154.31 .................... 30.86 

C9003 ...... Palivizumab, per 50 mg ................................. ........... K ....... 9003 .................... 609.62 .................... 121.92 

C9113 ...... Inj pantoprazole sodium, via .......................... ........... N ....... .......... .................... .................... .................... ....................

C9121 ...... Injection, argatroban ...................................... ........... K ....... 9121 .................... 16.40 .................... 3.28 

C9220 ...... Sodium hyaluronate ....................................... CH .... K ....... 9220 .................... 197.62 .................... 39.52 

C9221 ...... Graftjacket Reg Matrix ................................... CH .... B ....... .......... .................... .................... .................... ....................

C9222 ...... Graftjacket SftTis ............................................ CH .... K ....... 9222 .................... 883.78 .................... 176.76 

C9224 ...... Injection, galsulfase ........................................ ........... K ....... 9224 .................... 1,503.23 .................... 300.65 

C9225 ...... Fluocinolone acetonide .................................. ........... G ....... 9225 .................... 19,345.00 .................... 3,869.00 

C9227 ...... Injection, micafungin sodium .......................... ........... G ...... 9227 .................... 1.98 .................... 0.40 

C9228 ...... Injection, tigecycline ....................................... ........... G ....... 9228 .................... 0.96 .................... 0.19 

C9716 ...... Radiofrequency energy to anu ....................... CH .... T ....... 0150 29.4386 1,811.98 437.12 362.40 

C9723 ...... Dyn IR Perf Img ............................................. ........... S ....... 1502 .................... 75.00 .................... 15.00 

C9724 ...... EPS gast cardia plic ....................................... ........... T ....... 0422 27.5493 1,695.69 448.81 339.14 

C9725 ...... Place endorectal app ..................................... ........... S ....... 1507 .................... 550.00 .................... 110.00 

C9726 ...... Rxt breast appl place/remov .......................... ........... S ....... 1508 .................... 650.00 .................... 130.00 

D0150 ...... Comprehensve oral evaluation ...................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0240 ...... Intraoral occlusal film ..................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0250 ...... Extraoral first film ........................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0260 ...... Extraoral ea additional film ............................ ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0270 ...... Dental bitewing single film ............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0272 ...... Dental bitewings two films ............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0274 ...... Dental bitewings four films ............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0277 ...... Vert bitewings-sev to eight ............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D0460 ...... Pulp vitality test .............................................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D1510 ...... Space maintainer fxd unilat ........................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D1515 ...... Fixed bilat space maintainer .......................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D1520 ...... Remove unilat space maintain ....................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D1525 ...... Remove bilat space maintain ......................... ........... S ....... 0330 9.5891 590.22 .................... 118.04

D1550 ...... Recement space maintainer .......................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D2999 ...... Dental unspec restorative pr .......................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D3460 ...... Endodontic endosseous implan ..................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D3999 ...... Endodontic procedure .................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4260 ...... Osseous surgery per quadrant ...................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4263 ...... Bone replce graft first site .............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4264 ...... Bone replce graft each add ........................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4268 ...... Surgical revision procedure ........................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4270 ...... Pedicle soft tissue graft pr ............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4271 ...... Free soft tissue graft proc .............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4273 ...... Subepithelial tissue graft ................................ ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4355 ...... Full mouth debridement ................................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D4381 ...... Localized delivery antimicro ........................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D5911 ...... Facial moulage sectional ............................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D5912 ...... Facial moulage complete ............................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D5983 ...... Radiation applicator ....................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D5984 ...... Radiation shield .............................................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D5985 ...... Radiation cone locator ................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D5987 ...... Commissure splint .......................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D6920 ...... Dental connector bar ...................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7111 ...... Extraction coronal remnants .......................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7140 ...... Extraction erupted tooth/exr ........................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7210 ...... Rem imp tooth w mucoper flp ........................ ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7220 ...... Impact tooth remov soft tiss ........................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7230 ...... Impact tooth remov part bony ........................ ........... S ....... 0330 9.5891 590.22 .................... 118.04

D7240 ...... Impact tooth remov comp bony ..................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7241 ...... Impact tooth rem bony w/comp ..................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7250 ...... Tooth root removal ......................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7260 ...... Oral antral fistula closure ............................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7261 ...... Primary closure sinus perf ............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D7291 ...... Transseptal fiberotomy ................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 


sroberts on PROD1PC70 with PROPOSALS
49836 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

D7940 ...... Reshaping bone orthognathic ........................ ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D9110 ...... Tx dental pain minor proc .............................. ........... N ....... .......... .................... .................... .................... ....................

D9230 ...... Analgesia ........................................................ ........... N ....... .......... .................... .................... .................... ....................

D9248 ...... Sedation (non-iv) ............................................ ........... N ....... .......... .................... .................... .................... ....................

D9630 ...... Other drugs/medicaments .............................. ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D9930 ...... Treatment of complications ............................ ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D9940 ...... Dental occlusal guard .................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D9950 ...... Occlusion analysis ......................................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D9951 ...... Limited occlusal adjustment ........................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

D9952 ...... Complete occlusal adjustment ....................... ........... S ....... 0330 9.5891 590.22 .................... 118.04 

E0616 ...... Cardiac event recorder .................................. ........... N ....... .......... .................... .................... .................... ....................

E0749 ...... Elec osteogen stim implanted ........................ ........... N ....... .......... .................... .................... .................... ....................

E0782 ...... Non-programble infusion pump ...................... ........... N ....... .......... .................... .................... .................... ....................

E0783 ...... Programmable infusion pump ........................ ........... N ....... .......... .................... .................... .................... ....................

E0785 ...... Replacement impl pump cathet ..................... ........... N ....... .......... .................... .................... .................... ....................

E0786 ...... Implantable pump replacement ...................... ........... N ....... .......... .................... .................... .................... ....................

E0830 ...... Ambulatory traction device ............................. ........... N ....... .......... .................... .................... .................... ....................

E1399 ...... Durable medical equipment mi ...................... ........... N ....... .......... .................... .................... .................... ....................

G0008 ...... Admin influenza virus vac .............................. CH .... S ....... 0350 0.4107 25.28 0.00 0.00 

G0009 ...... Admin pneumococcal vaccine ....................... CH .... S ....... 0350 0.4107 25.28 0.00 0.00 

G0101 ...... CA screen;pelvic/breast exam ....................... CH .... V ....... 0604 0.8083 49.75 .................... 9.95 

G0102 ...... Prostate ca screening; dre ............................. ........... N ....... .......... .................... .................... .................... ....................

G0104 ...... CA screen;flexi sigmoidscope ........................ ........... S ....... 0159 3.8973 239.88 .................... 59.97 

G0105 ...... Colorectal scrn; hi risk ind ............................. ........... T ....... 0158 7.8134 480.92 .................... 120.23 

G0106 ...... Colon CA screen;barium enema .................... ........... S ....... 0157 2.4974 153.72 .................... 30.74 

G0117 ...... Glaucoma scrn hgh risk direc ........................ ........... S ....... 0230 0.8126 50.02 14.97 10.00 

G0118 ...... Glaucoma scrn hgh risk direc ........................ ........... S ....... 0230 0.8126 50.02 14.97 10.00 

G0120 ...... Colon ca scrn; barium enema ........................ ........... S ....... 0157 2.4974 153.72 .................... 30.74 

G0121 ...... Colon ca scrn not hi rsk ind ........................... ........... T ....... 0158 7.8134 480.92 .................... 120.23 

G0127 ...... Trim nail(s) ..................................................... ........... T ....... 0009 0.6803 41.87 .................... 8.37 

G0129 ...... Partial hosp prog service ............................... ........... P ....... 0033 3.3837 208.27 .................... 41.65 

G0130 ...... Single energy x-ray study .............................. ........... X ....... 0260 0.7276 44.78 .................... 8.96

G0166 ...... Extrnl counterpulse, per tx ............................. ........... T ....... 0678 1.7263 106.26 .................... 21.25 

G0173 ...... Linear acc stereo radsur com ........................ CH .... S ....... 0067 65.7255 4,045.47 .................... 809.09 

G0175 ...... OPPS Service,sched team conf .................... CH .... V ....... 0608 2.1226 130.65 .................... 26.13 

G0176 ...... OPPS/PHP;activity therapy ............................ ........... P ....... 0033 3.3837 208.27 .................... 41.65

G0177 ...... OPPS/PHP; train&educ serv .......................... ........... P ....... 0033 3.3837 208.27 .................... 41.65 

G0186 ...... Dstry eye lesn,fdr vssl tech ............................ ........... T ....... 0235 4.0750 250.82 61.14 50.16 

G0237 ...... Therapeutic procd strg endur ......................... ........... S ....... 0411 0.3793 23.35 .................... 4.67 

G0238 ...... Oth resp proc, indiv ........................................ ........... S ....... 0411 0.3793 23.35 .................... 4.67 

G0239 ...... Oth resp proc, group ...................................... ........... S ....... 0411 0.3793 23.35 .................... 4.67 

G0243 ...... Multisour photon stero treat ........................... ........... S ....... 0127 126.8566 7,808.15 .................... 1,561.63 

G0245 ...... Initial foot exam pt lops .................................. CH .... V ....... 0604 0.8083 49.75 .................... 9.95 

G0246 ...... Followup eval of foot pt lop ............................ CH .... V ....... 0605 1.0057 61.90 .................... 12.38 

G0247 ...... Routine footcare pt w lops ............................. ........... T ....... 0009 0.6803 41.87 .................... 8.37

G0248 ...... Demonstrate use home inr mon .................... CH .... V ....... 0604 0.8083 49.75 .................... 9.95 

G0249 ...... Provide test material,equipm ......................... CH .... V ....... 0604 0.8083 49.75 .................... 9.95 

G0251 ...... Linear acc based stero radio ......................... CH .... S ....... 0065 22.4428 1,381.38 .................... 276.28 

G0257 ...... Unsched dialysis ESRD pt hos ...................... ........... S ....... 0170 6.8096 419.14 .................... 83.83 

G0259 ...... Inject for sacroiliac joint ................................. ........... N ....... .......... .................... .................... .................... ....................

G0260 ...... Inj for sacroiliac jt anesth ............................... ........... T ....... 0206 5.5439 341.23 75.55 68.25 

G0267 ...... Bone marrow or psc harvest .......................... ........... S ....... 0110 3.4570 212.78 .................... 42.56 

G0268 ...... Removal of impacted wax md ....................... ........... X ....... 0340 0.6211 38.23 .................... 7.65 

G0269 ...... Occlusive device in vein art ........................... ........... N ....... .......... .................... .................... .................... ....................

G0275 ...... Renal angio, cardiac cath .............................. ........... N ....... .......... .................... .................... .................... ....................

G0278 ...... Iliac art angio,cardiac cath ............................. ........... N ....... .......... .................... .................... .................... ....................

G0288 ...... Recon, CTA for surg plan .............................. ........... S ....... 0417 3.1140 191.67 .................... 38.33 

G0289 ...... Arthro, loose body + chondro ........................ ........... N ....... .......... .................... .................... .................... ....................

G0290 ...... Drug-eluting stents, single ............................. ........... T ....... 0656 106.8902 6,579.20 .................... 1,315.84 

G0291 ...... Drug-eluting stents,each add ......................... ........... T ....... 0656 106.8902 6,579.20 .................... 1,315.84 

G0293 ...... Non-cov surg proc,clin trial ............................ CH .... X ....... 0340 0.6211 38.23 .................... 7.65 

G0294 ...... Non-cov proc, clinical trial .............................. CH .... X ....... 0340 0.6211 38.23 .................... 7.65 

G0297 ...... Insert single chamber/cd ................................ ........... T ....... 0107 279.2049 17,185.34 .................... 3,437.07 

G0298 ...... Insert dual chamber/cd .................................. ........... T ....... 0107 279.2049 17,185.34 .................... 3,437.07 

G0299 ...... Inser/repos single icd+leads .......................... ........... T ....... 0108 370.5535 22,807.94 .................... 4,561.59 

G0300 ...... Insert reposit lead dual+gen .......................... ........... T ....... 0108 370.5535 22,807.94 .................... 4,561.59 

G0302 ...... Pre-op service LVRS complete ...................... ........... S ....... 1509 .................... 750.00 .................... 150.00 

G0303 ...... Pre-op service LVRS 10–15dos .................... ........... S ....... 1507 .................... 550.00 .................... 110.00 

G0304 ...... Pre-op service LVRS 1–9 dos ....................... ........... S ....... 1504 .................... 250.00 .................... 50.00 

G0305 ...... Post op service LVRS min 6 .......................... ........... S ....... 1504 .................... 250.00 .................... 50.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49837 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

G0332 ...... Preadmin IV immunoglobulin ......................... CH .... B ....... .......... .................... .................... .................... ....................

G0339 ...... Robot lin-radsurg com, first ............................ CH .... S ....... 0067 65.7255 4,045.47 .................... 809.09 

G0340 ...... Robt lin-radsurg fractx 2–5 ............................ CH .... S ....... 0066 47.2213 2,906.52 .................... 581.30 

G0344 ...... Initial preventive exam ................................... CH .... V ....... 0605 1.0057 61.90 .................... 12.38 

G0364 ...... Bone marrow aspirate &biopsy ...................... CH .... T ....... 0002 1.0948 67.39 .................... 13.48 

G0365 ...... Vessel mapping hemo access ....................... ........... S ....... 0267 2.5166 154.90 60.80 30.98 

G0367 ...... EKG tracing for initial prev ............................. ........... S ....... 0099 0.3835 23.60 .................... 4.72 

G0375 ...... Smoke/tobacco counselng 3–10 .................... CH .... X ....... 0031 0.1716 10.56 .................... 2.11 

G0376 ...... Smoke/tobacco counseling >10 ..................... CH .... X ....... 0031 0.1716 10.56 .................... 2.11 

G0378 ...... Hospital observation per hr ............................ ........... Q ....... 0339 7.1587 440.63 .................... 88.13 

G0379 ...... Direct admit hospital observ .......................... CH .... Q ....... 0604 0.8083 49.75 .................... 9.95 

G3001 ...... Admin + supply, tositumomab ....................... CH .... S ....... 0442 24.5410 1,510.52 .................... 302.10 

J0120 ....... Tetracyclin injection ........................................ ........... N ....... .......... .................... .................... .................... ....................

J0128 ....... Abarelix injection ............................................ CH .... K ....... 9216 .................... 66.20 .................... 13.24 

J0130 ....... Abciximab injection ........................................ ........... K ....... 1605 .................... 452.96 .................... 90.59 

J0132 ....... Acetylcysteine injection .................................. ........... K ....... 1680 .................... 1.86 .................... 0.37 

J0133 ....... Acyclovir injection ........................................... ........... N ....... .......... .................... .................... .................... ....................

J0135 ....... Adalimumab injection ..................................... ........... K ....... 1083 .................... 304.40 .................... 60.88 

J0150 ....... Injection adenosine 6 MG .............................. ........... K ....... 0379 .................... 29.90 .................... 5.98 

J0152 ....... Adenosine injection ........................................ ........... K ....... 0917 .................... 69.41 .................... 13.88 

J0170 ....... Adrenalin epinephrin inject ............................. ........... N ....... .......... .................... .................... .................... ....................

J0180 ....... Agalsidase beta injection ............................... ........... K ....... 9208 .................... 126.00 .................... 25.20 

J0190 ....... Inj biperiden lactate/5 mg ............................... CH .... K ....... 3038 .................... 88.36 .................... 17.67 

J0200 ....... Alatrofloxacin mesylate .................................. ........... N ....... .......... .................... .................... .................... ....................

J0205 ....... Alglucerase injection ...................................... ........... K ....... 0900 .................... 38.85 .................... 7.77 

J0207 ....... Amifostine ....................................................... ........... K ....... 7000 .................... 448.41 .................... 89.68 

J0210 ....... Methyldopate hcl injection .............................. ........... K ....... 2210 .................... 9.86 .................... 1.97 

J0215 ....... Alefacept ........................................................ ........... K ....... 1633 .................... 26.03 .................... 5.21 

J0256 ....... Alpha 1 proteinase inhibitor ........................... ........... K ....... 0901 .................... 3.21 .................... 0.64 

J0278 ....... Amikacin sulfate injection ............................... CH .... N ....... .......... .................... .................... .................... ....................

J0280 ....... Aminophyllin 250 MG inj ................................ ........... N ....... .......... .................... .................... .................... ....................

J0282 ....... Amiodarone HCl ............................................. ........... N ....... .......... .................... .................... .................... ....................

J0285 ....... Amphotericin B ............................................... CH .... N ....... .......... .................... .................... .................... ....................

J0287 ....... Amphotericin b lipid complex ......................... ........... K ....... 9024 .................... 11.10 .................... 2.22 

J0288 ....... Ampho b cholesteryl sulfate ........................... ........... K ....... 0735 .................... 12.00 .................... 2.40 

J0289 ....... Amphotericin b liposome inj ........................... ........... K ....... 0736 .................... 17.40 .................... 3.48 

J0290 ....... Ampicillin 500 MG inj ..................................... ........... N ....... .......... .................... .................... .................... ....................

J0295 ....... Ampicillin sodium per 1.5 gm ......................... ........... N ....... .......... .................... .................... .................... ....................

J0300 ....... Amobarbital 125 MG inj ................................. ........... N ....... .......... .................... .................... .................... ....................

J0330 ....... Succinycholine chloride inj ............................. ........... N ....... .......... .................... .................... .................... ....................

J0350 ....... Injection anistreplase 30 u ............................. ........... K ....... 1606 .................... 2,265.46 .................... 453.09 

J0360 ....... Hydralazine hcl injection ................................ ........... N ....... .......... .................... .................... .................... ....................

J0365 ....... Aprotonin, 10,000 kiu ..................................... ........... K ....... 1682 .................... 2.32 .................... 0.46 

J0380 ....... Inj metaraminol bitartrate ............................... CH .... K ....... 3039 .................... 17.68 .................... 3.54 

J0390 ....... Chloroquine injection ...................................... ........... N ....... .......... .................... .................... .................... ....................

J0395 ....... Arbutamine HCl injection ............................... ........... K ....... 9031 .................... 160.00 .................... 32.00 

J0456 ....... Azithromycin ................................................... ........... N ....... .......... .................... .................... .................... ....................

J0460 ....... Atropine sulfate injection ................................ ........... N ....... .......... .................... .................... .................... ....................

J0470 ....... Dimecaprol injection ....................................... CH .... N ....... .......... .................... .................... .................... ....................

J0475 ....... Baclofen 10 MG injection ............................... ........... K ....... 9032 .................... 191.50 .................... 38.30 

J0476 ....... Baclofen intrathecal trial ................................. ........... K ....... 1631 .................... 70.20 .................... 14.04 

J0480 ....... Basiliximab ..................................................... ........... K ....... 1683 .................... 1,388.81 .................... 277.76 

J0500 ....... Dicyclomine injection ...................................... ........... N ....... .......... .................... .................... .................... ....................

J0515 ....... Inj benztropine mesylate ................................ ........... N ....... .......... .................... .................... .................... ....................

J0520 ....... Bethanechol chloride inject ............................ ........... N ....... .......... .................... .................... .................... ....................

J0530 ....... Penicillin g benzathine inj .............................. ........... N ....... .......... .................... .................... .................... ....................

J0540 ....... Penicillin g benzathine inj .............................. ........... N ....... .......... .................... .................... .................... ....................

J0550 ....... Penicillin g benzathine inj .............................. ........... N ....... .......... .................... .................... .................... ....................

J0560 ....... Penicillin g benzathine inj .............................. ........... N ....... .......... .................... .................... .................... ....................

J0570 ....... Penicillin g benzathine inj .............................. ........... N ....... .......... .................... .................... .................... ....................

J0580 ....... Penicillin g benzathine inj .............................. CH .... K ....... 3040 .................... 67.86 .................... 13.57 

J0583 ....... Bivalirudin ....................................................... CH .... K ....... 3041 .................... 1.62 .................... 0.32 

J0585 ....... Botulinum toxin a per unit .............................. ........... K ....... 0902 .................... 4.85 .................... 0.97 

J0587 ....... Botulinum toxin type B ................................... ........... K ....... 9018 .................... 7.85 .................... 1.57 

J0592 ....... Buprenorphine hydrochloride ......................... ........... N ....... .......... .................... .................... .................... ....................

J0595 ....... Butorphanol tartrate 1 mg .............................. ........... N ....... .......... .................... .................... .................... ....................

J0600 ....... Edetate calcium disodium inj ......................... ........... K ....... 0892 .................... 39.80 .................... 7.96 

J0610 ....... Calcium gluconate injection ........................... ........... N ....... .......... .................... .................... .................... ....................

J0620 ....... Calcium glycer&lact/10 ML ............................ ........... N ....... .......... .................... .................... .................... ....................

J0630 ....... Calcitonin salmon injection ............................ CH .... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
49838 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J0636 ....... Inj calcitriol per 0.1 mcg ................................. ........... N ....... .......... .................... .................... .................... ....................

J0637 ....... Caspofungin acetate ...................................... ........... K ....... 9019 .................... 32.19 .................... 6.44 

J0640 ....... Leucovorin calcium injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J0670 ....... Inj mepivacaine HCL/10 ml ............................ ........... N ....... .......... .................... .................... .................... ....................

J0690 ....... Cefazolin sodium injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J0692 ....... Cefepime HCl for injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J0694 ....... Cefoxitin sodium injection .............................. ........... N ....... .......... .................... .................... .................... ....................

J0696 ....... Ceftriaxone sodium injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J0697 ....... Sterile cefuroxime injection ............................ ........... N ....... .......... .................... .................... .................... ....................

J0698 ....... Cefotaxime sodium injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J0702 ....... Betamethasone acet&sod phosp ................... ........... N ....... .......... .................... .................... .................... ....................

J0704 ....... Betamethasone sod phosp/4 MG .................. ........... N ....... .......... .................... .................... .................... ....................

J0706 ....... Caffeine citrate injection ................................. ........... K ....... 0876 .................... 3.34 .................... 0.67 

J0710 ....... Cephapirin sodium injection ........................... ........... N ....... .......... .................... .................... .................... ....................

J0713 ....... Inj ceftazidime per 500 mg ............................ ........... N ....... .......... .................... .................... .................... ....................

J0715 ....... Ceftizoxime sodium/500 MG .......................... ........... N ....... .......... .................... .................... .................... ....................

J0720 ....... Chloramphenicol sodium injec ....................... ........... N ....... .......... .................... .................... .................... ....................

J0725 ....... Chorionic gonadotropin/1000u ....................... ........... N ....... .......... .................... .................... .................... ....................

J0735 ....... Clonidine hydrochloride .................................. ........... K ....... 0935 .................... 62.71 .................... 12.54 

J0740 ....... Cidofovir injection ........................................... ........... K ....... 9033 .................... 757.03 .................... 151.41 

J0743 ....... Cilastatin sodium injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J0744 ....... Ciprofloxacin iv ............................................... ........... N ....... .......... .................... .................... .................... ....................

J0745 ....... Inj codeine phosphate/30 MG ........................ ........... N ....... .......... .................... .................... .................... ....................

J0760 ....... Colchicine injection ........................................ ........... N ....... .......... .................... .................... .................... ....................

J0770 ....... Colistimethate sodium inj ............................... ........... N ....... .......... .................... .................... .................... ....................

J0780 ....... Prochlorperazine injection .............................. ........... N ....... .......... .................... .................... .................... ....................

J0795 ....... Corticorelin ovine triflutal ................................ ........... K ....... 1684 .................... 4.22 .................... 0.84 

J0800 ....... Corticotropin injection ..................................... ........... K ....... 1280 .................... 108.85 .................... 21.77 

J0835 ....... Inj cosyntropin per 0.25 MG .......................... ........... K ....... 0835 .................... 63.55 .................... 12.71 

J0850 ....... Cytomegalovirus imm IV/vial .......................... ........... K ....... 0903 .................... 755.79 .................... 151.16 

J0878 ....... Daptomycin injection ...................................... CH .... K ....... 9124 .................... 0.31 .................... 0.06 

J0881 ....... Darbepoetin alfa, non-esrd ............................ ........... K ....... 1685 .................... 3.00 .................... 0.60 

J0882 ....... Darbepoetin alfa, esrd use ............................. CH .... A ....... .......... .................... .................... .................... ....................

J0885 ....... Epoetin alfa, non-esrd .................................... ........... K ....... 1686 .................... 9.25 .................... 1.85 

J0886 ....... Epoetin alfa, esrd ........................................... CH .... A ....... .......... .................... .................... .................... ....................

J0895 ....... Deferoxamine mesylate inj ............................. ........... K ....... 0895 .................... 14.77 .................... 2.95 

J0900 ....... Testosterone enanthate inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J0945 ....... Brompheniramine maleate inj ........................ ........... N ....... .......... .................... .................... .................... ....................

J0970 ....... Estradiol valerate injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J1000 ....... Depo-estradiol cypionate inj ........................... ........... N ....... .......... .................... .................... .................... ....................

J1020 ....... Methylprednisolone 20 MG inj ....................... ........... N ....... .......... .................... .................... .................... ....................

J1030 ....... Methylprednisolone 40 MG inj ....................... ........... N ....... .......... .................... .................... .................... ....................

J1040 ....... Methylprednisolone 80 MG inj ....................... ........... N ....... .......... .................... .................... .................... ....................

J1051 ....... Medroxyprogesterone inj ................................ ........... N ....... .......... .................... .................... .................... ....................

J1060 ....... Testosterone cypionate 1 ML ........................ ........... N ....... .......... .................... .................... .................... ....................

J1070 ....... Testosterone cypionat 100 MG ...................... ........... N ....... .......... .................... .................... .................... ....................

J1080 ....... Testosterone cypionat 200 MG ...................... ........... N ....... .......... .................... .................... .................... ....................

J1094 ....... Inj dexamethasone acetate ............................ ........... N ....... .......... .................... .................... .................... ....................

J1100 ....... Dexamethasone sodium phos ....................... ........... N ....... .......... .................... .................... .................... ....................

J1110 ....... Inj dihydroergotamine mesylt ......................... CH .... N ....... .......... .................... .................... .................... ....................

J1120 ....... Acetazolamid sodium injectio ......................... ........... N ....... .......... .................... .................... .................... ....................

J1160 ....... Digoxin injection ............................................. ........... N ....... .......... .................... .................... .................... ....................

J1162 ....... Digoxin immune fab (ovine) ........................... ........... K ....... 1687 .................... 527.46 .................... 105.49 

J1165 ....... Phenytoin sodium injection ............................ ........... N ....... .......... .................... .................... .................... ....................

J1170 ....... Hydromorphone injection ............................... ........... N ....... .......... .................... .................... .................... ....................

J1180 ....... Dyphylline injection ........................................ CH .... N ....... .......... .................... .................... .................... ....................

J1190 ....... Dexrazoxane HCl injection ............................. ........... K ....... 0726 .................... 179.62 .................... 35.92 

J1200 ....... Diphenhydramine hcl injectio ......................... ........... N ....... .......... .................... .................... .................... ....................

J1205 ....... Chlorothiazide sodium inj ............................... ........... N ....... .......... .................... .................... .................... ....................

J1212 ....... Dimethyl sulfoxide 50% 50 ML ...................... ........... N ....... .......... .................... .................... .................... ....................

J1230 ....... Methadone injection ....................................... ........... N ....... .......... .................... .................... .................... ....................

J1240 ....... Dimenhydrinate injection ................................ ........... N ....... .......... .................... .................... .................... ....................

J1245 ....... Dipyridamole injection .................................... ........... N ....... .......... .................... .................... .................... ....................

J1250 ....... Inj dobutamine HCL/250 mg .......................... ........... N ....... .......... .................... .................... .................... ....................

J1260 ....... Dolasetron mesylate ...................................... ........... K ....... 0750 .................... 6.76 .................... 1.35 

J1265 ....... Dopamine injection ......................................... ........... N ....... .......... .................... .................... .................... ....................

J1270 ....... Injection, doxercalciferol ................................. ........... N ....... .......... .................... .................... .................... ....................

J1320 ....... Amitriptyline injection ..................................... ........... N ....... .......... .................... .................... .................... ....................

J1325 ....... Epoprostenol injection .................................... ........... N ....... .......... .................... .................... .................... ....................

J1327 ....... Eptifibatide injection ....................................... ........... K ....... 1607 .................... 13.31 .................... 2.66 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49839 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J1330 ....... Ergonovine maleate injection ......................... ........... K ....... 1330 .................... 27.56 .................... 5.51 

J1335 ....... Ertapenem injection ....................................... ........... N ....... .......... .................... .................... .................... ....................

J1364 ....... Erythro lactobionate/500 MG ......................... ........... N ....... .......... .................... .................... .................... ....................

J1380 ....... Estradiol valerate 10 MG inj .......................... ........... N ....... .......... .................... .................... .................... ....................

J1390 ....... Estradiol valerate 20 MG inj .......................... ........... N ....... .......... .................... .................... .................... ....................

J1410 ....... Inj estrogen conjugate 25 MG ....................... ........... K ....... 9038 .................... 57.78 .................... 11.56 

J1430 ....... Ethanolamine oleate 100 mg ......................... ........... K ....... 1688 .................... 71.57 .................... 14.31 

J1435 ....... Injection estrone per 1 MG ............................ ........... N ....... .......... .................... .................... .................... ....................

J1436 ....... Etidronate disodium inj ................................... ........... K ....... 1436 .................... 70.73 .................... 14.15 

J1438 ....... Etanercept injection ........................................ ........... K ....... 1608 .................... 154.12 .................... 30.82 

J1440 ....... Filgrastim 300 mcg injection .......................... ........... K ....... 0728 .................... 182.53 .................... 36.51 

J1441 ....... Filgrastim 480 mcg injection .......................... ........... K ....... 7049 .................... 289.59 .................... 57.92 

J1450 ....... Fluconazole .................................................... ........... N ....... .......... .................... .................... .................... ....................

J1451 ....... Fomepizole, 15 mg ........................................ ........... K ....... 1689 .................... 11.82 .................... 2.36 

J1452 ....... Intraocular Fomivirsen na .............................. ........... K ....... 9040 .................... 210.00 .................... 42.00 

J1455 ....... Foscarnet sodium injection ............................ CH .... K ....... 3042 .................... 10.69 .................... 2.14 

J1457 ....... Gallium nitrate injection .................................. CH .... N ....... .......... .................... .................... .................... ....................

J1460 ....... Gamma globulin 1 CC inj ............................... CH .... K ....... 3043 .................... 10.59 .................... 2.12 

J1565 ....... RSV-ivig ......................................................... ........... K ....... 0906 .................... 16.02 .................... 3.20 

J1566 ....... Immune globulin, powder ............................... ........... K ....... 2731 .................... 22.05 .................... 4.41 

J1567 ....... Immune globulin, liquid .................................. ........... K ....... 2732 .................... 28.82 .................... 5.76 

J1570 ....... Ganciclovir sodium injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J1580 ....... Garamycin gentamicin inj ............................... ........... N ....... .......... .................... .................... .................... ....................

J1590 ....... Gatifloxacin injection ...................................... ........... N ....... .......... .................... .................... .................... ....................

J1595 ....... Injection glatiramer acetate ............................ ........... N ....... .......... .................... .................... .................... ....................

J1600 ....... Gold sodium thiomaleate inj .......................... ........... N ....... .......... .................... .................... .................... ....................

J1610 ....... Glucagon hydrochloride/1 MG ....................... ........... K ....... 9042 .................... 62.42 .................... 12.48 

J1620 ....... Gonadorelin hydroch/100 mcg ....................... ........... K ....... 7005 .................... 178.59 .................... 35.72 

J1626 ....... Granisetron HCl injection ............................... ........... K ....... 0764 .................... 6.80 .................... 1.36 

J1630 ....... Haloperidol injection ....................................... ........... N ....... .......... .................... .................... .................... ....................

J1631 ....... Haloperidol decanoate inj .............................. ........... N ....... .......... .................... .................... .................... ....................

J1640 ....... Hemin, 1 mg ................................................... ........... K ....... 1690 .................... 6.59 .................... 1.32 

J1642 ....... Inj heparin sodium per 10 u ........................... ........... N ....... .......... .................... .................... .................... ....................

J1644 ....... Inj heparin sodium per 1000u ........................ ........... N ....... .......... .................... .................... .................... ....................

J1645 ....... Dalteparin sodium .......................................... ........... N ....... .......... .................... .................... .................... ....................

J1650 ....... Inj enoxaparin sodium .................................... ........... N ....... .......... .................... .................... .................... ....................

J1652 ....... Fondaparinux sodium ..................................... ........... N ....... .......... .................... .................... .................... ....................

J1655 ....... Tinzaparin sodium injection ........................... ........... K ....... 1655 .................... 2.18 .................... 0.44 

J1670 ....... Tetanus immune globulin inj .......................... ........... K ....... 1670 .................... 90.71 .................... 18.14 

J1700 ....... Hydrocortisone acetate inj ............................. ........... N ....... .......... .................... .................... .................... ....................

J1710 ....... Hydrocortisone sodium ph inj ........................ ........... N ....... .......... .................... .................... .................... ....................

J1720 ....... Hydrocortisone sodium succ i ........................ ........... N ....... .......... .................... .................... .................... ....................

J1730 ....... Diazoxide injection ......................................... ........... K ....... 1740 .................... 110.88 .................... 22.18 

J1742 ....... Ibutilide fumarate injection ............................. ........... K ....... 9044 .................... 249.01 .................... 49.80 

J1745 ....... Infliximab injection .......................................... ........... K ....... 7043 .................... 53.73 .................... 10.75 

J1751 ....... Iron dextran 165 injection .............................. ........... K ....... 1691 .................... 12.30 .................... 2.46 

J1752 ....... Iron dextran 267 injection .............................. ........... K ....... 1692 .................... 10.17 .................... 2.03 

J1756 ....... Iron sucrose injection ..................................... ........... K ....... 9046 .................... 0.36 .................... 0.07 

J1785 ....... Injection imiglucerase/unit .............................. ........... K ....... 0916 .................... 3.87 .................... 0.77 

J1790 ....... Droperidol injection ........................................ ........... N ....... .......... .................... .................... .................... ....................

J1800 ....... Propranolol injection ....................................... ........... N ....... .......... .................... .................... .................... ....................

J1815 ....... Insulin injection ............................................... ........... N ....... .......... .................... .................... .................... ....................

J1817 ....... Insulin for insulin pump use ........................... ........... N ....... .......... .................... .................... .................... ....................

J1830 ....... Interferon beta-1b/.25 MG .............................. ........... K ....... 0910 .................... 91.34 .................... 18.27 

J1835 ....... Itraconazole injection ..................................... ........... K ....... 9047 .................... 36.23 .................... 7.25 

J1840 ....... Kanamycin sulfate 500 MG inj ....................... ........... N ....... .......... .................... .................... .................... ....................

J1850 ....... Kanamycin sulfate 75 MG inj ......................... ........... N ....... .......... .................... .................... .................... ....................

J1885 ....... Ketorolac tromethamine inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J1890 ....... Cephalothin sodium injection ......................... ........... N ....... .......... .................... .................... .................... ....................

J1931 ....... Laronidase injection ....................................... ........... K ....... 9209 .................... 23.64 .................... 4.73 

J1940 ....... Furosemide injection ...................................... ........... N ....... .......... .................... .................... .................... ....................

J1945 ....... Lepirudin ......................................................... ........... K ....... 1693 .................... 146.38 .................... 29.28 

J1950 ....... Leuprolide acetate/3.75 MG ........................... ........... K ....... 0800 .................... 440.36 .................... 88.07 

J1956 ....... Levofloxacin injection ..................................... ........... N ....... .......... .................... .................... .................... ....................

J1960 ....... Levorphanol tartrate inj .................................. ........... N ....... .......... .................... .................... .................... ....................

J1980 ....... Hyoscyamine sulfate inj ................................. ........... N ....... .......... .................... .................... .................... ....................

J1990 ....... Chlordiazepoxide injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J2001 ....... Lidocaine injection .......................................... ........... N ....... .......... .................... .................... .................... ....................

J2010 ....... Lincomycin injection ....................................... ........... N ....... .......... .................... .................... .................... ....................

J2020 ....... Linezolid injection ........................................... ........... K ....... 9001 .................... 23.50 .................... 4.70 


sroberts on PROD1PC70 with PROPOSALS
49840 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J2060 ....... Lorazepam injection ....................................... ........... N ....... .......... .................... .................... .................... ....................

J2150 ....... Mannitol injection ........................................... ........... N ....... .......... .................... .................... .................... ....................

J2175 ....... Meperidine hydrochl/100 MG ......................... ........... N ....... .......... .................... .................... .................... ....................

J2180 ....... Meperidine/promethazine inj .......................... ........... N ....... .......... .................... .................... .................... ....................

J2185 ....... Meropenem .................................................... CH .... K ....... 3045 .................... 3.76 .................... 0.75 

J2210 ....... Methylergonovin maleate inj .......................... ........... N ....... .......... .................... .................... .................... ....................

J2250 ....... Inj midazolam hydrochloride .......................... ........... N ....... .......... .................... .................... .................... ....................

J2260 ....... Inj milrinone lactate/5 MG .............................. ........... N ....... .......... .................... .................... .................... ....................

J2270 ....... Morphine sulfate injection .............................. ........... N ....... .......... .................... .................... .................... ....................

J2271 ....... Morphine so4 injection 100mg ....................... ........... N ....... .......... .................... .................... .................... ....................

J2275 ....... Morphine sulfate injection .............................. ........... N ....... .......... .................... .................... .................... ....................

J2278 ....... Ziconotide injection ........................................ ........... G ....... 1694 .................... 6.20 .................... 1.24 

J2280 ....... Inj, moxifloxacin 100 mg ................................ ........... N ....... .......... .................... .................... .................... ....................

J2300 ....... Inj nalbuphine hydrochloride .......................... ........... N ....... .......... .................... .................... .................... ....................

J2310 ....... Inj naloxone hydrochloride ............................. ........... N ....... .......... .................... .................... .................... ....................

J2320 ....... Nandrolone decanoate 50 MG ....................... ........... N ....... .......... .................... .................... .................... ....................

J2321 ....... Nandrolone decanoate 100 MG ..................... ........... N ....... .......... .................... .................... .................... ....................

J2322 ....... Nandrolone decanoate 200 MG ..................... ........... N ....... .......... .................... .................... .................... ....................

J2325 ....... Nesiritide injection .......................................... ........... K ....... 1695 .................... 29.72 .................... 5.94 

J2353 ....... Octreotide injection, depot ............................. ........... K ....... 1207 .................... 89.50 .................... 17.90 

J2354 ....... Octreotide inj, non-depot ................................ CH .... K ....... 3046 .................... 4.34 .................... 0.87 

J2355 ....... Oprelvekin injection ........................................ ........... K ....... 7011 .................... 243.39 .................... 48.68 

J2357 ....... Omalizumab injection ..................................... CH .... K ....... 9300 .................... 16.34 .................... 3.27 

J2360 ....... Orphenadrine injection ................................... ........... N ....... .......... .................... .................... .................... ....................

J2370 ....... Phenylephrine hcl injection ............................ ........... N ....... .......... .................... .................... .................... ....................

J2400 ....... Chloroprocaine hcl injection ........................... ........... N ....... .......... .................... .................... .................... ....................

J2405 ....... Ondansetron hcl injection .............................. ........... K ....... 0768 .................... 3.69 .................... 0.74 

J2410 ....... Oxymorphone hcl injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J2425 ....... Palifermin injection ......................................... ........... K ....... 1696 .................... 11.37 .................... 2.27 

J2430 ....... Pamidronate disodium/30 MG ....................... ........... K ....... 0730 .................... 29.31 .................... 5.86 

J2440 ....... Papaverin hcl injection ................................... ........... N ....... .......... .................... .................... .................... ....................

J2460 ....... Oxytetracycline injection ................................ ........... N ....... .......... .................... .................... .................... ....................

J2469 ....... Palonosetron HCl ........................................... ........... K ....... 9210 .................... 17.51 .................... 3.50 

J2501 ....... Paricalcitol ...................................................... ........... N ....... .......... .................... .................... .................... ....................

J2503 ....... Pegaptanib sodium injection .......................... ........... G ....... 1697 .................... 1,107.54 .................... 221.51 

J2504 ....... Pegademase bovine, 25 iu ............................ ........... K ....... 1739 .................... 164.50 .................... 32.90 

J2505 ....... Injection, pegfilgrastim 6mg ........................... ........... K ....... 9119 .................... 2,142.79 .................... 428.56 

J2510 ....... Penicillin g procaine inj .................................. ........... N ....... .......... .................... .................... .................... ....................

J2513 ....... Pentastarch 10% solution .............................. CH .... N ....... .......... .................... .................... .................... ....................

J2515 ....... Pentobarbital sodium inj ................................. ........... N ....... .......... .................... .................... .................... ....................

J2540 ....... Penicillin g potassium inj ................................ ........... N ....... .......... .................... .................... .................... ....................

J2543 ....... Piperacillin/tazobactam .................................. ........... N ....... .......... .................... .................... .................... ....................

J2550 ....... Promethazine hcl injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J2560 ....... Phenobarbital sodium inj ................................ ........... N ....... .......... .................... .................... .................... ....................

J2590 ....... Oxytocin injection ........................................... ........... N ....... .......... .................... .................... .................... ....................

J2597 ....... Inj desmopressin acetate ............................... ........... N ....... .......... .................... .................... .................... ....................

J2650 ....... Prednisolone acetate inj ................................. ........... N ....... .......... .................... .................... .................... ....................

J2670 ....... Totazoline hcl injection ................................... ........... N ....... .......... .................... .................... .................... ....................

J2675 ....... Inj progesterone per 50 MG ........................... ........... N ....... .......... .................... .................... .................... ....................

J2680 ....... Fluphenazine decanoate 25 MG .................... ........... N ....... .......... .................... .................... .................... ....................

J2690 ....... Procainamide hcl injection ............................. ........... N ....... .......... .................... .................... .................... ....................

J2700 ....... Oxacillin sodium injeciton ............................... CH .... N ....... .......... .................... .................... .................... ....................

J2710 ....... Neostigmine methylslfte inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J2720 ....... Inj protamine sulfate/10 MG ........................... ........... N ....... .......... .................... .................... .................... ....................

J2725 ....... Inj protirelin per 250 mcg ............................... ........... N ....... .......... .................... .................... .................... ....................

J2730 ....... Pralidoxime chloride inj .................................. CH .... N ....... .......... .................... .................... .................... ....................

J2760 ....... Phentolaine mesylate inj ................................ ........... N ....... .......... .................... .................... .................... ....................

J2765 ....... Metoclopramide hcl injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J2770 ....... Quinupristin/dalfopristin .................................. ........... K ....... 2770 .................... 108.03 .................... 21.61 

J2780 ....... Ranitidine hydrochloride inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J2783 ....... Rasburicase ................................................... CH .... K ....... 0738 .................... 110.36 .................... 22.07 

J2788 ....... Rho d immune globulin 50 mcg ..................... ........... K ....... 9023 .................... 14.13 .................... 2.83 

J2790 ....... Rho d immune globulin inj ............................. ........... K ....... 0884 .................... 97.11 .................... 19.42 

J2792 ....... Rho(D) immune globulin h, sd ....................... ........... K ....... 1609 .................... 13.57 .................... 2.71 

J2794 ....... Risperidone, long acting ................................ CH .... K ....... 9125 .................... 4.73 .................... 0.95 

J2795 ....... Ropivacaine HCl injection .............................. ........... N ....... .......... .................... .................... .................... ....................

J2800 ....... Methocarbamol injection ................................ ........... N ....... .......... .................... .................... .................... ....................

J2805 ....... Sincalide injection .......................................... CH .... N ....... .......... .................... .................... .................... ....................

J2810 ....... Inj theophylline per 40 MG ............................. ........... N ....... .......... .................... .................... .................... ....................

J2820 ....... Sargramostim injection ................................... ........... K ....... 0731 .................... 23.12 .................... 4.62 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49841 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J2850 ....... Inj secretin synthetic human .......................... ........... K ....... 1700 .................... 20.31 .................... 4.06 

J2910 ....... Aurothioglucose injeciton ............................... CH .... N ....... .......... .................... .................... .................... ....................

J2912 ....... Sodium chloride injection ............................... ........... N ....... .......... .................... .................... .................... ....................

J2916 ....... Na ferric gluconate complex .......................... ........... N ....... .......... .................... .................... .................... ....................

J2920 ....... Methylprednisolone injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J2930 ....... Methylprednisolone injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J2940 ....... Somatrem injection ........................................ ........... K ....... 2940 .................... 583.74 .................... 116.75 

J2941 ....... Somatropin injection ....................................... ........... K ....... 7034 .................... 43.73 .................... 8.75 

J2950 ....... Promazine hcl injection .................................. ........... N ....... .......... .................... .................... .................... ....................

J2993 ....... Reteplase injection ......................................... ........... K ....... 9005 .................... 754.71 .................... 150.94 

J2995 ....... Inj streptokinase/250000 IU ........................... ........... K ....... 0911 .................... 78.75 .................... 15.75 

J2997 ....... Alteplase recombinant .................................... ........... K ....... 7048 .................... 31.06 .................... 6.21 

J3000 ....... Streptomycin injection .................................... ........... N ....... .......... .................... .................... .................... ....................

J3010 ....... Fentanyl citrate injeciton ................................ ........... N ....... .......... .................... .................... .................... ....................

J3030 ....... Sumatriptan succinate/6 MG .......................... ........... K ....... 3030 .................... 51.75 .................... 10.35 

J3070 ....... Pentazocine injection ..................................... ........... N ....... .......... .................... .................... .................... ....................

J3100 ....... Tenecteplase injection ................................... ........... K ....... 9002 .................... 2,059.01 .................... 411.80 

J3105 ....... Terbutaline sulfate inj ..................................... ........... N ....... .......... .................... .................... .................... ....................

J3120 ....... Testosterone enanthate inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J3130 ....... Testosterone enanthate inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J3140 ....... Testosterone suspension inj .......................... ........... N ....... .......... .................... .................... .................... ....................

J3150 ....... Testosteron propionate inj ............................. ........... N ....... .......... .................... .................... .................... ....................

J3230 ....... Chlorpromazine hcl injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J3240 ....... Thyrotropin injection ....................................... ........... K ....... 9108 .................... 766.61 .................... 153.32 

J3246 ....... Tirofiban HCl .................................................. ........... K ....... 7041 .................... 7.61 .................... 1.52 

J3250 ....... Trimethobenzamide hcl inj ............................. ........... N ....... .......... .................... .................... .................... ....................

J3260 ....... Tobramycin sulfate injection .......................... ........... N ....... .......... .................... .................... .................... ....................

J3265 ....... Injection torsemide 10 mg/ml ......................... ........... N ....... .......... .................... .................... .................... ....................

J3280 ....... Thiethylperazine maleate inj .......................... ........... N ....... .......... .................... .................... .................... ....................

J3285 ....... Treprostinil injection ....................................... ........... K ....... 1701 .................... 53.51 .................... 10.70 

J3301 ....... Triamcinolone acetonide inj ........................... ........... N ....... .......... .................... .................... .................... ....................

J3302 ....... Triamcinolone diacetate inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J3303 ....... Triamcinolone hexacetonl inj ......................... ........... N ....... .......... .................... .................... .................... ....................

J3305 ....... Inj trimetrexate glucoronate ........................... ........... K ....... 7045 .................... 144.39 .................... 28.88 

J3310 ....... Perphenazine injeciton ................................... ........... N ....... .......... .................... .................... .................... ....................

J3315 ....... Triptorelin pamoate ........................................ ........... K ....... 9122 .................... 300.90 .................... 60.18 

J3320 ....... Spectinomycn di-hcl inj .................................. ........... N ....... .......... .................... .................... .................... ....................

J3350 ....... Urea injection ................................................. ........... K ....... 9051 .................... 69.10 .................... 13.82 

J3355 ....... Urofollitropin, 75 iu ......................................... ........... K ....... 1741 .................... 48.84 .................... 9.77 

J3360 ....... Diazepam injection ......................................... ........... N ....... .......... .................... .................... .................... ....................

J3364 ....... Urokinase 5000 IU injection ........................... ........... N ....... .......... .................... .................... .................... ....................

J3365 ....... Urokinase 250,000 IU inj ............................... ........... K ....... 7036 .................... 453.41 .................... 90.68 

J3370 ....... Vancomycin hcl injection ................................ ........... N ....... .......... .................... .................... .................... ....................

J3396 ....... Verteporfin injection ....................................... ........... K ....... 1203 .................... 8.89 .................... 1.78 

J3400 ....... Triflupromazine hcl inj .................................... ........... N ....... .......... .................... .................... .................... ....................

J3410 ....... Hydroxyzine hcl injection ............................... ........... N ....... .......... .................... .................... .................... ....................

J3411 ....... Thiamine hcl 100 mg ..................................... ........... N ....... .......... .................... .................... .................... ....................

J3415 ....... Pyridoxine hcl 100 mg ................................... ........... N ....... .......... .................... .................... .................... ....................

J3420 ....... Vitamin b12 injection ...................................... ........... N ....... .......... .................... .................... .................... ....................

J3430 ....... Vitamin k phytonadione inj ............................. ........... N ....... .......... .................... .................... .................... ....................

J3465 ....... Injection, voriconazole .................................... ........... K ....... 1052 .................... 4.55 .................... 0.91 

J3470 ....... Hyaluronidase injection .................................. CH .... N ....... .......... .................... .................... .................... ....................

J3471 ....... Ovine, up to 999 USP units ........................... CH .... N ....... .......... .................... .................... .................... ....................

J3472 ....... Ovine, 1000 USP units .................................. ........... K ....... 1703 .................... 133.77 .................... 26.75 

J3475 ....... Inj magnesium sulfate .................................... ........... N ....... .......... .................... .................... .................... ....................

J3480 ....... Inj potassium chloride .................................... ........... N ....... .......... .................... .................... .................... ....................

J3485 ....... Zidovudine ...................................................... ........... N ....... .......... .................... .................... .................... ....................

J3486 ....... Ziprasidone mesylate ..................................... ........... N ....... .......... .................... .................... .................... ....................

J3487 ....... Zoledronic acid ............................................... ........... K ....... 9115 .................... 200.82 .................... 40.16 

J3490 ....... Drugs unclassified injection ........................... ........... N ....... .......... .................... .................... .................... ....................

J3530 ....... Nasal vaccine inhalation ................................ ........... N ....... .......... .................... .................... .................... ....................

J3590 ....... Unclassified biologics ..................................... ........... N ....... .......... .................... .................... .................... ....................

J7030 ....... Normal saline solution infus ........................... ........... N ....... .......... .................... .................... .................... ....................

J7040 ....... Normal saline solution infus ........................... ........... N ....... .......... .................... .................... .................... ....................

J7042 ....... 5% dextrose/normal saline ............................. ........... N ....... .......... .................... .................... .................... ....................

J7050 ....... Normal saline solution infus ........................... ........... N ....... .......... .................... .................... .................... ....................

J7060 ....... 5% dextrose/water ......................................... ........... N ....... .......... .................... .................... .................... ....................

J7070 ....... D5w infusion ................................................... ........... N ....... .......... .................... .................... .................... ....................

J7100 ....... Dextran 40 infusion ........................................ ........... N ....... .......... .................... .................... .................... ....................

J7110 ....... Dextran 75 infusion ........................................ ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
49842 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J7120 ....... Ringers lactate infusion .................................. ........... N ....... .......... .................... .................... .................... ....................

J7130 ....... Hypertonic saline solution .............................. ........... N ....... .......... .................... .................... .................... ....................

J7188 ....... Inj Vonwillebrand factor iu .............................. ........... K ....... 1704 .................... 0.87 .................... 0.17 

J7189 ....... Factor viia ....................................................... ........... K ....... 1705 .................... 1.08 .................... 0.22 

J7190 ....... Factor viii ........................................................ ........... K ....... 0925 .................... 0.68 .................... 0.14 

J7191 ....... Factor VIII (porcine) ....................................... ........... K ....... 0926 .................... 0.66 .................... 0.13 

J7192 ....... Factor viii recombinant ................................... ........... K ....... 0927 .................... 1.05 .................... 0.21 

J7193 ....... Factor IX non-recombinant ............................ ........... K ....... 0931 .................... 0.88 .................... 0.18 

J7194 ....... Factor ix complex ........................................... ........... K ....... 0928 .................... 0.63 .................... 0.13 

J7195 ....... Factor IX recombinant .................................... ........... K ....... 0932 .................... 0.98 .................... 0.20 

J7197 ....... Antithrombin iii injection ................................. ........... K ....... 0930 .................... 1.62 .................... 0.32 

J7198 ....... Anti-inhibitor ................................................... ........... K ....... 0929 .................... 1.29 .................... 0.26 

J7308 ....... Aminolevulinic acid hcl top ............................. ........... K ....... 7308 .................... 99.92 .................... 19.98 

J7310 ....... Ganciclovir long act implant ........................... ........... K ....... 0913 .................... 4,200.00 .................... 840.00 

J7317 ....... Sodium hyaluronate injection ......................... ........... K ....... 7316 .................... 112.04 .................... 22.41 

J7320 ....... Hylan G-F 20 injection ................................... ........... K ....... 1611 .................... 196.99 .................... 39.40 

J7340 ....... Metabolic active D/E tissue ............................ ........... K ....... 1632 .................... 27.56 .................... 5.51 

J7341 ....... Non-human, metabolic tissue ........................ ........... K ....... 1707 .................... 1.64 .................... 0.33 

J7342 ....... Metabolically active tissue ............................. ........... K ....... 9054 .................... 15.01 .................... 3.00 

J7343 ....... Nonmetabolic act d/e tissue ........................... ........... K ....... 1629 .................... 15.20 .................... 3.04 

J7344 ....... Nonmetabolic active tissue ............................ ........... K ....... 9156 .................... 66.39 .................... 13.28 

J7350 ....... Injectable human tissue ................................. CH .... N ....... .......... .................... .................... .................... ....................

J7500 ....... Azathioprine oral 50mg .................................. ........... N ....... .......... .................... .................... .................... ....................

J7501 ....... Azathioprine parenteral .................................. ........... K ....... 0887 .................... 48.73 .................... 9.75 

J7502 ....... Cyclosporine oral 100 mg .............................. ........... K ....... 0888 .................... 3.88 .................... 0.78 

J7504 ....... Lymphocyte immune globulin ........................ ........... K ....... 0890 .................... 295.38 .................... 59.08 

J7505 ....... Monoclonal antibodies ................................... ........... K ....... 7038 .................... 860.94 .................... 172.19 

J7506 ....... Prednisone oral .............................................. ........... N ....... .......... .................... .................... .................... ....................

J7507 ....... Tacrolimus oral per 1 MG .............................. ........... K ....... 0891 .................... 3.40 .................... 0.68 

J7509 ....... Methylprednisolone oral ................................. ........... N ....... .......... .................... .................... .................... ....................

J7510 ....... Prednisolone oral per 5 mg ........................... ........... N ....... .......... .................... .................... .................... ....................

J7511 ....... Antithymocyte globuln rabbit .......................... ........... K ....... 9104 .................... 301.48 .................... 60.30 

J7513 ....... Daclizumab, parenteral .................................. ........... K ....... 1612 .................... 345.07 .................... 69.01 

J7515 ....... Cyclosporine oral 25 mg ................................ CH .... N ....... .......... .................... .................... .................... ....................

J7516 ....... Cyclosporin parenteral 250mg ....................... ........... N ....... .......... .................... .................... .................... ....................

J7517 ....... Mycophenolate mofetil oral ............................ ........... K ....... 9015 .................... 2.50 .................... 0.50 

J7518 ....... Mycophenolic acid .......................................... CH .... K ....... 9219 .................... 2.15 .................... 0.43 

J7520 ....... Sirolimus, oral ................................................ ........... K ....... 9020 .................... 6.84 .................... 1.37 

J7525 ....... Tacrolimus injection ....................................... ........... K ....... 9006 .................... 135.17 .................... 27.03 

J7599 ....... Immunosuppressive drug noc ........................ ........... N ....... .......... .................... .................... .................... ....................

J7674 ....... Methacholine chloride, neb ............................ ........... N ....... .......... .................... .................... .................... ....................

J7799 ....... Non-inhalation drug for DME ......................... ........... N ....... .......... .................... .................... .................... ....................

J8501 ....... Oral aprepitant ............................................... ........... G ....... 0868 .................... 4.63 .................... 0.93 

J8510 ....... Oral busulfan .................................................. ........... K ....... 7015 .................... 1.95 .................... 0.39 

J8520 ....... Capecitabine, oral, 150 mg ............................ ........... K ....... 7042 .................... 3.60 .................... 0.72 

J8530 ....... Cyclophosphamide oral 25 MG ..................... ........... N ....... .......... .................... .................... .................... ....................

J8540 ....... Oral dexamethasone ...................................... CH .... N ....... .......... .................... .................... .................... ....................

J8560 ....... Etoposide oral 50 MG .................................... ........... K ....... 0802 .................... 32.73 .................... 6.55 

J8597 ....... Antiemetic drug oral NOS .............................. ........... N ....... .......... .................... .................... .................... ....................

J8600 ....... Melphalan oral 2 MG ..................................... CH .... K ....... 3047 .................... 4.39 .................... 0.88 

J8610 ....... Methotrexate oral 2.5 MG .............................. ........... N ....... .......... .................... .................... .................... ....................

J8700 ....... Temozolomide ................................................ ........... K ....... 1086 .................... 7.16 .................... 1.43 

J9000 ....... Doxorubic hcl 10 MG vl chemo ..................... CH .... K ....... 3048 .................... 6.23 .................... 1.25 

J9001 ....... Doxorubicin hcl liposome inj .......................... ........... K ....... 7046 .................... 367.56 .................... 73.51 

J9010 ....... Alemtuzumab injection ................................... ........... K ....... 9110 .................... 525.75 .................... 105.15 

J9015 ....... Aldesleukin/single use vial ............................. ........... K ....... 0807 .................... 734.10 .................... 146.82 

J9017 ....... Arsenic trioxide ............................................... ........... K ....... 9012 .................... 32.92 .................... 6.58 

J9020 ....... Asparaginase injection ................................... ........... K ....... 0814 .................... 53.66 .................... 10.73 

J9025 ....... Azacitidine injection ........................................ ........... K ....... 1709 .................... 4.09 .................... 0.82 

J9027 ....... Clofarabine injection ....................................... ........... G ....... 1710 .................... 116.68 .................... 23.34 

J9031 ....... Bcg live intravesical vac ................................. ........... K ....... 0809 .................... 110.48 .................... 22.10 

J9035 ....... Bevacizumab injection ................................... CH .... K ....... 9214 .................... 56.36 .................... 11.27 

J9040 ....... Bleomycin sulfate injection ............................. CH .... N ....... .......... .................... .................... .................... ....................

J9041 ....... Bortezomib injection ....................................... ........... K ....... 9207 .................... 29.81 .................... 5.96 

J9045 ....... Carboplatin injection ....................................... ........... K ....... 0811 .................... 13.74 .................... 2.75 

J9050 ....... Carmus bischl nitro inj ................................... ........... K ....... 0812 .................... 139.66 .................... 27.93 

J9055 ....... Cetuximab injection ........................................ CH .... K ....... 9215 .................... 49.39 .................... 9.88 

J9060 ....... Cisplatin 10 MG injection ............................... ........... N ....... .......... .................... .................... .................... ....................

J9065 ....... Inj cladribine per 1 MG .................................. ........... K ....... 0858 .................... 38.28 .................... 7.66 

J9070 ....... Cyclophosphamide 100 MG inj ...................... ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49843 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

J9093 ....... Cyclophosphamide lyophilized ....................... CH .... K ....... 3049 .................... 5.47 .................... 1.09 

J9098 ....... Cytarabine liposome ...................................... ........... K ....... 1166 .................... 374.75 .................... 74.95 

J9100 ....... Cytarabine hcl 100 MG inj ............................. ........... N ....... .......... .................... .................... .................... ....................

J9120 ....... Dactinomycin actinomycin d .......................... ........... N ....... .......... .................... .................... .................... ....................

J9130 ....... Dacarbazine 100 mg inj ................................. CH .... N ....... .......... .................... .................... .................... ....................

J9150 ....... Daunorubicin .................................................. ........... K ....... 0820 .................... 23.36 .................... 4.67 

J9151 ....... Daunorubicin citrate liposom .......................... ........... K ....... 0821 .................... 55.72 .................... 11.14 

J9160 ....... Denileukin diftitox, 300 mcg ........................... ........... K ....... 1084 .................... 1,391.05 .................... 278.21 

J9165 ....... Diethylstilbestrol injection ............................... ........... N ....... .......... .................... .................... .................... ....................

J9170 ....... Docetaxel ....................................................... ........... K ....... 0823 .................... 294.48 .................... 58.90 

J9175 ....... Elliotts b solution per ml ................................. ........... N ....... .......... .................... .................... .................... ....................

J9178 ....... Inj, epirubicin hcl, 2 mg .................................. ........... K ....... 1167 .................... 24.47 .................... 4.89 

J9181 ....... Etoposide 10 MG inj ...................................... ........... N ....... .......... .................... .................... .................... ....................

J9185 ....... Fludarabine phosphate inj .............................. ........... K ....... 0842 .................... 230.11 .................... 46.02 

J9190 ....... Fluorouracil injection ...................................... ........... N ....... .......... .................... .................... .................... ....................

J9200 ....... Floxuridine injection ....................................... ........... K ....... 0827 .................... 62.61 .................... 12.52 

J9201 ....... Gemcitabine HCl ............................................ ........... K ....... 0828 .................... 116.59 .................... 23.32 

J9202 ....... Goserelin acetate implant .............................. ........... K ....... 0810 .................... 197.59 .................... 39.52 

J9206 ....... Irinotecan injection ......................................... ........... K ....... 0830 .................... 125.28 .................... 25.06 

J9208 ....... Ifosfomide injection ........................................ ........... K ....... 0831 .................... 54.19 .................... 10.84 

J9209 ....... Mesna injection .............................................. ........... K ....... 0732 .................... 7.87 .................... 1.57 

J9211 ....... Idarubicin hcl injection .................................... ........... K ....... 0832 .................... 265.53 .................... 53.11 

J9212 ....... Interferon alfacon-1 ........................................ ........... K ....... 0912 .................... 3.92 .................... 0.78 

J9213 ....... Interferon alfa-2a inj ....................................... ........... K ....... 0834 .................... 33.53 .................... 6.71 

J9214 ....... Interferon alfa-2b inj ....................................... ........... K ....... 0836 .................... 13.54 .................... 2.71 

J9215 ....... Interferon alfa-n3 inj ....................................... ........... K ....... 0865 .................... 50.33 .................... 10.07 

J9216 ....... Interferon gamma 1-b inj ................................ ........... K ....... 0838 .................... 289.87 .................... 57.97 

J9217 ....... Leuprolide acetate suspnsion ........................ ........... K ....... 9217 .................... 242.99 .................... 48.60 

J9218 ....... Leuprolide acetate injeciton ........................... ........... K ....... 0861 .................... 7.86 .................... 1.57 

J9219 ....... Leuprolide acetate implant ............................. ........... K ....... 7051 .................... 2,157.81 .................... 431.56 

J9225 ....... Histrelin implant .............................................. ........... K ....... 1711 .................... 2,019.82 .................... 403.96 

J9230 ....... Mechlorethamine hcl inj ................................. ........... N ....... .......... .................... .................... .................... ....................

J9245 ....... Inj melphalan hydrochl 50 MG ....................... ........... K ....... 0840 .................... 1,190.81 .................... 238.16 

J9250 ....... Methotrexate sodium inj ................................. ........... N ....... .......... .................... .................... .................... ....................

J9263 ....... Oxaliplatin ....................................................... ........... K ....... 1738 .................... 8.47 .................... 1.69 

J9264 ....... Paclitaxel injection .......................................... ........... G ....... 1712 .................... 8.73 .................... 1.75 

J9265 ....... Paclitaxel injection .......................................... ........... K ....... 0863 .................... 15.44 .................... 3.09 

J9266 ....... Pegaspargase/singl dose vial ........................ ........... K ....... 0843 .................... 1,596.00 .................... 319.20 

J9268 ....... Pentostatin injection ....................................... ........... K ....... 0844 .................... 2,000.96 .................... 400.19 

J9270 ....... Plicamycin (mithramycin) inj .......................... ........... K ....... 0860 .................... 173.66 .................... 34.73 

J9280 ....... Mitomycin 5 MG inj ........................................ ........... K ....... 0862 .................... 18.82 .................... 3.76 

J9293 ....... Mitoxantrone hydrochl/5 MG .......................... ........... K ....... 0864 .................... 336.76 .................... 67.35 

J9300 ....... Gemtuzumab ozogamicin .............................. ........... K ....... 9004 .................... 2,265.57 .................... 453.11 

J9305 ....... Pemetrexed injection ...................................... CH .... K ....... 9213 .................... 40.90 .................... 8.18 

J9310 ....... Rituximab cancer treatment ........................... ........... K ....... 0849 .................... 465.23 .................... 93.05 

J9320 ....... Streptozocin injection ..................................... ........... K ....... 0850 .................... 147.45 .................... 29.49 

J9340 ....... Thiotepa injection ........................................... ........... K ....... 0851 .................... 45.38 .................... 9.08 

J9350 ....... Topotecan ...................................................... ........... K ....... 0852 .................... 780.54 .................... 156.11 

J9355 ....... Trastuzumab .................................................. ........... K ....... 1613 .................... 54.59 .................... 10.92 

J9357 ....... Valrubicin, 200 mg ......................................... ........... K ....... 9167 .................... 76.03 .................... 15.21 

J9360 ....... Vinblastine sulfate inj ..................................... ........... N ....... .......... .................... .................... .................... ....................

J9370 ....... Vincristine sulfate 1 MG inj ............................ ........... N ....... .......... .................... .................... .................... ....................

J9390 ....... Vinorelbine tartrate/10 mg .............................. ........... K ....... 0855 .................... 22.04 .................... 4.41 

J9395 ....... Injection, Fulvestrant ...................................... ........... K ....... 9120 .................... 80.31 .................... 16.06 

J9600 ....... Porfimer sodium ............................................. ........... K ....... 0856 .................... 2,481.76 .................... 496.35 

J9999 ....... Chemotherapy drug ....................................... ........... N ....... .......... .................... .................... .................... ....................

L8600 ....... Implant breast silicone/eq .............................. ........... N ....... .......... .................... .................... .................... ....................

L8603 ....... Collagen imp urinary 2.5 ml ........................... ........... N ....... .......... .................... .................... .................... ....................

L8606 ....... Synthetic implnt urinary 1ml ........................... ........... N ....... .......... .................... .................... .................... ....................

L8609 ....... Artificial cornea ............................................... ........... N ....... .......... .................... .................... .................... ....................

L8610 ....... Ocular implant ................................................ ........... N ....... .......... .................... .................... .................... ....................

L8612 ....... Aqueous shunt prosthesis .............................. ........... N ....... .......... .................... .................... .................... ....................

L8613 ....... Ossicular implant ............................................ ........... N ....... .......... .................... .................... .................... ....................

L8614 ....... Cochlear device/system ................................. ........... N ....... .......... .................... .................... .................... ....................

L8630 ....... Metacarpophalangeal implant ........................ ........... N ....... .......... .................... .................... .................... ....................

L8631 ....... MCP joint repl 2 pc or more .......................... ........... N ....... .......... .................... .................... .................... ....................

L8641 ....... Metatarsal joint implant .................................. ........... N ....... .......... .................... .................... .................... ....................

L8642 ....... Hallux implant ................................................. ........... N ....... .......... .................... .................... .................... ....................

L8658 ....... Interphalangeal joint spacer ........................... ........... N ....... .......... .................... .................... .................... ....................

L8659 ....... Interphalangeal joint repl ................................ ........... N ....... .......... .................... .................... .................... ....................


sroberts on PROD1PC70 with PROPOSALS
49844 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

L8670 ....... Vascular graft, synthetic ................................. ........... N ....... .......... .................... .................... .................... ....................

L8682 ....... Implt neurostim radiofq rec ............................ ........... N ....... .......... .................... .................... .................... ....................

L8699 ....... Prosthetic implant NOS .................................. ........... N ....... .......... .................... .................... .................... ....................

M0064 ...... Visit for drug monitoring ................................. ........... X ....... 0374 1.1509 70.84 .................... 14.17 

P9010 ...... Whole blood for transfusion ........................... ........... K ....... 0950 2.1824 134.33 .................... 26.87 

P9011 ...... Blood split unit ................................................ ........... K ....... 0967 2.2087 135.95 .................... 27.19 

P9012 ...... Cryoprecipitate each unit ............................... ........... K ....... 0952 0.8571 52.76 .................... 10.55 

P9016 ...... RBC leukocytes reduced ............................... ........... K ....... 0954 2.8738 176.89 .................... 35.38

P9017 ...... Plasma 1 donor frz w/in 8 hr ......................... ........... K ....... 9508 1.1677 71.87 .................... 14.37 

P9019 ...... Platelets, each unit ......................................... ........... K ....... 0957 0.9794 60.28 .................... 12.06 

P9020 ...... Plaelet rich plasma unit .................................. ........... K ....... 0958 2.5336 155.95 .................... 31.19 

P9021 ...... Red blood cells unit ....................................... ........... K ....... 0959 2.1045 129.53 .................... 25.91 

P9022 ...... Washed red blood cells unit .......................... ........... K ....... 0960 3.5028 215.60 .................... 43.12

P9023 ...... Frozen plasma, pooled, sd ............................ ........... K ....... 0949 0.9060 55.77 .................... 11.15 

P9031 ...... Platelets leukocytes reduced ......................... ........... K ....... 1013 1.5318 94.28 .................... 18.86 

P9032 ...... Platelets, irradiated ........................................ ........... K ....... 9500 2.0957 128.99 .................... 25.80 

P9033 ...... Platelets leukoreduced irrad .......................... ........... K ....... 0968 2.1192 130.44 .................... 26.09 

P9034 ...... Platelets, pheresis .......................................... ........... K ....... 9507 7.5381 463.98 .................... 92.80 

P9035 ...... Platelet pheres leukoreduced ........................ ........... K ....... 9501 7.9414 488.80 .................... 97.76 

P9036 ...... Platelet pheresis irradiated ............................ ........... K ....... 9502 6.6959 412.14 .................... 82.43 

P9037 ...... Plate pheres leukoredu irrad .......................... ........... K ....... 1019 9.9841 614.53 .................... 122.91 

P9038 ...... RBC irradiated ................................................ ........... K ....... 9505 3.2600 200.66 .................... 40.13 

P9039 ...... RBC deglycerolized ........................................ ........... K ....... 9504 5.7106 351.49 .................... 70.30 

P9040 ...... RBC leukoreduced irradiated ......................... ........... K ....... 0969 3.7037 227.97 .................... 45.59 

P9041 ...... Albumin (human),5%, 50ml ............................ ........... K ....... 0961 .................... 25.48 .................... 5.10 

P9043 ...... Plasma protein fract,5%,50ml ........................ ........... K ....... 0956 0.4016 24.72 .................... 4.94 

P9044 ...... Cryoprecipitatereducedplasma ....................... ........... K ....... 1009 1.2990 79.95 .................... 15.99 

P9045 ...... Albumin (human), 5%, 250 ml ....................... ........... K ....... 0963 .................... 72.09 .................... 14.42 

P9046 ...... Albumin (human), 25%, 20 ml ....................... ........... K ....... 0964 .................... 26.79 .................... 5.36 

P9047 ...... Albumin (human), 25%, 50ml ........................ ........... K ....... 0965 .................... 61.77 .................... 12.35 

P9048 ...... Plasmaprotein fract,5%,250ml ....................... ........... K ....... 0966 3.1309 192.71 .................... 38.54 

P9050 ...... Granulocytes, pheresis unit ........................... ........... K ....... 9506 4.1030 252.54 .................... 50.51 

P9051 ...... Blood, l/r, cmv-neg ......................................... ........... K ....... 1010 2.1991 135.36 .................... 27.07 

P9052 ...... Platelets, hla-m, l/r, unit ................................. ........... K ....... 1011 10.5084 646.80 .................... 129.36 

P9053 ...... Plt, pher, l/r cmv-neg, irr ................................ ........... K ....... 1020 11.7025 720.30 .................... 144.06 

P9054 ...... Blood, l/r, froz/degly/wash .............................. ........... K ....... 1016 1.4462 89.02 .................... 17.80 

P9055 ...... Plt, aph/pher, l/r, cmv-neg .............................. ........... K ....... 1017 6.1508 378.59 .................... 75.72 

P9056 ...... Blood, l/r, irradiated ........................................ ........... K ....... 1018 2.1765 133.97 .................... 26.79 

P9057 ...... RBC, frz/deg/wsh, l/r, irrad ............................. ........... K ....... 1021 6.9189 425.87 .................... 85.17 

P9058 ...... RBC, l/r, cmv-neg, irrad ................................. ........... K ....... 1022 4.2818 263.55 .................... 52.71 

P9059 ...... Plasma, frz between 8-24hour ....................... ........... K ....... 0955 1.1864 73.02 .................... 14.60 

P9060 ...... Fr frz plasma donor retested ......................... ........... K ....... 9503 1.1915 73.34 .................... 14.67 

P9612 ...... Catheterize for urine spec .............................. CH .... A ....... .......... .................... .................... .................... ....................

P9615 ...... Urine specimen collect mult ........................... ........... N ....... .......... .................... .................... .................... ....................

Q0035 ...... Cardiokymography ......................................... ........... X ....... 0100 2.5352 156.04 41.44 31.21 

Q0091 ...... Obtaining screen pap smear .......................... ........... T ....... 0191 0.1501 9.24 .................... 1.85 

Q0092 ...... Set up port xray equipment ........................... ........... N ....... .......... .................... .................... .................... ....................

Q0163 ...... Diphenhydramine HCl 50mg .......................... ........... N ....... .......... .................... .................... .................... ....................

Q0164 ...... Prochlorperazine maleate 5mg ...................... ........... N ....... .......... .................... .................... .................... ....................

Q0166 ...... Granisetron HCl 1 mg oral ............................. ........... K ....... 0765 .................... 37.08 .................... 7.42 

Q0167 ...... Dronabinol 2.5mg oral .................................... ........... N ....... .......... .................... .................... .................... ....................

Q0169 ...... Promethazine HCl 12.5mg oral ...................... ........... N ....... .......... .................... .................... .................... ....................

Q0171 ...... Chlorpromazine HCl 10mg oral ..................... ........... N ....... .......... .................... .................... .................... ....................

Q0173 ...... Trimethobenzamide HCl 250mg .................... ........... N ....... .......... .................... .................... .................... ....................

Q0174 ...... Thiethylperazine maleate10mg ...................... ........... N ....... .......... .................... .................... .................... ....................

Q0175 ...... Perphenazine 4mg oral .................................. ........... N ....... .......... .................... .................... .................... ....................

Q0177 ...... Hydroxyzine pamoate 25mg .......................... ........... N ....... .......... .................... .................... .................... ....................

Q0179 ...... Ondansetron HCl 8mg oral ............................ ........... K ....... 0769 .................... 34.21 .................... 6.84 

Q0180 ...... Dolasetron mesylate oral ............................... ........... K ....... 0763 .................... 47.52 .................... 9.50 

Q0512 ...... Px sup fee anti-can sub pres ......................... CH .... B ....... .......... .................... .................... .................... ....................

Q0515 ...... Sermorelin acetate injection ........................... CH .... K ....... 3050 .................... 1.73 .................... 0.35 

Q1003 ...... Ntiol category 3 .............................................. ........... N ....... .......... .................... .................... .................... ....................

Q1004 ...... Ntiol category 4 .............................................. ........... N ....... .......... .................... .................... .................... ....................

Q1005 ...... Ntiol category 5 .............................................. ........... N ....... .......... .................... .................... .................... ....................

Q2004 ...... Bladder calculi irrig sol ................................... ........... N ....... .......... .................... .................... .................... ....................

Q2009 ...... Fosphenytoin, 50 mg ..................................... ........... K ....... 7028 .................... 5.18 .................... 1.04 

Q2017 ...... Teniposide, 50 mg ......................................... ........... K ....... 7035 .................... 264.26 .................... 52.85 

Q3019 ...... ALS emer trans no ALS serv ......................... CH .... E ....... .......... .................... .................... .................... ....................

Q3020 ...... ALS nonemer trans no ALS ser ..................... CH .... E ....... .......... .................... .................... .................... ....................

Q3025 ...... IM inj interferon beta 1-a ................................ ........... K ....... 9022 .................... 97.99 .................... 19.60 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49845 

ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued 

CPT/ 

HCPCS Description CI SI APC Relative weight 

Payment 

rate 

National 

unadjusted 

copayment 

Minimum 

unadjusted 

copayment 

Q3031 ...... Collagen skin test ........................................... ........... N ....... .......... .................... .................... .................... ....................

Q4079 ...... Natalizumab injection ..................................... ........... G ....... 9126 .................... 6.39 .................... 1.28 

Q9945 ...... LOCM <=149 mg/ml iodine, 1ml .................... ........... K ....... 9157 .................... 0.30 .................... 0.06 

Q9946 ...... LOCM 150–199mg/ml iodine,1ml .................. ........... K ....... 9158 .................... 1.84 .................... 0.37 

Q9947 ...... LOCM 200–249mg/ml iodine,1ml .................. ........... K ....... 9159 .................... 1.25 .................... 0.25 

Q9948 ...... LOCM 250–299mg/ml iodine,1ml .................. ........... K ....... 9160 .................... 0.32 .................... 0.06 

Q9949 ...... LOCM 300–349mg/ml iodine,1ml .................. ........... K ....... 9161 .................... 0.34 .................... 0.07 

Q9950 ...... LOCM 350–399mg/ml iodine,1ml .................. ........... K ....... 9162 .................... 0.21 .................... 0.04 

Q9951 ...... LOCM >= 400 mg/ml iodine,1ml .................... ........... K ....... 9163 .................... 0.30 .................... 0.06 

Q9952 ...... Inj Gad-base MR contrast,1ml ....................... ........... K ....... 9164 .................... 2.88 .................... 0.58 

Q9953 ...... Inj Fe-based MR contrast,1ml ........................ ........... K ....... 1713 .................... 30.12 .................... 6.02 

Q9954 ...... Oral MR contrast, 100 ml ............................... ........... K ....... 9165 .................... 8.87 .................... 1.77 

Q9955 ...... Inj perflexane lip micros,ml ............................ ........... K ....... 9203 .................... 8.22 .................... 1.64 

Q9956 ...... Inj octafluoropropane mic,ml .......................... ........... K ....... 9202 .................... 40.75 .................... 8.15 

Q9957 ...... Inj perflutren lip micros,ml .............................. ........... K ....... 9112 .................... 61.25 .................... 12.25 

Q9958 ...... HOCM <=149 mg/ml iodine, 1ml ................... CH .... N ....... .......... .................... .................... .................... ....................

Q9959 ...... HOCM 150–199mg/ml iodine,1ml .................. ........... N ....... .......... .................... .................... .................... ....................

Q9960 ...... HOCM 200–249mg/ml iodine,1ml .................. CH .... N ....... .......... .................... .................... .................... ....................

Q9961 ...... HOCM 250–299mg/ml iodine,1ml .................. CH .... N ....... .......... .................... .................... .................... ....................

Q9962 ...... HOCM 300–349mg/ml iodine,1ml .................. CH .... N ....... .......... .................... .................... .................... ....................

Q9963 ...... HOCM 350–399mg/ml iodine,1ml .................. CH .... N ....... .......... .................... .................... .................... ....................

Q9964 ...... HOCM>= 400mg/ml iodine, 1ml .................... CH .... N ....... .......... .................... .................... .................... ....................

V2630 ...... Anter chamber intraocul lens ......................... ........... N ....... .......... .................... .................... .................... ....................

V2631 ...... Iris support intraoclr lens ................................ ........... N ....... .......... .................... .................... .................... ....................

V2632 ...... Post chmbr intraocular lens ........................... ........... N ....... .......... .................... .................... .................... ....................

V2790 ...... Amniotic membrane ....................................... ........... N ....... .......... .................... .................... .................... ....................

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

10021 ....... Fna w/o image Y .............. Y .............. .................. 1.0948 $43.45 $43.45 $8.69 $8.69 

10022 ....... Fna w/image .... Y .............. .................. .................. 2.0147 $79.96 $79.96 $15.99 $15.99 

10040 ....... Acne surgery .... Y .............. Y .............. .................. 0.4829 $19.17 $19.17 $3.83 $3.83 

10060 ....... Drainage of skin 

abscess.

Y .............. Y .............. Y .............. 1.1457 $45.47 $45.47 $9.09 $9.09 

10061 ....... Drainage of skin 

abscess.

Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

10080 ....... Drainage of 

pilonidal cyst.

Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

10081 ....... Drainage of 

pilonidal cyst.

Y .............. Y .............. Y .............. 3.2148 $127.59 $127.59 $25.52 $25.52 

10120 ....... Remove foreign 

body.

Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

10121 ....... Remove foreign 

body.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

10140 ....... Drainage of hematoma/fluid.Y .............. Y .............. Y .............. 1.7090 $67.83 $67.83 $13.57 $13.57 

10160 ....... Puncture drainage of lesion.Y .............. Y .............. .................. 1.0534 $41.81 $41.81 $8.36 $8.36 

10180 ....... Complex drainage, wound................... .................. .................. 17.4686 $693.30 $569.65 $138.66 $113.93 

11000 ....... Debride infected 

skin.

Y .............. Y .............. Y .............. 0.5503 $21.84 $21.84 $4.37 $4.37 

11001 ....... Debride infected 

skin add-on.

Y .............. Y .............. Y .............. 0.1942 $7.71 $7.71 $1.54 $1.54 

11010 ....... Debride skin, fx .................. .................. .................. 4.0123 $159.24 $203.10 $31.85 $40.62 

11011 ....... Debride skin/ 

muscle, fx.

.................. .................. .................. 4.0123 $159.24 $203.10 $31.85 $40.62 

11012 ....... Debride skin/ 

muscle/bone, 

fx.

.................. .................. .................. 4.0123 $159.24 $203.10 $31.85 $40.62 

11040 ....... Debride skin, 

partial.

Y .............. Y .............. Y .............. 0.5040 $20.00 $20.00 $4.00 $4.00 


sroberts on PROD1PC70 with PROPOSALS
49846 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

11041 ....... Debride skin, 

full.

Y .............. Y .............. Y .............. 0.6042 $23.98 $23.98 $4.80 $4.80 

11042 ....... Debride skin/tissue................... .................. .................. 2.6253 $104.19 $132.89 $20.84 $26.58 

11043 ....... Debride tissue/ 

muscle.

.................. .................. .................. 2.6253 $104.19 $132.89 $20.84 $26.58 

11044 ....... Debride tissue/ 

muscle/bone.

.................. .................. .................. 6.7529 $268.01 $341.83 $53.60 $68.37 

11055 ....... Trim skin lesion Y .............. Y .............. Y .............. 0.5762 $22.87 $22.87 $4.57 $4.57 

11056 ....... Trim skin lesions, 2 to 4.Y .............. Y .............. Y .............. 0.6403 $25.41 $25.41 $5.08 $5.08 

11057 ....... Trim skin lesions, over 4.Y .............. Y .............. Y .............. 0.7268 $28.85 $28.85 $5.77 $5.77 

11100 ....... Biopsy, skin lesion.Y .............. Y .............. .................. 1.0534 $41.81 $41.81 $8.36 $8.36 

11101 ....... Biopsy, skin 

add-on.

Y .............. Y .............. Y .............. 0.3217 $12.77 $12.77 $2.55 $2.55 

11200 ....... Removal of skin 

tags.

Y .............. Y .............. Y .............. 0.9713 $38.55 $38.55 $7.71 $7.71 

11201 ....... Remove skin 

tags add-on.

Y .............. Y .............. Y .............. 0.1365 $5.42 $5.42 $1.08 $1.08 

11300 ....... Shave skin lesion.Y .............. Y .............. .................. 0.8076 $32.05 $32.05 $6.41 $6.41 

11301 ....... Shave skin lesion.Y .............. Y .............. .................. 0.8076 $32.05 $32.05 $6.41 $6.41 

11302 ....... Shave skin lesion.Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

11303 ....... Shave skin lesion.Y .............. Y .............. Y .............. 1.5547 $61.70 $61.70 $12.34 $12.34 

11305 ....... Shave skin lesion.Y .............. Y .............. Y .............. 0.8112 $32.20 $32.20 $6.44 $6.44 

11306 ....... Shave skin lesion.Y .............. Y .............. Y .............. 1.0789 $42.82 $42.82 $8.56 $8.56 

11307 ....... Shave skin lesion.Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

11308 ....... Shave skin lesion.Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

11310 ....... Shave skin lesion.Y .............. Y .............. Y .............. 1.0785 $42.80 $42.80 $8.56 $8.56 

11311 ....... Shave skin lesion.Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

11312 ....... Shave skin lesion.Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

11313 ....... Shave skin lesion.Y .............. Y .............. Y .............. 1.7299 $68.66 $68.66 $13.73 $13.73 

11400 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 1.6618 $65.96 $65.96 $13.19 $13.19 

11401 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 1.8178 $72.14 $72.14 $14.43 $14.43 

11402 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 1.9768 $78.45 $78.45 $15.69 $15.69 

11403 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.1118 $83.81 $83.81 $16.76 $16.76 

11404 ....... Exc tr-ext 

b9+marg 3.1- 

4 cm.

.................. .................. .................. 14.9563 $593.59 $463.29 $118.72 $92.66 

11406 ....... Exc tr-ext 

b9+marg > 

4.0 cm.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

11420 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 1.5323 $60.81 $60.81 $12.16 $12.16 

11421 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 1.8294 $72.61 $72.61 $14.52 $14.52 

11422 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 1.9996 $79.36 $79.36 $15.87 $15.87 

11423 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.2405 $88.92 $88.92 $17.78 $17.78 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49847 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

11424 ....... Exc h-f-nk-sp 

b9+marg 3.1- 

4.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

11426 ....... Exc h-f-nk-sp 

b9+marg > 4 

cm.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11440 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 1.8212 $72.28 $72.28 $14.46 $14.46 

11441 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.0319 $80.64 $80.64 $16.13 $16.13 

11442 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.2205 $88.13 $88.13 $17.63 $17.63 

11443 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.4880 $98.75 $98.75 $19.75 $19.75 

11444 ....... Exc face-mm 

b9+marg 3.1- 

4 cm.

.................. .................. .................. 6.5128 $258.48 $295.74 $51.70 $59.15 

11446 ....... Exc face-mm 

b9+marg > 4 

cm.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11450 ....... Removal, sweat 

gland lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11451 ....... Removal, sweat 

gland lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11462 ....... Removal, sweat 

gland lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11463 ....... Removal, sweat 

gland lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11470 ....... Removal, sweat 

gland lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11471 ....... Removal, sweat 

gland lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11600 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.2612 $89.74 $89.74 $17.95 $17.95 

11601 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.5980 $103.11 $103.11 $20.62 $20.62 

11602 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.8188 $111.87 $111.87 $22.37 $22.37 

11603 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 3.0099 $119.46 $119.46 $23.89 $23.89 

11604 ....... Exc tr-ext 

mlg+marg 

3.1-4 cm.

.................. .................. .................. 6.5128 $258.48 $329.68 $51.70 $65.94 

11606 ....... Exc tr-ext 

mlg+marg > 4 

cm.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

11620 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.2902 $90.89 $90.89 $18.18 $18.18 

11621 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.6216 $104.05 $104.05 $20.81 $20.81 

11622 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.9059 $115.33 $115.33 $23.07 $23.07 

11623 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 3.1563 $125.27 $125.27 $25.05 $25.05 

11624 ....... Exc h-f-nk-sp 

mlg+marg 

3.1-4.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

11626 ....... Exc h-f-nk-sp 

mlg+mar > 4 

cm.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11640 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.4089 $95.60 $95.60 $19.12 $19.12 

11641 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 2.8188 $111.87 $111.87 $22.37 $22.37 

11642 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 3.1554 $125.23 $125.23 $25.05 $25.05 

11643 ....... Removal of skin 

lesion.

Y .............. Y .............. Y .............. 3.4305 $136.15 $136.15 $27.23 $27.23 


sroberts on PROD1PC70 with PROPOSALS
49848 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

11644 ....... Exc face-mm 

malig+marg 

3.1-4.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

11646 ....... Exc face-mm 

mlg+marg > 4 

cm.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

11719 ....... Trim nail(s) ....... Y .............. Y .............. Y .............. 0.2643 $10.49 $10.49 $2.10 $2.10 

11720 ....... Debride nail, 1- 

5.

Y .............. Y .............. Y .............. 0.3393 $13.47 $13.47 $2.69 $2.69 

11721 ....... Debride nail, 6 

or more.

Y .............. Y .............. Y .............. 0.4134 $16.41 $16.41 $3.28 $3.28 

11730 ....... Removal of nail 

plate.

Y .............. Y .............. Y .............. 0.9967 $39.56 $39.56 $7.91 $7.91 

11732 ....... Remove nail 

plate, add-on.

Y .............. Y .............. Y .............. 0.4138 $16.42 $16.42 $3.28 $3.28 

11740 ....... Drain blood 

from under 

nail.

Y .............. Y .............. Y .............. 0.5675 $22.52 $22.52 $4.50 $4.50 

11750 ....... Removal of nail 

bed.

Y .............. Y .............. Y .............. 2.1520 $85.41 $85.41 $17.08 $17.08 

11752 ....... Remove nail 

bed/finger tip.

Y .............. Y .............. Y .............. 3.0179 $119.78 $119.78 $23.96 $23.96 

11755 ....... Biopsy, nail unit Y .............. Y .............. Y .............. 1.5236 $60.47 $60.47 $12.09 $12.09 

11760 ....... Repair of nail 

bed.

Y .............. .................. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

11762 ....... Reconstruction 

of nail bed.

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

11765 ....... Excision of nail 

fold, toe.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

11770 ....... Removal of 

pilonidal lesion.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

11771 ....... Removal of 

pilonidal lesion.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

11772 ....... Removal of 

pilonidal lesion.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

11900 ....... Injection into 

skin lesions.

Y .............. Y .............. Y .............. 0.6789 $26.94 $26.94 $5.39 $5.39 

11901 ....... Added skin lesions injection.Y .............. Y .............. Y .............. 0.7259 $28.81 $28.81 $5.76 $5.76 

11920 ....... Correct skin 

color defects.

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

11921 ....... Correct skin 

color defects.

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

11922 ....... Correct skin 

color defects.

Y .............. Y .............. Y .............. 0.8864 $35.18 $35.18 $7.04 $7.04 

11950 ....... Therapy for 

contour defects.

Y .............. Y .............. Y .............. 0.8811 $34.97 $34.97 $6.99 $6.99 

11951 ....... Therapy for 

contour defects.

Y .............. Y .............. Y .............. 1.1485 $45.58 $45.58 $9.12 $9.12 

11952 ....... Therapy for 

contour defects.

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

11954 ....... Therapy for 

contour defects.

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

11960 ....... Insert tissue expander(s)................... .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

11970 ....... Replace tissue 

expander.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

11971 ....... Remove tissue 

expander(s).

.................. .................. .................. 19.9760 $792.81 $562.90 $158.56 $112.58 

11976 ....... Removal of contraceptive cap.Y .............. Y .............. Y .............. 1.4625 $58.04 $58.04 $11.61 $11.61 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49849 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

11980 ....... Implant hormone pellet(s).Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

11981 ....... Insert drug implant device.Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

11982 ....... Remove drug 

implant device.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

11983 ....... Remove/insert 

drug implant.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

12001 ....... Repair superficial 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12002 ....... Repair superficial 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12004 ....... Repair superficial 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12005 ....... Repair superficial 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12006 ....... Repair superficial 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12007 ....... Repair superficial 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12011 ....... Repair superficial 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12013 ....... Repair superficial 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12014 ....... Repair superficial 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12015 ....... Repair superficial 

wound(s).

Y .............. .................. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12016 ....... Repair superficial 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12017 ....... Repair superficial 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12018 ....... Repair superficial 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12020 ....... Closure of split 

wound.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12021 ....... Closure of split 

wound.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12031 ....... Layer closure of 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12032 ....... Layer closure of 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12034 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12035 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12036 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12037 ....... Layer closure of 

wound(s).

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

12041 ....... Layer closure of 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12042 ....... Layer closure of 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 


sroberts on PROD1PC70 with PROPOSALS
49850 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

12044 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12045 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12046 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12047 ....... Layer closure of 

wound(s).

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

12051 ....... Layer closure of 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12052 ....... Layer closure of 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12053 ....... Layer closure of 

wound(s).

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

12054 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12055 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12056 ....... Layer closure of 

wound(s).

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

12057 ....... Layer closure of 

wound(s).

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

13100 ....... Repair of wound 

or lesion.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

13101 ....... Repair of wound 

or lesion.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

13102 ....... Repair wound/ 

lesion add-on.

Y .............. .................. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

13120 ....... Repair of wound 

or lesion.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

13121 ....... Repair of wound 

or lesion.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

13122 ....... Repair wound/ 

lesion add-on.

Y .............. .................. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

13131 ....... Repair of wound 

or lesion.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

13132 ....... Repair of wound 

or lesion.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

13133 ....... Repair wound/ 

lesion add-on.

Y .............. Y .............. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

13150 ....... Repair of wound 

or lesion.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

13151 ....... Repair of wound 

or lesion.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

13152 ....... Repair of wound 

or lesion.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

13153 ....... Repair wound/ 

lesion add-on.

Y .............. .................. .................. 1.4924 $59.23 $59.23 $11.85 $11.85 

13160 ....... Late closure of 

wound.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

14000 ....... Skin tissue rearrangement................... .................. .................. 13.3433 $529.57 $487.79 $105.91 $97.56 

14001 ....... Skin tissue rearrangement................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

14020 ....... Skin tissue rearrangement................... .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

14021 ....... Skin tissue rearrangement................... .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

14040 ....... Skin tissue rearrangement................... .................. .................. 13.3433 $529.57 $487.79 $105.91 $97.56 

14041 ....... Skin tissue rearrangement................... .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

14060 ....... Skin tissue rearrangement................... .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

14061 ....... Skin tissue rearrangement................... .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

14300 ....... Skin tissue rearrangement................... .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49851 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

14350 ....... Skin tissue rearrangement................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15000 ....... Wound prep, 

1st 100 sq cm.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15001 ....... Wound prep, 

addl 100 sq 

cm.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15040 ....... Harvest cultured 

skin graft.

.................. .................. .................. 1.4924 $59.23 $75.55 $11.85 $15.11 

15050 ....... Skin pinch graft .................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15100 ....... Skin splt grft, 

trnk/arm/leg.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15101 ....... Skin splt grft t/a/ 

l, add-on.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15110 ....... Epidrm autogrft 

trnk/arm/leg.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15111 ....... Epidrm autogrft 

t/a/l add-on.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15115 ....... Epidrm a-grft 

face/nck/hf/g.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15116 ....... Epidrm a-grft f/ 

n/hf/g addl.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15120 ....... Skn splt a-grft 

fac/nck/hf/g.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15121 ....... Skn splt a-grft f/ 

n/hf/g add.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15130 ....... Derm autograft, 

trnk/arm/leg.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15131 ....... Derm autograft 

t/a/l add-on.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15135 ....... Derm autograft 

face/nck/hf/g.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15136 ....... Derm autograft, 

f/n/hf/g add.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15150 ....... Cult epiderm 

grft t/arm/leg.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15151 ....... Cult epiderm 

grft t/a/l addl.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15152 ....... Cult epiderm 

graft t/a/l +%.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15155 ....... Cult epiderm 

graft, f/n/hf/g.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15156 ....... Cult epidrm grft 

f/n/hfg add.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15157 ....... Cult epiderm 

grft f/n/hfg +%.

.................. .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

15200 ....... Skin full graft, 

trunk.

.................. .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

15201 ....... Skin full graft 

trunk add-on.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15220 ....... Skin full graft 

sclp/arm/leg.

.................. .................. .................. 13.3433 $529.57 $487.79 $105.91 $97.56 

15221 ....... Skin full graft 

add-on.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15240 ....... Skin full grft 

face/genit/hf.

.................. .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

15241 ....... Skin full graft 

add-on.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15260 ....... Skin full graft 

een & lips.

.................. .................. .................. 13.3433 $529.57 $487.79 $105.91 $97.56 

15261 ....... Skin full graft 

add-on.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15300 ....... Apply 

skinallogrft, t/ 

arm/lg.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15301 ....... Apply sknallogrft 

t/a/l addl.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 


sroberts on PROD1PC70 with PROPOSALS
49852 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

15320 ....... Apply skin 

allogrft f/n/hf/g.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15321 ....... Aply sknallogrft 

f/n/hfg add.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15330 ....... Aply acell 

alogrft t/arm/ 

leg.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15331 ....... Aply acell grft t/ 

a/l add-on.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15335 ....... Apply acell 

graft, f/n/hf/g.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15336 ....... Aply acell grft f/ 

n/hf/g add.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15340 ....... Apply cult skin 

substitute.

Y .............. Y .............. Y .............. 3.2865 $130.44 $130.44 $26.09 $26.09 

15341 ....... Apply cult skin 

sub add-on.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

15360 ....... Apply cult derm 

sub, t/a/l.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

15361 ....... Aply cult derm 

sub t/a/l add.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

15365 ....... Apply cult derm 

sub f/n/hf/g.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

15366 ....... Apply cult derm 

f/hf/g add.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

15400 ....... Apply skin 

xenograft, t/a/l.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15401 ....... Apply skn 

xenogrft t/a/l 

add.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15420 ....... Apply skin 

xgraft, f/n/hf/g.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15421 ....... Apply skn xgrft 

f/n/hf/g add.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15430 ....... Apply acellular 

xenograft.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15431 ....... Apply acellular 

xgraft add.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15570 ....... Form skin pedicle flap................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15572 ....... Form skin pedicle flap................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15574 ....... Form skin pedicle flap................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15576 ....... Form skin pedicle flap................... .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

15600 ....... Skin graft .......... .................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15610 ....... Skin graft .......... .................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15620 ....... Skin graft .......... .................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15630 ....... Skin graft .......... .................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15650 ....... Transfer skin 

pedicle flap.

.................. .................. .................. 21.2645 $843.95 $780.47 $168.79 $156.09 

15732 ....... Muscle-skin 

graft, head/ 

neck.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15734 ....... Muscle-skin 

graft, trunk.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15736 ....... Muscle-skin 

graft, arm.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15738 ....... Muscle-skin 

graft, leg.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15740 ....... Island pedicle 

flap graft.

.................. .................. .................. 13.3433 $529.57 $487.79 $105.91 $97.56 

15750 ....... Neurovascular 

pedicle graft.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

15760 ....... Composite skin 

graft.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49853 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

15770 ....... Derma-fat-fascia 

graft.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15775 ....... Hair transplant 

punch grafts.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15776 ....... Hair transplant 

punch grafts.

.................. .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15780 ....... Abrasion treatment of skin.Y .............. Y .............. Y .............. 10.0118 $397.35 $397.35 $79.47 $79.47 

15781 ....... Abrasion treatment of skin.Y .............. Y .............. .................. 4.0123 $159.24 $159.24 $31.85 $31.85 

15782 ....... Dressing 

change not 

for burn.

Y .............. Y .............. .................. 4.0123 $159.24 $159.24 $31.85 $31.85 

15783 ....... Abrasion treatment of skin.Y .............. Y .............. .................. 2.6253 $104.19 $104.19 $20.84 $20.84 

15786 ....... Abrasion, lesion, single.Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

15787 ....... Abrasion, lesions, add-on.Y .............. Y .............. Y .............. 0.8221 $32.63 $32.63 $6.53 $6.53 

15788 ....... Chemical peel, 

face, epiderm.

Y .............. Y .............. .................. 0.8076 $32.05 $32.05 $6.41 $6.41 

15789 ....... Chemical peel, 

face, dermal.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

15792 ....... Chemical peel, 

nonfacial.

Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

15793 ....... Chemical peel, 

nonfacial.

Y .............. Y .............. .................. 0.8076 $32.05 $32.05 $6.41 $6.41 

15819 ....... Plastic surgery, 

neck.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

15820 ....... Revision of 

lower eyelid.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15821 ....... Revision of 

lower eyelid.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15822 ....... Revision of 

upper eyelid.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15823 ....... Revision of 

upper eyelid.

.................. .................. .................. 13.3433 $529.57 $623.29 $105.91 $124.66 

15824 ....... Removal of 

forehead 

wrinkles.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15825 ....... Removal of 

neck wrinkles.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15826 ....... Removal of 

brow wrinkles.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15828 ....... Removal of face 

wrinkles.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15829 ....... Removal of skin 

wrinkles.

.................. .................. .................. 21.2645 $843.95 $780.47 $168.79 $156.09 

15831 ....... Excise excessive skin tissue................... .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15832 ....... Excise excessive skin tissue................... .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15833 ....... Excise excessive skin tissue................... .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15834 ....... Excise excessive skin tissue................... .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15835 ....... Excise excessive skin tissue................... .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

15836 ....... Excise excessive skin tissue................... .................. .................. 14.9563 $593.59 $551.79 $118.72 $110.36 


sroberts on PROD1PC70 with PROPOSALS
49854 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

15837 ....... Excise excessive skin tissue.Y .............. .................. .................. 14.9563 $593.59 $593.59 $118.72 $118.72 

15838 ....... Excise excessive skin tissue.Y .............. .................. .................. 14.9563 $593.59 $593.59 $118.72 $118.72 

15839 ....... Excise excessive skin tissue................... .................. .................. 14.9563 $593.59 $551.79 $118.72 $110.36 

15840 ....... Graft for face 

nerve palsy.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15841 ....... Graft for face 

nerve palsy.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15845 ....... Skin and muscle repair, 

face.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15850 ....... Removal of sutures.Y .............. .................. .................. 2.6253 $104.19 $104.19 $20.84 $20.84 

15851 ....... Removal of sutures.Y .............. Y .............. Y .............. 1.2829 $50.92 $50.92 $10.18 $10.18 

15852 ....... Dressing 

change not 

for burn.

Y .............. .................. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

15860 ....... Test for blood 

flow in graft.

Y .............. .................. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

15876 ....... Suction assisted 

lipectomy.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15877 ....... Suction assisted 

lipectomy.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15878 ....... Suction assisted 

lipectomy.

.................. .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

15879 ....... Suction assisted 

lipectomy.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15920 ....... Removal of tail 

bone ulcer.

.................. .................. .................. 4.0123 $159.24 $203.10 $31.85 $40.62 

15922 ....... Removal of tail 

bone ulcer.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15931 ....... Remove sacrum 

pressure sore.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15933 ....... Remove sacrum 

pressure sore.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15934 ....... Remove sacrum 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15935 ....... Remove sacrum 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15936 ....... Remove sacrum 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15937 ....... Remove sacrum 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15940 ....... Remove hip 

pressure sore.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15941 ....... Remove hip 

pressure sore.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15944 ....... Remove hip 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15945 ....... Remove hip 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15946 ....... Remove hip 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

15950 ....... Remove thigh 

pressure sore.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

15951 ....... Remove thigh 

pressure sore.

.................. .................. .................. 19.9760 $792.81 $711.40 $158.56 $142.28 

15952 ....... Remove thigh 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15953 ....... Remove thigh 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49855 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

15956 ....... Remove thigh 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

15958 ....... Remove thigh 

pressure sore.

.................. .................. .................. 21.2645 $843.95 $736.97 $168.79 $147.39 

16000 ....... Initial treatment 

of burn(s).

Y .............. Y .............. Y .............. 0.6709 $26.63 $26.63 $5.33 $5.33 

16020 ....... Treatment of 

burn(s).

Y .............. Y .............. Y .............. 1.0167 $40.35 $40.35 $8.07 $8.07 

16025 ....... Dress/debrid pthick burn, m................... .................. .................. 1.0876 $43.16 $55.05 $8.63 $11.01 

16030 ....... Dress/debrid pthick burn, l................... .................. .................. 1.6062 $63.75 $81.30 $12.75 $16.26 

17000 ....... Destroy benign/ 

premlg lesion.

Y .............. Y .............. .................. 0.4829 $19.17 $19.17 $3.83 $3.83 

17003 ....... Destroy lesions, 

2-14.

Y .............. Y .............. Y .............. 0.0928 $3.68 $3.68 $0.74 $0.74 

17004 ....... Destroy lesions, 

15 or more.

Y .............. Y .............. Y .............. 2.0221 $80.25 $80.25 $16.05 $16.05 

17106 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 2.6478 $105.09 $105.09 $21.02 $21.02 

17107 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 2.6478 $105.09 $105.09 $21.02 $21.02 

17108 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 2.6478 $105.09 $105.09 $21.02 $21.02 

17110 ....... Destruct lesion, 

1-14.

Y .............. Y .............. .................. 0.8076 $32.05 $32.05 $6.41 $6.41 

17111 ....... Destruct lesion, 

15 or more.

Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

17250 ....... Chemical cautery, tissue.Y .............. Y .............. Y .............. 1.0812 $42.91 $42.91 $8.58 $8.58 

17260 ....... Destruction of 

skin lesions.

Y .............. Y .............. Y .............. 1.1651 $46.24 $46.24 $9.25 $9.25 

17261 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17262 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17263 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17264 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17266 ....... Destruction of 

skin lesions.

Y .............. Y .............. Y .............. 2.6129 $103.70 $103.70 $20.74 $20.74 

17270 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17271 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

17272 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17273 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17274 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 2.6253 $104.19 $104.19 $20.84 $20.84 

17276 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 2.6253 $104.19 $104.19 $20.84 $20.84 

17280 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17281 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17282 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17283 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17284 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 2.6253 $104.19 $104.19 $20.84 $20.84 

17286 ....... Destruction of 

skin lesions.

Y .............. Y .............. .................. 1.6062 $63.75 $63.75 $12.75 $12.75 

17304 ....... 1 stage mohs, 

up to 5 spec.

Y .............. Y .............. .................. 3.4844 $138.29 $138.29 $27.66 $27.66 


sroberts on PROD1PC70 with PROPOSALS
49856 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

17305 ....... 2 stage mohs, 

up to 5 spec.

Y .............. Y .............. .................. 3.4844 $138.29 $138.29 $27.66 $27.66 

17306 ....... 3 stage mohs, 

up to 5 spec.

Y .............. Y .............. .................. 3.4844 $138.29 $138.29 $27.66 $27.66 

17307 ....... Mohs addl 

stage up to 5 

spec.

Y .............. Y .............. .................. 3.4844 $138.29 $138.29 $27.66 $27.66 

17310 ....... Mohs any stage 

> 5 spec each.

Y .............. Y .............. Y .............. 1.5657 $62.14 $62.14 $12.43 $12.43 

17340 ....... Cryotherapy of 

skin.

Y .............. Y .............. Y .............. 0.3096 $12.29 $12.29 $2.46 $2.46 

17360 ....... Skin peel therapy.Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

17380 ....... Hair removal by 

electrolysis.

Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

19000 ....... Drainage of 

breast lesion.

Y .............. Y .............. Y .............. 1.7129 $67.98 $67.98 $13.60 $13.60 

19001 ....... Drain breast lesion add-on.Y .............. Y .............. Y .............. 0.2210 $8.77 $8.77 $1.75 $1.75 

19020 ....... Incision of 

breast lesion.

.................. .................. .................. 17.4686 $693.30 $569.65 $138.66 $113.93 

19100 ....... Bx breast percut 

w/o image.

.................. .................. .................. 3.8051 $151.02 $192.61 $30.20 $38.52 

19101 ....... Biopsy of 

breast, open.

.................. .................. .................. 19.2250 $763.00 $604.50 $152.60 $120.90 

19102 ....... Bx breast percut 

w/image.

.................. .................. .................. 3.8051 $151.02 $192.61 $30.20 $38.52 

19103 ....... Bx breast percut 

w/device.

.................. .................. .................. 6.4482 $255.92 $326.40 $51.18 $65.28 

19110 ....... Nipple exploration................... .................. .................. 19.2250 $763.00 $604.50 $152.60 $120.90 

19112 ....... Excise breast 

duct fistula.

.................. .................. .................. 19.2250 $763.00 $636.50 $152.60 $127.30 

19120 ....... Removal of 

breast lesion.

.................. .................. .................. 19.2250 $763.00 $636.50 $152.60 $127.30 

19125 ....... Excision, breast 

lesion.

.................. .................. .................. 19.2250 $763.00 $636.50 $152.60 $127.30 

19126 ....... Excision, addl 

breast lesion.

.................. .................. .................. 19.2250 $763.00 $636.50 $152.60 $127.30 

19140 ....... Removal of 

breast tissue.

.................. .................. .................. 19.2250 $763.00 $696.50 $152.60 $139.30 

19160 ....... Partial mastectomy................... .................. .................. 19.2250 $763.00 $636.50 $152.60 $127.30 

19162 ....... P-mastectomy 

w/ln removal.

.................. .................. .................. 37.4843 $1,487.68 $1,241.34 $297.54 $248.27 

19180 ....... Removal of 

breast.

.................. .................. .................. 28.1505 $1,117.24 $873.62 $223.45 $174.72 

19182 ....... Removal of 

breast.

.................. .................. .................. 28.1505 $1,117.24 $873.62 $223.45 $174.72 

19295 ....... Place breast 

clip, percut.

Y .............. .................. .................. 1.7625 $69.95 $69.95 $13.99 $13.99 

19296 ....... Place po breast 

cath for rad.

.................. .................. .................. 40.7495 $1,617.27 $1,478.13 $323.45 $295.63 

19297 ....... Place breast 

cath for rad.

Y .............. .................. .................. 28.1505 $1,117.24 $1,117.24 $223.45 $223.45 

19298 ....... Place breast rad 

tube/caths.

.................. .................. .................. - $ - $166.50 $ - $33.30 

19316 ....... Suspension of 

breast.

.................. .................. .................. 28.1505 $1,117.24 $873.62 $223.45 $174.72 

19318 ....... Reduction of 

large breast.

.................. .................. .................. 37.4843 $1,487.68 $1,058.84 $297.54 $211.77 

19324 ....... Enlarge breast .................. .................. .................. 37.4843 $1,487.68 $1,058.84 $297.54 $211.77 

19325 ....... Enlarge breast 

with implant.

.................. .................. .................. 48.7796 $1,935.97 $1,637.48 $387.19 $327.50 

19328 ....... Removal of 

breast implant.

.................. .................. .................. 28.1505 $1,117.24 $725.12 $223.45 $145.02 

19330 ....... Removal of implant material................... .................. .................. 28.1505 $1,117.24 $725.12 $223.45 $145.02 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49857 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

19340 ....... Immediate 

breast prosthesis.

.................. .................. .................. 40.7495 $1,617.27 $1,031.63 $323.45 $206.33 

19342 ....... Delayed breast 

prosthesis.

.................. .................. .................. 48.7796 $1,935.97 $1,222.98 $387.19 $244.60 

19350 ....... Breast reconstruction................... .................. .................. 19.2250 $763.00 $696.50 $152.60 $139.30 

19355 ....... Correct inverted 

nipple(s).

.................. .................. .................. 28.1505 $1,117.24 $873.62 $223.45 $174.72 

19357 ....... Breast reconstruction................... .................. .................. 48.7796 $1,935.97 $1,326.48 $387.19 $265.30 

19366 ....... Breast reconstruction................... .................. .................. 28.1505 $1,117.24 $917.12 $223.45 $183.42 

19370 ....... Surgery of 

breast capsule.

.................. .................. .................. 28.1505 $1,117.24 $873.62 $223.45 $174.72 

19371 ....... Removal of 

breast capsule.

.................. .................. .................. 28.1505 $1,117.24 $873.62 $223.45 $174.72 

19380 ....... Revise breast 

reconstruction.

.................. .................. .................. 40.7495 $1,617.27 $1,167.13 $323.45 $233.43 

19396 ....... Design custom 

breast implant.

Y .............. .................. .................. 28.1505 $1,117.24 $1,117.24 $223.45 $223.45 

20000 ....... Incision of abscess.Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

20005 ....... Incision of deep 

abscess.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

20103 ....... Explore wound, 

extremity.

Y .............. .................. .................. 4.1133 $163.25 $163.25 $32.65 $32.65 

20150 ....... Excise 

epiphyseal 

bar.

Y .............. .................. .................. 41.2543 $1,637.30 $1,637.30 $327.46 $327.46 

20200 ....... Muscle biopsy .. .................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

20205 ....... Deep muscle biopsy................... .................. .................. 14.9563 $593.59 $551.79 $118.72 $110.36 

20206 ....... Needle biopsy, 

muscle.

.................. .................. .................. 3.8051 $151.02 $192.61 $30.20 $38.52 

20220 ....... Bone biopsy, 

trocar/needle.

.................. .................. .................. 4.0123 $159.24 $203.10 $31.85 $40.62 

20225 ....... Bone biopsy, 

trocar/needle.

.................. .................. .................. 6.5128 $258.48 $329.68 $51.70 $65.94 

20240 ....... Bone biopsy, 

excisional.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

20245 ....... Bone biopsy, 

excisional.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

20250 ....... Open bone biopsy................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

20251 ....... Open bone biopsy................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

20500 ....... Injection of 

sinus tract.

Y .............. Y .............. Y .............. 1.5496 $61.50 $61.50 $12.30 $12.30 

20520 ....... Removal of foreign body.Y .............. Y .............. Y .............. 2.3536 $93.41 $93.41 $18.68 $18.68 

20525 ....... Removal of foreign body................... .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

20526 ....... Ther injection, 

carp tunnel.

Y .............. Y .............. Y .............. 0.7740 $30.72 $30.72 $6.14 $6.14 

20550 ....... Inject tendon/ligament/cyst.Y .............. Y .............. Y .............. 0.5718 $22.69 $22.69 $4.54 $4.54 

20551 ....... Inj tendon origin/insertion.Y .............. Y .............. Y .............. 0.5635 $22.37 $22.37 $4.47 $4.47 

20552 ....... Inj trigger point, 

1/2 muscl.

Y .............. Y .............. Y .............. 0.5564 $22.08 $22.08 $4.42 $4.42 

20553 ....... Inject trigger 

points, > 3.

Y .............. Y .............. Y .............. 0.6242 $24.77 $24.77 $4.95 $4.95 

20600 ....... Drain/inject, 

joint/bursa.

Y .............. Y .............. Y .............. 0.5622 $22.31 $22.31 $4.46 $4.46 


sroberts on PROD1PC70 with PROPOSALS
49858 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

20605 ....... Drain/inject, 

joint/bursa.

Y .............. Y .............. Y .............. 0.6427 $25.51 $25.51 $5.10 $5.10 

20610 ....... Drain/inject, 

joint/bursa.

Y .............. Y .............. Y .............. 0.8759 $34.76 $34.76 $6.95 $6.95 

20612 ....... Aspirate/inj ganglion cyst.Y .............. Y .............. Y .............. 0.6035 $23.95 $23.95 $4.79 $4.79 

20615 ....... Treatment of 

bone cyst.

Y .............. Y .............. .................. 2.0863 $82.80 $82.80 $16.56 $16.56 

20650 ....... Insert and remove bone 

pin.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

20662 ....... Application of 

pelvis brace.

Y .............. Y .............. Y .............. 4.4737 $177.55 $177.55 $35.51 $35.51 

20663 ....... Application of 

thigh brace.

Y .............. Y .............. Y .............. 4.2278 $167.79 $167.79 $33.56 $33.56 

20665 ....... Removal of fixation device.Y .............. .................. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

20670 ....... Removal of support implant................... .................. .................. 14.9563 $593.59 $463.29 $118.72 $92.66 

20680 ....... Removal of support implant................... .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

20690 ....... Apply bone fixation device................... .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

20692 ....... Apply bone fixation device................... .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

20693 ....... Adjust bone fixation device................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

20694 ....... Remove bone 

fixation device.

.................. .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

20822 ....... Replantation 

digit, complete.

Y .............. .................. .................. 25.8425 $1,025.64 $1,025.64 $205.13 $205.13 

20900 ....... Removal of 

bone for graft.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

20902 ....... Removal of 

bone for graft.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

20910 ....... Remove cartilage for graft................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

20912 ....... Remove cartilage for graft................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

20920 ....... Removal of fascia for graft................... .................. .................. 13.3433 $529.57 $579.79 $105.91 $115.96 

20922 ....... Removal of fascia for graft................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

20924 ....... Removal of tendon for graft................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

20926 ....... Removal of tissue for graft................... .................. .................. 13.3433 $529.57 $579.79 $105.91 $115.96 

20972 ....... Bone/skin graft, 

metatarsal.

Y .............. .................. .................. 41.2239 $1,636.10 $1,636.10 $327.22 $327.22 

20973 ....... Bone/skin graft, 

great toe.

Y .............. Y .............. Y .............. 16.9974 $674.60 $674.60 $134.92 $134.92 

20975 ....... Electrical bone 

stimulation.

.................. .................. .................. 0.6211 $24.65 $31.44 $4.93 $6.29 

20982 ....... Ablate, bone 

tumor(s) perq.

Y .............. .................. .................. 25.0600 $994.58 $994.58 $198.92 $198.92 

21010 ....... Incision of jaw 

joint.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

21015 ....... Resection of facial tumor................... .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

21025 ....... Excision of 

bone, lower 

jaw.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

21026 ....... Excision of facial bone(s)................... .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

21029 ....... Contour of face 

bone lesion.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49859 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

21030 ....... Removal of face 

bone lesion.

Y .............. Y .............. Y .............. 5.9541 $236.31 $236.31 $47.26 $47.26 

21031 ....... Remove 

exostosis, 

mandible.

Y .............. Y .............. Y .............. 4.9253 $195.47 $195.47 $39.09 $39.09 

21032 ....... Remove 

exostosis, 

maxilla.

Y .............. Y .............. Y .............. 5.0435 $200.17 $200.17 $40.03 $40.03 

21034 ....... Excise max/ 

zygoma mlg 

tumor.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

21040 ....... Excise mandible 

lesion.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

21044 ....... Removal of jaw 

bone lesion.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

21046 ....... Remove mandible cyst 

complex.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

21047 ....... Excise lwr jaw 

cyst w/repair.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

21048 ....... Remove maxilla 

cyst complex.

Y .............. Y .............. Y .............. 10.3744 $411.74 $411.74 $82.35 $82.35 

21050 ....... Removal of jaw 

joint.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

21060 ....... Remove jaw 

joint cartilage.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

21070 ....... Remove 

coronoid 

process.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

21076 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 8.9380 $354.73 $354.73 $70.95 $70.95 

21077 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 21.8677 $867.89 $867.89 $173.58 $173.58 

21079 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 15.4101 $611.60 $611.60 $122.32 $122.32 

21080 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 17.6321 $699.78 $699.78 $139.96 $139.96 

21081 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 16.1148 $639.56 $639.56 $127.91 $127.91 

21082 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 14.8249 $588.37 $588.37 $117.67 $117.67 

21083 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 14.5513 $577.51 $577.51 $115.50 $115.50 

21084 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 16.8041 $666.92 $666.92 $133.38 $133.38 

21085 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 6.5587 $260.30 $260.30 $52.06 $52.06 

21086 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 16.0903 $638.59 $638.59 $127.72 $127.72 

21087 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. Y .............. 15.9673 $633.71 $633.71 $126.74 $126.74 

21088 ....... Prepare face/ 

oral prosthesis.

Y .............. Y .............. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21100 ....... Maxillofacial fixation................... .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 


sroberts on PROD1PC70 with PROPOSALS
49860 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

21110 ....... Interdental fixation.Y .............. Y .............. .................. 7.7261 $306.63 $306.63 $61.33 $61.33 

21120 ....... Reconstruction 

of chin.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21121 ....... Reconstruction 

of chin.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21122 ....... Reconstruction 

of chin.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21123 ....... Reconstruction 

of chin.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21125 ....... Augmentation, 

lower jaw 

bone.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21127 ....... Augmentation, 

lower jaw 

bone.

.................. .................. .................. 37.7719 $1,499.09 $1,419.05 $299.82 $283.81 

21137 ....... Reduction of 

forehead.

Y .............. .................. .................. 23.1564 $919.03 $919.03 $183.81 $183.81 

21138 ....... Reduction of 

forehead.

Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21139 ....... Reduction of 

forehead.

Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21150 ....... Reconstruct 

midface, lefort.

Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21181 ....... Contour cranial 

bone lesion.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21198 ....... Reconstr lwr 

jaw segment.

Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21199 ....... Reconstr lwr 

jaw w/advance.

Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21206 ....... Reconstruct 

upper jaw 

bone.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

21208 ....... Augmentation of 

facial bones.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21209 ....... Reduction of facial bones................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

21210 ....... Face bone graft .................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21215 ....... Lower jaw bone 

graft.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21230 ....... Rib cartilage 

graft.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21235 ....... Ear cartilage 

graft.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21240 ....... Reconstruction 

of jaw joint.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

21242 ....... Reconstruction 

of jaw joint.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

21243 ....... Reconstruction 

of jaw joint.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

21244 ....... Reconstruction 

of lower jaw.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21245 ....... Reconstruction 

of jaw.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21246 ....... Reconstruction 

of jaw.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21248 ....... Reconstruction 

of jaw.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21249 ....... Reconstruction 

of jaw.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21260 ....... Revise eye 

sockets.

Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21267 ....... Revise eye 

sockets.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21270 ....... Augmentation, 

cheek bone.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49861 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

21275 ....... Revision, 

orbitofacial 

bones.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

21280 ....... Revision of eyelid................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

21282 ....... Revision of eyelid................... .................. .................. 16.4494 $652.85 $684.92 $130.57 $136.98 

21295 ....... Revision of jaw 

muscle/bone.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

21296 ....... Revision of jaw 

muscle/bone.

.................. .................. .................. 23.1564 $919.03 $626.02 $183.81 $125.20 

21300 ....... Treatment of 

skull fracture.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

21310 ....... Treatment of 

nose fracture.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

21315 ....... Treatment of 

nose fracture.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

21320 ....... Treatment of 

nose fracture.

.................. .................. .................. 7.7261 $306.63 $376.32 $61.33 $75.26 

21325 ....... Treatment of 

nose fracture.

.................. .................. .................. 23.1564 $919.03 $774.52 $183.81 $154.90 

21330 ....... Treatment of 

nose fracture.

.................. .................. .................. 23.1564 $919.03 $818.02 $183.81 $163.60 

21335 ....... Treatment of 

nose fracture.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21336 ....... Treat nasal septal fracture................... .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

21337 ....... Treat nasal septal fracture................... .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

21338 ....... Treat 

nasoethmoid 

fracture.

.................. .................. .................. 23.1564 $919.03 $774.52 $183.81 $154.90 

21339 ....... Treat 

nasoethmoid 

fracture.

.................. .................. .................. 23.1564 $919.03 $818.02 $183.81 $163.60 

21340 ....... Treatment of 

nose fracture.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

21345 ....... Treat nose/jaw 

fracture.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

21355 ....... Treat cheek 

bone fracture.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

21356 ....... Treat cheek 

bone fracture.

Y .............. .................. .................. 23.1564 $919.03 $919.03 $183.81 $183.81 

21390 ....... Treat eye socket fracture.Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21400 ....... Treat eye socket fracture................... .................. .................. 7.7261 $306.63 $376.32 $61.33 $75.26 

21401 ....... Treat eye socket fracture................... .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

21406 ....... Treat eye socket fracture.Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21407 ....... Treat eye socket fracture.Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

21421 ....... Treat mouth 

roof fracture.

.................. .................. .................. 23.1564 $919.03 $774.52 $183.81 $154.90 

21440 ....... Treat dental 

ridge fracture.

Y .............. Y .............. Y .............. 7.6734 $304.54 $304.54 $60.91 $60.91 

21445 ....... Treat dental 

ridge fracture.

.................. .................. .................. 23.1564 $919.03 $774.52 $183.81 $154.90 

21450 ....... Treat lower jaw 

fracture.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

21451 ....... Treat lower jaw 

fracture.

.................. .................. .................. 7.7261 $306.63 $391.09 $61.33 $78.22 

21452 ....... Treat lower jaw 

fracture.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

21453 ....... Treat lower jaw 

fracture.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 


sroberts on PROD1PC70 with PROPOSALS
49862 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

21454 ....... Treat lower jaw 

fracture.

.................. .................. .................. 23.1564 $919.03 $818.02 $183.81 $163.60 

21461 ....... Treat lower jaw 

fracture.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

21462 ....... Treat lower jaw 

fracture.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

21465 ....... Treat lower jaw 

fracture.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

21480 ....... Reset dislocated jaw................... .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

21485 ....... Reset dislocated jaw................... .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

21490 ....... Repair dislocated jaw................... .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

21495 ....... Treat hyoid 

bone fracture.

Y .............. .................. .................. 16.4494 $652.85 $652.85 $130.57 $130.57 

21497 ....... Interdental wiring................... .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

21501 ....... Drain neck/ 

chest lesion.

.................. .................. .................. 17.4686 $693.30 $569.65 $138.66 $113.93 

21502 ....... Drain chest lesion................... .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

21550 ....... Biopsy of neck/ 

chest.

Y .............. .................. .................. 6.5128 $258.48 $258.48 $51.70 $51.70 

21555 ....... Remove lesion, 

neck/chest.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

21556 ....... Remove lesion, 

neck/chest.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

21557 ....... Remove tumor, 

neck/chest.

Y .............. .................. .................. 19.9760 $792.81 $792.81 $158.56 $158.56 

21600 ....... Partial removal 

of rib.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

21610 ....... Partial removal 

of rib.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

21685 ....... Hyoid myotomy 

& suspension.

Y .............. .................. .................. 7.7261 $306.63 $306.63 $61.33 $61.33 

21700 ....... Revision of 

neck muscle.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

21720 ....... Revision of 

neck muscle.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

21725 ....... Revision of 

neck muscle.

.................. .................. .................. 1.4821 $58.82 $75.02 $11.76 $15.00 

21800 ....... Treatment of rib 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

21805 ....... Treatment of rib 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

21820 ....... Treat sternum 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

21920 ....... Biopsy soft tissue of back.Y .............. Y .............. Y .............. 3.3341 $132.32 $132.32 $26.46 $26.46 

21925 ....... Biopsy soft tissue of back................... .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

21930 ....... Remove lesion, 

back or flank.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

21935 ....... Remove tumor, 

back.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

22102 ....... Remove part, 

lumbar 

vertebra.

Y .............. .................. .................. 43.9030 $1,742.43 $1,742.43 $348.49 $348.49 

22103 ....... Remove extra 

spine segment.

Y .............. .................. .................. 43.9030 $1,742.43 $1,742.43 $348.49 $348.49 

22305 ....... Treat spine 

process fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

22310 ....... Treat spine fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49863 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

22315 ....... Treat spine fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

22505 ....... Manipulation of 

spine.

.................. .................. .................. 14.5502 $577.47 $511.73 $115.49 $102.35 

22520 ....... Percut 

vertebroplasty 

thor.

Y .............. .................. .................. 25.0600 $994.58 $994.58 $198.92 $198.92 

22521 ....... Percut 

vertebroplasty 

lumb.

Y .............. .................. .................. 25.0600 $994.58 $994.58 $198.92 $198.92 

22522 ....... Percut 

vertebroplasty 

add’l.

Y .............. .................. .................. 25.0600 $994.58 $994.58 $198.92 $198.92 

22523 ....... Percut 

kyphoplasty, 

thor.

Y .............. .................. .................. 65.8846 $2,614.83 $2,614.83 $522.97 $522.97 

22524 ....... Percut 

kyphoplasty, 

lumbar.

Y .............. .................. .................. 65.8846 $2,614.83 $2,614.83 $522.97 $522.97 

22525 ....... Percut 

kyphoplasty, 

add-on.

Y .............. .................. .................. 65.8846 $2,614.83 $2,614.83 $522.97 $522.97 

22900 ....... Remove abdominal wall 

lesion.

.................. .................. .................. 19.9760 $792.81 $711.40 $158.56 $142.28 

23000 ....... Removal of calcium deposits................... .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

23020 ....... Release shoulder joint................... .................. .................. 41.2543 $1,637.30 $1,041.65 $327.46 $208.33 

23030 ....... Drain shoulder 

lesion.

.................. .................. .................. 17.4686 $693.30 $513.15 $138.66 $102.63 

23031 ....... Drain shoulder 

bursa.

.................. .................. .................. 17.4686 $693.30 $601.65 $138.66 $120.33 

23035 ....... Drain shoulder 

bone lesion.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

23040 ....... Exploratory 

shoulder surgery.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

23044 ....... Exploratory 

shoulder surgery.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23065 ....... Biopsy shoulder 

tissues.

Y .............. Y .............. Y .............. 2.3504 $93.28 $93.28 $18.66 $18.66 

23066 ....... Biopsy shoulder 

tissues.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

23075 ....... Removal of 

shoulder lesion.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

23076 ....... Removal of 

shoulder lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

23077 ....... Remove tumor 

of shoulder.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

23100 ....... Biopsy of shoulder joint................... .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

23101 ....... Shoulder joint 

surgery.

.................. .................. .................. 25.0600 $994.58 $994.79 $198.92 $198.96 

23105 ....... Remove shoulder joint lining................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23106 ....... Incision of collarbone joint................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23107 ....... Explore treat 

shoulder joint.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23120 ....... Partial removal, 

collar bone.

.................. .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

23125 ....... Removal of collar bone................... .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 


sroberts on PROD1PC70 with PROPOSALS
49864 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

23130 ....... Remove shoulder bone, part................... .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

23140 ....... Removal of 

bone lesion.

.................. .................. .................. 20.8214 $826.36 $728.18 $165.27 $145.64 

23145 ....... Removal of 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

23146 ....... Removal of 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

23150 ....... Removal of humerus lesion................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23155 ....... Removal of humerus lesion................... .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

23156 ....... Removal of humerus lesion................... .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

23170 ....... Remove collar 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

23172 ....... Remove shoulder blade lesion................... .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

23174 ....... Remove humerus lesion................... .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

23180 ....... Remove collar 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23182 ....... Remove shoulder blade lesion................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23184 ....... Remove humerus lesion................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23190 ....... Partial removal 

of scapula.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

23195 ....... Removal of 

head of humerus.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

23330 ....... Remove shoulder foreign 

body.

.................. .................. .................. 6.5128 $258.48 $295.74 $51.70 $59.15 

23331 ....... Remove shoulder foreign 

body.

.................. .................. .................. 19.9760 $792.81 $562.90 $158.56 $112.58 

23395 ....... Muscle transfer,shoulder/ 

arm.

.................. .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

23397 ....... Muscle transfers .................. .................. .................. 65.8846 $2,614.83 $1,804.92 $522.97 $360.98 

23400 ....... Fixation of 

shoulder 

blade.

.................. .................. .................. 25.0600 $994.58 $994.79 $198.92 $198.96 

23405 ....... Incision of tendon & muscle................... .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

23406 ....... Incise tendon(s) 

& muscle(s).

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

23410 ....... Repair rotator 

cuff, acute.

.................. .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

23412 ....... Repair rotator 

cuff, chronic.

.................. .................. .................. 41.2543 $1,637.30 $1,316.15 $327.46 $263.23 

23415 ....... Release of 

shoulder ligament.

.................. .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

23420 ....... Repair of shoulder................... .................. .................. 41.2543 $1,637.30 $1,316.15 $327.46 $263.23 

23430 ....... Repair biceps 

tendon.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

23440 ....... Remove/transplant tendon................... .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

23450 ....... Repair shoulder 

capsule.

.................. .................. .................. 65.8846 $2,614.83 $1,665.92 $522.97 $333.18 

23455 ....... Repair shoulder 

capsule.

.................. .................. .................. 65.8846 $2,614.83 $1,804.92 $522.97 $360.98 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49865 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

23460 ....... Repair shoulder 

capsule.

.................. .................. .................. 65.8846 $2,614.83 $1,665.92 $522.97 $333.18 

23462 ....... Repair shoulder 

capsule.

.................. .................. .................. 41.2543 $1,637.30 $1,316.15 $327.46 $263.23 

23465 ....... Repair shoulder 

capsule.

.................. .................. .................. 65.8846 $2,614.83 $1,665.92 $522.97 $333.18 

23466 ....... Repair shoulder 

capsule.

.................. .................. .................. 41.2543 $1,637.30 $1,316.15 $327.46 $263.23 

23480 ....... Revision of collar bone................... .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

23485 ....... Revision of collar bone................... .................. .................. 65.8846 $2,614.83 $1,804.92 $522.97 $360.98 

23490 ....... Reinforce clavicle................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

23491 ....... Reinforce shoulder bones................... .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

23500 ....... Treat clavicle 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23505 ....... Treat clavicle 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23515 ....... Treat clavicle 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

23520 ....... Treat clavicle 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23525 ....... Treat clavicle 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23530 ....... Treat clavicle 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

23532 ....... Treat clavicle 

dislocation.

.................. .................. .................. 25.6702 $1,018.80 $824.40 $203.76 $164.88 

23540 ....... Treat clavicle 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23545 ....... Treat clavicle 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23550 ....... Treat clavicle 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

23552 ....... Treat clavicle 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

23570 ....... Treat shoulder 

blade fx.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23575 ....... Treat shoulder 

blade fx.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23585 ....... Treat scapula 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

23600 ....... Treat humerus 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

23605 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23615 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

23616 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

23620 ....... Treat humerus 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

23625 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23630 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,478.09 $447.84 $295.62 

23650 ....... Treat shoulder 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23655 ....... Treat shoulder 

dislocation.

.................. .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

23660 ....... Treat shoulder 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

23665 ....... Treat dislocation/fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23670 ....... Treat dislocation/fracture................... .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 


sroberts on PROD1PC70 with PROPOSALS
49866 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

23675 ....... Treat dislocation/fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

23680 ....... Treat dislocation/fracture................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

23700 ....... Fixation of 

shoulder.

.................. .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

23800 ....... Fusion of shoulder joint................... .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

23802 ....... Fusion of shoulder joint................... .................. .................. 41.2543 $1,637.30 $1,316.15 $327.46 $263.23 

23921 ....... Amputation follow-up surgery................... .................. .................. 5.0931 $202.14 $257.81 $40.43 $51.56 

23930 ....... Drainage of arm 

lesion.

.................. .................. .................. 17.4686 $693.30 $513.15 $138.66 $102.63 

23931 ....... Drainage of arm 

bursa.

.................. .................. .................. 17.4686 $693.30 $569.65 $138.66 $113.93 

23935 ....... Drain arm/elbow 

bone lesion.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

24000 ....... Exploratory 

elbow surgery.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24006 ....... Release elbow 

joint.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24065 ....... Biopsy arm/ 

elbow soft tissue.

Y .............. Y .............. Y .............. 3.1861 $126.45 $126.45 $25.29 $25.29 

24066 ....... Biopsy arm/ 

elbow soft tissue.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

24075 ....... Remove arm/ 

elbow lesion.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

24076 ....... Remove arm/ 

elbow lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

24077 ....... Remove tumor 

of arm/elbow.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

24100 ....... Biopsy elbow 

joint lining.

.................. .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

24101 ....... Explore/treat 

elbow joint.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24102 ....... Remove elbow 

joint lining.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24105 ....... Removal of 

elbow bursa.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

24110 ....... Remove humerus lesion................... .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

24115 ....... Remove/graft 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24116 ....... Remove/graft 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24120 ....... Remove elbow 

lesion.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

24125 ....... Remove/graft 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24126 ....... Remove/graft 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24130 ....... Removal of 

head of radius.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24134 ....... Removal of arm 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

24136 ....... Remove radius 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

24138 ....... Remove elbow 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

24140 ....... Partial removal 

of arm bone.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24145 ....... Partial removal 

of radius.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49867 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

24147 ....... Partial removal 

of elbow.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

24149 ....... Radical resection of elbow.Y .............. .................. .................. 25.0600 $994.58 $994.58 $198.92 $198.92 

24152 ....... Extensive radius 

surgery.

Y .............. .................. .................. 41.2543 $1,637.30 $1,637.30 $327.46 $327.46 

24153 ....... Extensive radius 

surgery.

Y .............. .................. .................. 65.8846 $2,614.83 $2,614.83 $522.97 $522.97 

24155 ....... Removal of 

elbow joint.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24160 ....... Remove elbow 

joint implant.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

24164 ....... Remove radius 

head implant.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24200 ....... Removal of arm 

foreign body.

Y .............. Y .............. Y .............. 2.6370 $104.66 $104.66 $20.93 $20.93 

24201 ....... Removal of arm 

foreign body.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

24300 ....... Manipulate 

elbow w/ 

anesth.

Y .............. .................. .................. 14.5502 $577.47 $577.47 $115.49 $115.49 

24301 ....... Muscle/tendon 

transfer.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24305 ....... Arm tendon 

lengthening.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24310 ....... Revision of arm 

tendon.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

24320 ....... Repair of arm 

tendon.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24330 ....... Revision of arm 

muscles.

.................. .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

24331 ....... Revision of arm 

muscles.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24332 ....... Tenolysis, triceps.Y .............. .................. .................. 20.8214 $826.36 $826.36 $165.27 $165.27 

24340 ....... Repair of biceps 

tendon.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24341 ....... Repair arm tendon/muscle................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24342 ....... Repair of ruptured tendon................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24343 ....... Repr elbow lat 

ligmnt w/tiss.

Y .............. .................. .................. 25.0600 $994.58 $994.58 $198.92 $198.92 

24344 ....... Reconstruct 

elbow lat 

ligmnt.

Y .............. .................. .................. 65.8846 $2,614.83 $2,614.83 $522.97 $522.97 

24345 ....... Repr elbw med 

ligmnt w/tissu.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

24346 ....... Reconstruct 

elbow med 

ligmnt.

Y .............. .................. .................. 41.2543 $1,637.30 $1,637.30 $327.46 $327.46 

24350 ....... Repair of tennis 

elbow.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24351 ....... Repair of tennis 

elbow.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24352 ....... Repair of tennis 

elbow.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24354 ....... Repair of tennis 

elbow.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24356 ....... Revision of tennis elbow................... .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

24360 ....... Reconstruct 

elbow joint.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

24361 ....... Reconstruct 

elbow joint.

.................. .................. .................. 105.1666 $4,173.86 $2,445.43 $834.77 $489.09 

24362 ....... Reconstruct 

elbow joint.

.................. .................. .................. 47.1644 $1,871.86 $1,294.43 $374.37 $258.89 


sroberts on PROD1PC70 with PROPOSALS
49868 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

24363 ....... Replace elbow 

joint.

.................. .................. .................. 105.1666 $4,173.86 $2,584.43 $834.77 $516.89 

24365 ....... Reconstruct 

head of radius.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

24366 ....... Reconstruct 

head of radius.

.................. .................. .................. 105.1666 $4,173.86 $2,445.43 $834.77 $489.09 

24400 ....... Revision of humerus................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24410 ....... Revision of humerus................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

24420 ....... Revision of humerus................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24430 ....... Repair of humerus................... .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

24435 ....... Repair humerus 

with graft.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

24470 ....... Revision of 

elbow joint.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

24495 ....... Decompression 

of forearm.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

24498 ....... Reinforce humerus................... .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

24500 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24505 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24515 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

24516 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

24530 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24535 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24538 ....... Treat humerus 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

24545 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

24546 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,478.09 $447.84 $295.62 

24560 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24565 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24566 ....... Treat humerus 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

24575 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

24576 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24577 ....... Treat humerus 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24579 ....... Treat humerus 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

24582 ....... Treat humerus 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

24586 ....... Treat elbow 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

24587 ....... Treat elbow 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,478.09 $447.84 $295.62 

24600 ....... Treat elbow dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24605 ....... Treat elbow dislocation................... .................. .................. 14.5502 $577.47 $511.73 $115.49 $102.35 

24615 ....... Treat elbow dislocation................... .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49869 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

24620 ....... Treat elbow 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24635 ....... Treat elbow 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

24640 ....... Treat elbow dislocation.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

24650 ....... Treat radius 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

24655 ....... Treat radius 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24665 ....... Treat radius 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

24666 ....... Treat radius 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

24670 ....... Treat ulnar fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24675 ....... Treat ulnar fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

24685 ....... Treat ulnar fracture................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

24800 ....... Fusion of elbow 

joint.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

24802 ....... Fusion/graft of 

elbow joint.

.................. .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

24925 ....... Amputation follow-up surgery................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25000 ....... Incision of tendon sheath................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25001 ....... Incise flexor 

carpi radialis.

Y .............. .................. .................. 20.8214 $826.36 $826.36 $165.27 $165.27 

25020 ....... Decompress 

forearm 1 

space.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25023 ....... Decompress 

forearm 1 

space.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25024 ....... Decompress 

forearm 2 

spaces.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25025 ....... Decompress 

forearm 2 

spaces.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25028 ....... Drainage of 

forearm lesion.

.................. .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

25031 ....... Drainage of 

forearm bursa.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

25035 ....... Treat forearm 

bone lesion.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

25040 ....... Explore/treat 

wrist joint.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

25065 ....... Biopsy forearm 

soft tissues.

Y .............. Y .............. Y .............. 3.2509 $129.02 $129.02 $25.80 $25.80 

25066 ....... Biopsy forearm 

soft tissues.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

25075 ....... Removal forearm lesion 

subcu.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

25076 ....... Removal forearm lesion 

deep.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

25077 ....... Remove tumor, 

forearm/wrist.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

25085 ....... Incision of wrist 

capsule.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25100 ....... Biopsy of wrist 

joint.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 


sroberts on PROD1PC70 with PROPOSALS
49870 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

25101 ....... Explore/treat 

wrist joint.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25105 ....... Remove wrist 

joint lining.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25107 ....... Remove wrist 

joint cartilage.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25110 ....... Remove wrist 

tendon lesion.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25111 ....... Remove wrist 

tendon lesion.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

25112 ....... Reremove wrist 

tendon lesion.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

25115 ....... Remove wrist/ 

forearm lesion.

.................. .................. .................. 20.8214 $826.36 $728.18 $165.27 $145.64 

25116 ....... Remove wrist/ 

forearm lesion.

.................. .................. .................. 20.8214 $826.36 $728.18 $165.27 $145.64 

25118 ....... Excise wrist tendon sheath................... .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

25119 ....... Partial removal 

of ulna.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25120 ....... Removal of 

forearm lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25125 ....... Remove/graft 

forearm lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25126 ....... Remove/graft 

forearm lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25130 ....... Removal of 

wrist lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25135 ....... Remove & graft 

wrist lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25136 ....... Remove & graft 

wrist lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25145 ....... Remove forearm bone lesion................... .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

25150 ....... Partial removal 

of ulna.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

25151 ....... Partial removal 

of radius.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

25210 ....... Removal of 

wrist bone.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

25215 ....... Removal of 

wrist bones.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

25230 ....... Partial removal 

of radius.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25240 ....... Partial removal 

of ulna.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25248 ....... Remove forearm foreign 

body.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

25250 ....... Removal of 

wrist prosthesis.

.................. .................. .................. 25.0600 $994.58 $663.79 $198.92 $132.76 

25251 ....... Removal of 

wrist prosthesis.

.................. .................. .................. 25.0600 $994.58 $663.79 $198.92 $132.76 

25259 ....... Manipulate wrist 

w/anesthes.

Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25260 ....... Repair forearm 

tendon/muscle.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25263 ....... Repair forearm 

tendon/muscle.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

25265 ....... Repair forearm 

tendon/muscle.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49871 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

25270 ....... Repair forearm 

tendon/muscle.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25272 ....... Repair forearm 

tendon/muscle.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25274 ....... Repair forearm 

tendon/muscle.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25275 ....... Repair forearm 

tendon sheath.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25280 ....... Revise wrist/ 

forearm tendon.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

25290 ....... Incise wrist/forearm tendon................... .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25295 ....... Release wrist/ 

forearm tendon.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25300 ....... Fusion of tendons at wrist................... .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25301 ....... Fusion of tendons at wrist................... .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25310 ....... Transplant forearm tendon................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25312 ....... Transplant forearm tendon................... .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

25315 ....... Revise palsy 

hand tendon(s).

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25316 ....... Revise palsy 

hand tendon(s).

.................. .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

25320 ....... Repair/revise 

wrist joint.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25332 ....... Revise wrist 

joint.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

25335 ....... Realignment of 

hand.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25337 ....... Reconstruct 

ulna/ 

radioulnar.

.................. .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

25350 ....... Revision of radius................... .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

25355 ....... Revision of radius................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25360 ....... Revision of ulna .................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25365 ....... Revise radius & 

ulna.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25370 ....... Revise radius or 

ulna.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25375 ....... Revise radius & 

ulna.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

25390 ....... Shorten radius 

or ulna.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25391 ....... Lengthen radius 

or ulna.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

25392 ....... Shorten radius 

& ulna.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25393 ....... Lengthen radius 

& ulna.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

25394 ....... Repair carpal 

bone, shorten.

Y .............. .................. .................. 16.0343 $636.37 $636.37 $127.27 $127.27 

25400 ....... Repair radius or 

ulna.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25405 ....... Repair/graft radius or ulna................... .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 


sroberts on PROD1PC70 with PROPOSALS
49872 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

25415 ....... Repair radius & 

ulna.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

25420 ....... Repair/graft radius & ulna................... .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

25425 ....... Repair/graft radius or ulna................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25426 ....... Repair/graft radius & ulna................... .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

25430 ....... Vasc graft into 

carpal bone.

Y .............. .................. .................. 25.8425 $1,025.64 $1,025.64 $205.13 $205.13 

25431 ....... Repair nonunion 

carpal bone.

Y .............. .................. .................. 25.8425 $1,025.64 $1,025.64 $205.13 $205.13 

25440 ....... Repair/graft 

wrist bone.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

25441 ....... Reconstruct 

wrist joint.

.................. .................. .................. 105.1666 $4,173.86 $2,445.43 $834.77 $489.09 

25442 ....... Reconstruct 

wrist joint.

.................. .................. .................. 105.1666 $4,173.86 $2,445.43 $834.77 $489.09 

25443 ....... Reconstruct 

wrist joint.

.................. .................. .................. 47.1644 $1,871.86 $1,294.43 $374.37 $258.89 

25444 ....... Reconstruct 

wrist joint.

.................. .................. .................. 47.1644 $1,871.86 $1,294.43 $374.37 $258.89 

25445 ....... Reconstruct 

wrist joint.

.................. .................. .................. 47.1644 $1,871.86 $1,294.43 $374.37 $258.89 

25446 ....... Wrist replacement................... .................. .................. 105.1666 $4,173.86 $2,584.43 $834.77 $516.89 

25447 ....... Repair wrist 

joint(s).

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

25449 ....... Remove wrist 

joint implant.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

25450 ....... Revision of wrist 

joint.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25455 ....... Revision of wrist 

joint.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25490 ....... Reinforce radius .................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25491 ....... Reinforce ulna .. .................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25492 ....... Reinforce radius 

and ulna.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

25500 ....... Treat fracture of 

radius.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25505 ....... Treat fracture of 

radius.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25515 ....... Treat fracture of 

radius.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

25520 ....... Treat fracture of 

radius.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25525 ....... Treat fracture of 

radius.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

25526 ....... Treat fracture of 

radius.

.................. .................. .................. 37.5680 $1,491.00 $1,104.00 $298.20 $220.80 

25530 ....... Treat fracture of 

ulna.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25535 ....... Treat fracture of 

ulna.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25545 ....... Treat fracture of 

ulna.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

25560 ....... Treat fracture 

radius & ulna.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25565 ....... Treat fracture 

radius & ulna.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25574 ....... Treat fracture 

radius & ulna.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

25575 ....... Treat fracture 

radius/ulna.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

25600 ....... Treat fracture 

radius/ulna.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25605 ....... Treat fracture 

radius/ulna.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49873 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

25611 ....... Treat fracture 

radius/ulna.

.................. .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

25620 ....... Treat fracture 

radius/ulna.

.................. .................. .................. 56.4195 $2,239.18 $1,478.09 $447.84 $295.62 

25622 ....... Treat wrist bone 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25624 ....... Treat wrist bone 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25628 ....... Treat wrist bone 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

25630 ....... Treat wrist bone 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25635 ....... Treat wrist bone 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25645 ....... Treat wrist bone 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

25650 ....... Treat wrist bone 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

25651 ....... Pin ulnar styloid 

fracture.

Y .............. .................. .................. 25.6702 $1,018.80 $1,018.80 $203.76 $203.76 

25652 ....... Treat fracture 

ulnar styloid.

Y .............. .................. .................. 37.5680 $1,491.00 $1,491.00 $298.20 $298.20 

25660 ....... Treat wrist dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25670 ....... Treat wrist dislocation................... .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

25671 ....... Pin radioulnar 

dislocation.

.................. .................. .................. 25.6702 $1,018.80 $675.90 $203.76 $135.18 

25675 ....... Treat wrist dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25676 ....... Treat wrist dislocation................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

25680 ....... Treat wrist fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25685 ....... Treat wrist fracture................... .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

25690 ....... Treat wrist dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

25695 ....... Treat wrist dislocation................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

25800 ....... Fusion of wrist 

joint.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

25805 ....... Fusion/graft of 

wrist joint.

.................. .................. .................. 41.2543 $1,637.30 $1,177.15 $327.46 $235.43 

25810 ....... Fusion/graft of 

wrist joint.

.................. .................. .................. 65.8846 $2,614.83 $1,665.92 $522.97 $333.18 

25820 ....... Fusion of hand 

bones.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

25825 ....... Fuse hand 

bones with 

graft.

.................. .................. .................. 25.8425 $1,025.64 $871.32 $205.13 $174.26 

25830 ....... Fusion, 

radioulnar jnt/ 

ulna.

.................. .................. .................. 65.8846 $2,614.83 $1,665.92 $522.97 $333.18 

25907 ....... Amputation follow-up surgery................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25922 ....... Amputate hand 

at wrist.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

25929 ....... Amputation follow-up surgery................... .................. .................. 13.3433 $529.57 $519.79 $105.91 $103.96 

26010 ....... Drainage of finger abscess.Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

26011 ....... Drainage of finger abscess................... .................. .................. 10.9184 $433.33 $383.17 $86.67 $76.63 

26020 ....... Drain hand tendon sheath................... .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 


sroberts on PROD1PC70 with PROPOSALS
49874 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

26025 ....... Drainage of 

palm bursa.

.................. .................. .................. 16.0343 $636.37 $484.69 $127.27 $96.94 

26030 ....... Drainage of 

palm bursa(s).

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26034 ....... Treat hand 

bone lesion.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26035 ....... Decompress fingers/hand.Y .............. .................. .................. 16.0343 $636.37 $636.37 $127.27 $127.27 

26040 ....... Release palm 

contracture.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26045 ....... Release palm 

contracture.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26055 ....... Incise finger 

tendon sheath.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26060 ....... Incision of finger 

tendon.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26070 ....... Explore/treat 

hand joint.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26075 ....... Explore/treat finger joint................... .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26080 ....... Explore/treat finger joint................... .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26100 ....... Biopsy hand 

joint lining.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26105 ....... Biopsy finger 

joint lining.

.................. .................. .................. 16.0343 $636.37 $484.69 $127.27 $96.94 

26110 ....... Biopsy finger 

joint lining.

.................. .................. .................. 16.0343 $636.37 $484.69 $127.27 $96.94 

26115 ....... Removal hand 

lesion subcut.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

26116 ....... Removal hand 

lesion, deep.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

26117 ....... Remove tumor, 

hand/finger.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

26121 ....... Release palm 

contracture.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26123 ....... Release palm 

contracture.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26125 ....... Release palm 

contracture.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26130 ....... Remove wrist 

joint lining.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26135 ....... Revise finger 

joint, each.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26140 ....... Revise finger 

joint, each.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26145 ....... Tendon excision, palm/finger................... .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26160 ....... Remove tendon 

sheath lesion.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26170 ....... Removal of 

palm tendon, 

each.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26180 ....... Removal of finger tendon................... .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26185 ....... Remove finger 

bone.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26200 ....... Remove hand 

bone lesion.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26205 ....... Remove/graft 

bone lesion.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26210 ....... Removal of finger lesion................... .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26215 ....... Remove/graft 

finger lesion.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26230 ....... Partial removal 

of hand bone.

.................. .................. .................. 16.0343 $636.37 $811.65 $127.27 $162.33 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49875 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

26235 ....... Partial removal, 

finger bone.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26236 ....... Partial removal, 

finger bone.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26250 ....... Extensive hand 

surgery.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26255 ....... Extensive hand 

surgery.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26260 ....... Extensive finger 

surgery.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26261 ....... Extensive finger 

surgery.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26262 ....... Partial removal 

of finger.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26320 ....... Removal of implant from 

hand.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

26340 ....... Manipulate finger w/anesth.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26350 ....... Repair finger/ 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $679.32 $205.13 $135.86 

26352 ....... Repair/graft 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26356 ....... Repair finger/ 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26357 ....... Repair finger/ 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26358 ....... Repair/graft 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26370 ....... Repair finger/ 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26372 ....... Repair/graft 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26373 ....... Repair finger/ 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26390 ....... Revise hand/finger tendon................... .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26392 ....... Repair/graft 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26410 ....... Repair hand 

tendon.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26412 ....... Repair/graft 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26415 ....... Excision, hand/ 

finger tendon.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26416 ....... Graft hand or 

finger tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26418 ....... Repair finger 

tendon.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26420 ....... Repair/graft finger tendon................... .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26426 ....... Repair finger/ 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26428 ....... Repair/graft finger tendon................... .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26432 ....... Repair finger 

tendon.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26433 ....... Repair finger 

tendon.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26434 ....... Repair/graft finger tendon................... .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26437 ....... Realignment of 

tendons.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26440 ....... Release palm/ 

finger tendon.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26442 ....... Release palm & 

finger tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 


sroberts on PROD1PC70 with PROPOSALS
49876 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

26445 ....... Release hand/ 

finger tendon.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26449 ....... Release forearm/hand tendon................... .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26450 ....... Incision of palm 

tendon.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26455 ....... Incision of finger 

tendon.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26460 ....... Incise hand/finger tendon................... .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26471 ....... Fusion of finger 

tendons.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26474 ....... Fusion of finger 

tendons.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26476 ....... Tendon lengthening................... .................. .................. 16.0343 $636.37 $484.69 $127.27 $96.94 

26477 ....... Tendon shortening................... .................. .................. 16.0343 $636.37 $484.69 $127.27 $96.94 

26478 ....... Lengthening of 

hand tendon.

.................. .................. .................. 16.0343 $636.37 $484.69 $127.27 $96.94 

26479 ....... Shortening of 

hand tendon.

.................. .................. .................. 16.0343 $636.37 $484.69 $127.27 $96.94 

26480 ....... Transplant hand 

tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26483 ....... Transplant/graft 

hand tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26485 ....... Transplant palm 

tendon.

.................. .................. .................. 25.8425 $1,025.64 $735.82 $205.13 $147.16 

26489 ....... Transplant/graft 

palm tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26490 ....... Revise thumb 

tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26492 ....... Tendon transfer 

with graft.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26494 ....... Hand tendon/ 

muscle transfer.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26496 ....... Revise thumb 

tendon.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26497 ....... Finger tendon 

transfer.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26498 ....... Finger tendon 

transfer.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26499 ....... Revision of finger................... .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26500 ....... Hand tendon reconstruction................... .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26502 ....... Hand tendon reconstruction................... .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26504 ....... Hand tendon reconstruction................... .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26508 ....... Release thumb 

contracture.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26510 ....... Thumb tendon 

transfer.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26516 ....... Fusion of 

knuckle joint.

.................. .................. .................. 25.8425 $1,025.64 $679.32 $205.13 $135.86 

26517 ....... Fusion of 

knuckle joints.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26518 ....... Fusion of 

knuckle joints.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26520 ....... Release knuckle 

contracture.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26525 ....... Release finger 

contracture.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26530 ....... Revise knuckle 

joint.

.................. .................. .................. 32.7543 $1,299.96 $904.98 $259.99 $181.00 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49877 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

26531 ....... Revise knuckle 

with implant.

.................. .................. .................. 47.1644 $1,871.86 $1,433.43 $374.37 $286.69 

26535 ....... Revise finger 

joint.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

26536 ....... Revise/implant 

finger joint.

.................. .................. .................. 47.1644 $1,871.86 $1,294.43 $374.37 $258.89 

26540 ....... Repair hand 

joint.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26541 ....... Repair hand 

joint with graft.

.................. .................. .................. 25.8425 $1,025.64 $1,010.32 $205.13 $202.06 

26542 ....... Repair hand 

joint with graft.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26545 ....... Reconstruct finger joint................... .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26546 ....... Repair nonunion 

hand.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26548 ....... Reconstruct finger joint................... .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26550 ....... Construct thumb 

replacement.

.................. .................. .................. 25.8425 $1,025.64 $735.82 $205.13 $147.16 

26555 ....... Positional 

change of finger.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26560 ....... Repair of web 

finger.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26561 ....... Repair of web 

finger.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26562 ....... Repair of web 

finger.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26565 ....... Correct metacarpal flaw................... .................. .................. 25.8425 $1,025.64 $871.32 $205.13 $174.26 

26567 ....... Correct finger 

deformity.

.................. .................. .................. 25.8425 $1,025.64 $871.32 $205.13 $174.26 

26568 ....... Lengthen metacarpal/finger................... .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26580 ....... Repair hand deformity................... .................. .................. 16.0343 $636.37 $676.69 $127.27 $135.34 

26587 ....... Reconstruct 

extra finger.

.................. .................. .................. 16.0343 $636.37 $676.69 $127.27 $135.34 

26590 ....... Repair finger 

deformity.

.................. .................. .................. 16.0343 $636.37 $676.69 $127.27 $135.34 

26591 ....... Repair muscles 

of hand.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26593 ....... Release muscles of hand................... .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

26596 ....... Excision constricting tissue................... .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26600 ....... Treat metacarpal fracture.Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26605 ....... Treat metacarpal fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

26607 ....... Treat metacarpal fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

26608 ....... Treat metacarpal fracture................... .................. .................. 25.6702 $1,018.80 $824.40 $203.76 $164.88 

26615 ....... Treat metacarpal fracture................... .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

26641 ....... Treat thumb dislocation.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26645 ....... Treat thumb 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

26650 ....... Treat thumb 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 


sroberts on PROD1PC70 with PROPOSALS
49878 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

26665 ....... Treat thumb 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

26670 ....... Treat hand dislocation.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26675 ....... Treat hand dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

26676 ....... Pin hand dislocation................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

26685 ....... Treat hand dislocation................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

26686 ....... Treat hand dislocation................... .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

26700 ....... Treat knuckle 

dislocation.

Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26705 ....... Treat knuckle 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

26706 ....... Pin knuckle dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

26715 ....... Treat knuckle 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

26720 ....... Treat finger 

fracture, each.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26725 ....... Treat finger 

fracture, each.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26727 ....... Treat finger 

fracture, each.

.................. .................. .................. 25.6702 $1,018.80 $1,006.90 $203.76 $201.38 

26735 ....... Treat finger 

fracture, each.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

26740 ....... Treat finger 

fracture, each.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26742 ....... Treat finger 

fracture, each.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

26746 ....... Treat finger 

fracture, each.

.................. .................. .................. 37.5680 $1,491.00 $1,104.00 $298.20 $220.80 

26750 ....... Treat finger 

fracture, each.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26755 ....... Treat finger 

fracture, each.

Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26756 ....... Pin finger fracture, each................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

26765 ....... Treat finger 

fracture, each.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

26770 ....... Treat finger dislocation.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

26775 ....... Treat finger dislocation.Y .............. .................. .................. 14.5502 $577.47 $577.47 $115.49 $115.49 

26776 ....... Pin finger dislocation................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

26785 ....... Treat finger dislocation................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

26820 ....... Thumb fusion 

with graft.

.................. .................. .................. 25.8425 $1,025.64 $871.32 $205.13 $174.26 

26841 ....... Fusion of thumb .................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26842 ....... Thumb fusion 

with graft.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26843 ....... Fusion of hand 

joint.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26844 ....... Fusion/graft of 

hand joint.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26850 ....... Fusion of 

knuckle.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26852 ....... Fusion of 

knuckle with 

graft.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26860 ....... Fusion of finger 

joint.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26861 ....... Fusion of finger 

jnt, add-on.

.................. .................. .................. 25.8425 $1,025.64 $735.82 $205.13 $147.16 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49879 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

26862 ....... Fusion/graft of 

finger joint.

.................. .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

26863 ....... Fuse/graft 

added joint.

.................. .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26910 ....... Amputate metacarpal bone................... .................. .................. 25.8425 $1,025.64 $767.82 $205.13 $153.56 

26951 ....... Amputation of 

finger/thumb.

.................. .................. .................. 16.0343 $636.37 $541.19 $127.27 $108.24 

26952 ....... Amputation of 

finger/thumb.

.................. .................. .................. 16.0343 $636.37 $633.19 $127.27 $126.64 

26990 ....... Drainage of pelvis lesion................... .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

26991 ....... Drainage of pelvis bursa................... .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

27000 ....... Incision of hip 

tendon.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27001 ....... Incision of hip 

tendon.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27003 ....... Incision of hip 

tendon.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27033 ....... Exploration of 

hip joint.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27035 ....... Denervation of 

hip joint.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27040 ....... Biopsy of soft 

tissues.

.................. .................. .................. 6.5128 $258.48 $295.74 $51.70 $59.15 

27041 ....... Biopsy of soft 

tissues.

.................. .................. .................. 6.5128 $258.48 $329.68 $51.70 $65.94 

27047 ....... Remove hip/pelvis lesion................... .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

27048 ....... Remove hip/pelvis lesion................... .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

27049 ....... Remove tumor, 

hip/pelvis.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

27050 ....... Biopsy of sacroiliac joint................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27052 ....... Biopsy of hip 

joint.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27060 ....... Removal of 

ischial bursa.

.................. .................. .................. 20.8214 $826.36 $771.68 $165.27 $154.34 

27062 ....... Remove femur 

lesion/bursa.

.................. .................. .................. 20.8214 $826.36 $771.68 $165.27 $154.34 

27065 ....... Removal of hip 

bone lesion.

.................. .................. .................. 20.8214 $826.36 $771.68 $165.27 $154.34 

27066 ....... Removal of hip 

bone lesion.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

27067 ....... Remove/graft 

hip bone lesion.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

27080 ....... Removal of tail 

bone.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27086 ....... Remove hip foreign body................... .................. .................. 6.5128 $258.48 $295.74 $51.70 $59.15 

27087 ....... Remove hip foreign body................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27097 ....... Revision of hip 

tendon.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27098 ....... Transfer tendon 

to pelvis.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27100 ....... Transfer of abdominal muscle................... .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27105 ....... Transfer of spinal muscle................... .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27110 ....... Transfer of 

iliopsoas 

muscle.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 


sroberts on PROD1PC70 with PROPOSALS
49880 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

27111 ....... Transfer of 

iliopsoas 

muscle.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27193 ....... Treat pelvic ring 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27194 ....... Treat pelvic ring 

fracture.

.................. .................. .................. 14.5502 $577.47 $511.73 $115.49 $102.35 

27200 ....... Treat tail bone 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

27202 ....... Treat tail bone 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $968.50 $298.20 $193.70 

27230 ....... Treat thigh fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27238 ....... Treat thigh fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27246 ....... Treat thigh fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27250 ....... Treat hip dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27252 ....... Treat hip dislocation................... .................. .................. 14.5502 $577.47 $511.73 $115.49 $102.35 

27256 ....... Treat hip dislocation.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

27257 ....... Treat hip dislocation................... .................. .................. 14.5502 $577.47 $543.73 $115.49 $108.75 

27265 ....... Treat hip dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27266 ....... Treat hip dislocation................... .................. .................. 14.5502 $577.47 $511.73 $115.49 $102.35 

27275 ....... Manipulation of 

hip joint.

.................. .................. .................. 14.5502 $577.47 $511.73 $115.49 $102.35 

27301 ....... Drain thigh/knee 

lesion.

.................. .................. .................. 17.4686 $693.30 $601.65 $138.66 $120.33 

27305 ....... Incise thigh tendon & fascia................... .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27306 ....... Incision of thigh 

tendon.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27307 ....... Incision of thigh 

tendons.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27310 ....... Exploration of 

knee joint.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27315 ....... Partial removal, 

thigh nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

27320 ....... Partial removal, 

thigh nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

27323 ....... Biopsy, thigh 

soft tissues.

.................. .................. .................. 6.5128 $258.48 $295.74 $51.70 $59.15 

27324 ....... Biopsy, thigh 

soft tissues.

.................. .................. .................. 19.9760 $792.81 $562.90 $158.56 $112.58 

27327 ....... Removal of 

thigh lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

27328 ....... Removal of 

thigh lesion.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

27329 ....... Remove tumor, 

thigh/knee.

.................. .................. .................. 19.9760 $792.81 $711.40 $158.56 $142.28 

27330 ....... Biopsy, knee 

joint lining.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27331 ....... Explore/treat 

knee joint.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27332 ....... Removal of 

knee cartilage.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27333 ....... Removal of 

knee cartilage.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27334 ....... Remove knee 

joint lining.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27335 ....... Remove knee 

joint lining.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49881 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

27340 ....... Removal of 

kneecap 

bursa.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27345 ....... Removal of 

knee cyst.

.................. .................. .................. 20.8214 $826.36 $728.18 $165.27 $145.64 

27347 ....... Remove knee 

cyst.

.................. .................. .................. 20.8214 $826.36 $728.18 $165.27 $145.64 

27350 ....... Removal of 

kneecap.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27355 ....... Remove femur 

lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27356 ....... Remove femur 

lesion/graft.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27357 ....... Remove femur 

lesion/graft.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

27358 ....... Remove femur 

lesion/fixation.

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

27360 ....... Partial removal, 

leg bone(s).

.................. .................. .................. 25.0600 $994.58 $855.79 $198.92 $171.16 

27372 ....... Removal of foreign body................... .................. .................. 19.9760 $792.81 $893.90 $158.56 $178.78 

27380 ....... Repair of kneecap tendon................... .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

27381 ....... Repair/graft 

kneecap tendon.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27385 ....... Repair of thigh 

muscle.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27386 ....... Repair/graft of 

thigh muscle.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27390 ....... Incision of thigh 

tendon.

.................. .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

27391 ....... Incision of thigh 

tendons.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27392 ....... Incision of thigh 

tendons.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27393 ....... Lengthening of 

thigh tendon.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27394 ....... Lengthening of 

thigh tendons.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27395 ....... Lengthening of 

thigh tendons.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27396 ....... Transplant of 

thigh tendon.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27397 ....... Transplants of 

thigh tendons.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27400 ....... Revise thigh 

muscles/tendons.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27403 ....... Repair of knee 

cartilage.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27405 ....... Repair of knee 

ligament.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27407 ....... Repair of knee 

ligament.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

27409 ....... Repair of knee 

ligaments.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27418 ....... Repair degenerated kneecap................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27420 ....... Revision of unstable kneecap................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27422 ....... Revision of unstable kneecap................... .................. .................. 41.2543 $1,637.30 $1,316.15 $327.46 $263.23 


sroberts on PROD1PC70 with PROPOSALS
49882 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

27424 ....... Revision/removal of 

kneecap.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27425 ....... Lat retinacular 

release open.

.................. .................. .................. 25.0600 $994.58 $994.79 $198.92 $198.96 

27427 ....... Reconstruction, 

knee.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27428 ....... Reconstruction, 

knee.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

27429 ....... Reconstruction, 

knee.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

27430 ....... Revision of 

thigh muscles.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27435 ....... Incision of knee 

joint.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27437 ....... Revise kneecap .................. .................. .................. 32.7543 $1,299.96 $964.98 $259.99 $193.00 

27438 ....... Revise kneecap 

with implant.

.................. .................. .................. 47.1644 $1,871.86 $1,294.43 $374.37 $258.89 

27441 ....... Revision of 

knee joint.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

27442 ....... Revision of 

knee joint.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

27443 ....... Revision of 

knee joint.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

27496 ....... Decompression 

of thigh/knee.

.................. .................. .................. 20.8214 $826.36 $771.68 $165.27 $154.34 

27497 ....... Decompression 

of thigh/knee.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27498 ....... Decompression 

of thigh/knee.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27499 ....... Decompression 

of thigh/knee.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27500 ....... Treatment of 

thigh fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27501 ....... Treatment of 

thigh fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27502 ....... Treatment of 

thigh fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27503 ....... Treatment of 

thigh fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27508 ....... Treatment of 

thigh fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27509 ....... Treatment of 

thigh fracture.

.................. .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

27510 ....... Treatment of 

thigh fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27516 ....... Treat thigh fx 

growth plate.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27517 ....... Treat thigh fx 

growth plate.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27520 ....... Treat kneecap 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27530 ....... Treat knee fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27532 ....... Treat knee fracture................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27538 ....... Treat knee fracture(s)................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27550 ....... Treat knee dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27552 ....... Treat knee dislocation................... .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

27560 ....... Treat kneecap 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27562 ....... Treat kneecap 

dislocation.

.................. .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

27566 ....... Treat kneecap 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $968.50 $298.20 $193.70 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49883 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

27570 ....... Fixation of knee 

joint.

.................. .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

27594 ....... Amputation follow-up surgery................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27600 ....... Decompression 

of lower leg.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27601 ....... Decompression 

of lower leg.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27602 ....... Decompression 

of lower leg.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27603 ....... Drain lower leg 

lesion.

.................. .................. .................. 17.4686 $693.30 $569.65 $138.66 $113.93 

27604 ....... Drain lower leg 

bursa.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27605 ....... Incision of achilles tendon................... .................. .................. 20.2255 $802.71 $567.86 $160.54 $113.57 

27606 ....... Incision of achilles tendon................... .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

27607 ....... Treat lower leg 

bone lesion.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27610 ....... Explore/treat 

ankle joint.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27612 ....... Exploration of 

ankle joint.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27613 ....... Biopsy lower leg 

soft tissue.

Y .............. Y .............. Y .............. 3.0423 $120.74 $120.74 $24.15 $24.15 

27614 ....... Biopsy lower leg 

soft tissue.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

27615 ....... Remove tumor, 

lower leg.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27618 ....... Remove lower 

leg lesion.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

27619 ....... Remove lower 

leg lesion.

.................. .................. .................. 19.9760 $792.81 $651.40 $158.56 $130.28 

27620 ....... Explore/treat 

ankle joint.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27625 ....... Remove ankle 

joint lining.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27626 ....... Remove ankle 

joint lining.

.................. .................. .................. 25.0600 $994.58 $812.29 $198.92 $162.46 

27630 ....... Removal of tendon lesion................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27635 ....... Remove lower 

leg bone lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27637 ....... Remove/graft 

leg bone lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27638 ....... Remove/graft 

leg bone lesion.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27640 ....... Partial removal 

of tibia.

.................. .................. .................. 41.2543 $1,637.30 $1,041.65 $327.46 $208.33 

27641 ....... Partial removal 

of fibula.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27647 ....... Extensive ankle/ 

heel surgery.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27650 ....... Repair achilles 

tendon.

.................. .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27652 ....... Repair/graft 

achilles tendon.

.................. .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

27654 ....... Repair of achilles tendon................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27656 ....... Repair leg fascia defect................... .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 


sroberts on PROD1PC70 with PROPOSALS
49884 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

27658 ....... Repair of leg 

tendon, each.

.................. .................. .................. 20.8214 $826.36 $579.68 $165.27 $115.94 

27659 ....... Repair of leg 

tendon, each.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27664 ....... Repair of leg 

tendon, each.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27665 ....... Repair of leg 

tendon, each.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27675 ....... Repair lower leg 

tendons.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27676 ....... Repair lower leg 

tendons.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27680 ....... Release of 

lower leg tendon.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27681 ....... Release of 

lower leg tendons.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27685 ....... Revision of 

lower leg tendon.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27686 ....... Revise lower 

leg tendons.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27687 ....... Revision of calf 

tendon.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27690 ....... Revise lower 

leg tendon.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27691 ....... Revise lower 

leg tendon.

.................. .................. .................. 41.2543 $1,637.30 $1,133.65 $327.46 $226.73 

27692 ....... Revise additional leg tendon................... .................. .................. 41.2543 $1,637.30 $1,073.65 $327.46 $214.73 

27695 ....... Repair of ankle 

ligament.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27696 ....... Repair of ankle 

ligaments.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27698 ....... Repair of ankle 

ligament.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27700 ....... Revision of 

ankle joint.

.................. .................. .................. 32.7543 $1,299.96 $1,008.48 $259.99 $201.70 

27704 ....... Removal of 

ankle implant.

.................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27705 ....... Incision of tibia .................. .................. .................. 41.2543 $1,637.30 $1,041.65 $327.46 $208.33 

27707 ....... Incision of fibula .................. .................. .................. 20.8214 $826.36 $636.18 $165.27 $127.24 

27709 ....... Incision of tibia 

& fibula.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27730 ....... Repair of tibia 

epiphysis.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27732 ....... Repair of fibula 

epiphysis.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27734 ....... Repair lower leg 

epiphyses.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27740 ....... Repair of leg 

epiphyses.

.................. .................. .................. 25.0600 $994.58 $720.29 $198.92 $144.06 

27742 ....... Repair of leg 

epiphyses.

.................. .................. .................. 41.2543 $1,637.30 $1,041.65 $327.46 $208.33 

27745 ....... Reinforce tibia .. .................. .................. .................. 65.8846 $2,614.83 $1,562.42 $522.97 $312.48 

27750 ....... Treatment of 

tibia fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27752 ....... Treatment of 

tibia fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27756 ....... Treatment of 

tibia fracture.

.................. .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

27758 ....... Treatment of 

tibia fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

27759 ....... Treatment of 

tibia fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49885 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

27760 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27762 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27766 ....... Treatment of 

ankle fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27780 ....... Treatment of 

fibula fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27781 ....... Treatment of 

fibula fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27784 ....... Treatment of 

fibula fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27786 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27788 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27792 ....... Treatment of 

ankle fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27808 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27810 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27814 ....... Treatment of 

ankle fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27816 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27818 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27822 ....... Treatment of 

ankle fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27823 ....... Treatment of 

ankle fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

27824 ....... Treat lower leg 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27825 ....... Treat lower leg 

fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27826 ....... Treat lower leg 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27827 ....... Treat lower leg 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,374.59 $447.84 $274.92 

27828 ....... Treat lower leg 

fracture.

.................. .................. .................. 56.4195 $2,239.18 $1,434.59 $447.84 $286.92 

27829 ....... Treat lower leg 

joint.

.................. .................. .................. 37.5680 $1,491.00 $968.50 $298.20 $193.70 

27830 ....... Treat lower leg 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27831 ....... Treat lower leg 

dislocation.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27832 ....... Treat lower leg 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $968.50 $298.20 $193.70 

27840 ....... Treat ankle dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

27842 ....... Treat ankle dislocation................... .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

27846 ....... Treat ankle dislocation................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27848 ....... Treat ankle dislocation................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

27860 ....... Fixation of ankle 

joint.

.................. .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

27870 ....... Fusion of ankle 

joint, open.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

27871 ....... Fusion of 

tibiofibular 

joint.

.................. .................. .................. 65.8846 $2,614.83 $1,622.42 $522.97 $324.48 

27884 ....... Amputation follow-up surgery................... .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 


sroberts on PROD1PC70 with PROPOSALS
49886 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

27889 ....... Amputation of 

foot at ankle.

.................. .................. .................. 25.0600 $994.58 $752.29 $198.92 $150.46 

27892 ....... Decompression 

of leg.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27893 ....... Decompression 

of leg.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

27894 ....... Decompression 

of leg.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

28001 ....... Drainage of 

bursa of foot.

Y .............. Y .............. Y .............. 2.9456 $116.90 $116.90 $23.38 $23.38 

28002 ....... Treatment of 

foot infection.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

28003 ....... Treatment of 

foot infection.

.................. .................. .................. 20.8214 $826.36 $668.18 $165.27 $133.64 

28005 ....... Treat foot bone 

lesion.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28008 ....... Incision of foot 

fascia.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28010 ....... Incision of toe 

tendon.

Y .............. Y .............. Y .............. 2.2064 $87.57 $87.57 $17.51 $17.51 

28011 ....... Incision of toe 

tendons.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28020 ....... Exploration of 

foot joint.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28022 ....... Exploration of 

foot joint.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28024 ....... Exploration of 

toe joint.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28030 ....... Removal of foot 

nerve.

.................. .................. .................. 17.7609 $704.90 $667.45 $140.98 $133.49 

28035 ....... Decompression 

of tibia nerve.

.................. .................. .................. 17.7609 $704.90 $667.45 $140.98 $133.49 

28043 ....... Excision of foot 

lesion.

.................. .................. .................. 19.9760 $792.81 $619.40 $158.56 $123.88 

28045 ....... Excision of foot 

lesion.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28046 ....... Resection of 

tumor, foot.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28050 ....... Biopsy of foot 

joint lining.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28052 ....... Biopsy of foot 

joint lining.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28054 ....... Biopsy of toe 

joint lining.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28060 ....... Partial removal, 

foot fascia.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28062 ....... Removal of foot 

fascia.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28070 ....... Removal of foot 

joint lining.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28072 ....... Removal of foot 

joint lining.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28080 ....... Removal of foot 

lesion.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28086 ....... Excise foot tendon sheath................... .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28088 ....... Excise foot tendon sheath................... .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28090 ....... Removal of foot 

lesion.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28092 ....... Removal of toe 

lesions.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28100 ....... Removal of 

ankle/heel lesion.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28102 ....... Remove/graft 

foot lesion.

.................. .................. .................. 41.2239 $1,636.10 $1,073.05 $327.22 $214.61 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49887 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

28103 ....... Remove/graft 

foot lesion.

.................. .................. .................. 41.2239 $1,636.10 $1,073.05 $327.22 $214.61 

28104 ....... Removal of foot 

lesion.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28106 ....... Remove/graft 

foot lesion.

.................. .................. .................. 41.2239 $1,636.10 $1,073.05 $327.22 $214.61 

28107 ....... Remove/graft 

foot lesion.

.................. .................. .................. 41.2239 $1,636.10 $1,073.05 $327.22 $214.61 

28108 ....... Removal of toe 

lesions.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28110 ....... Part removal of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28111 ....... Part removal of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28112 ....... Part removal of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28113 ....... Part removal of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28114 ....... Removal of 

metatarsal 

heads.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28116 ....... Revision of foot .................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28118 ....... Removal of heel 

bone.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28119 ....... Removal of heel 

spur.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28120 ....... Part removal of 

ankle/heel.

.................. .................. .................. 20.2255 $802.71 $898.86 $160.54 $179.77 

28122 ....... Partial removal 

of foot bone.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28124 ....... Partial removal 

of toe.

Y .............. Y .............. Y .............. 4.9541 $196.62 $196.62 $39.32 $39.32 

28126 ....... Partial removal 

of toe.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28130 ....... Removal of 

ankle bone.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28140 ....... Removal of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28150 ....... Removal of toe .................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28153 ....... Partial removal 

of toe.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28160 ....... Partial removal 

of toe.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28171 ....... Extensive foot 

surgery.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28173 ....... Extensive foot 

surgery.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28175 ....... Extensive foot 

surgery.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28190 ....... Removal of foot 

foreign body.

Y .............. Y .............. Y .............. 3.1309 $124.26 $124.26 $24.85 $24.85 

28192 ....... Removal of foot 

foreign body.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

28193 ....... Removal of foot 

foreign body.

.................. .................. .................. 6.5128 $258.48 $329.68 $51.70 $65.94 

28200 ....... Repair of foot 

tendon.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28202 ....... Repair/graft of 

foot tendon.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28208 ....... Repair of foot 

tendon.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28210 ....... Repair/graft of 

foot tendon.

.................. .................. .................. 41.2239 $1,636.10 $1,073.05 $327.22 $214.61 

28220 ....... Release of foot 

tendon.

Y .............. Y .............. Y .............. 4.6712 $185.39 $185.39 $37.08 $37.08 

28222 ....... Release of foot 

tendons.

.................. .................. .................. 20.2255 $802.71 $567.86 $160.54 $113.57 


sroberts on PROD1PC70 with PROPOSALS
49888 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

28225 ....... Release of foot 

tendon.

.................. .................. .................. 20.2255 $802.71 $567.86 $160.54 $113.57 

28226 ....... Release of foot 

tendons.

.................. .................. .................. 20.2255 $802.71 $567.86 $160.54 $113.57 

28230 ....... Incision of foot 

tendon(s).

Y .............. Y .............. Y .............. 4.6363 $184.00 $184.00 $36.80 $36.80 

28232 ....... Incision of toe 

tendon.

Y .............. Y .............. Y .............. 4.4311 $175.86 $175.86 $35.17 $35.17 

28234 ....... Incision of foot 

tendon.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28238 ....... Revision of foot 

tendon.

.................. .................. .................. 41.2239 $1,636.10 $1,073.05 $327.22 $214.61 

28240 ....... Release of big 

toe.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28250 ....... Revision of foot 

fascia.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28260 ....... Release of 

midfoot joint.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28261 ....... Revision of foot 

tendon.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28262 ....... Revision of foot 

and ankle.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28264 ....... Release of 

midfoot joint.

.................. .................. .................. 41.2239 $1,636.10 $984.55 $327.22 $196.91 

28270 ....... Release of foot 

contracture.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28272 ....... Release of toe 

joint, each.

Y .............. Y .............. Y .............. 4.2127 $167.19 $167.19 $33.44 $33.44 

28280 ....... Fusion of toes .. .................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28285 ....... Repair of 

hammertoe.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28286 ....... Repair of 

hammertoe.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28288 ....... Partial removal 

of foot bone.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28289 ....... Repair hallux 

rigidus.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28290 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $780.56 $223.02 $156.11 

28292 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $780.56 $223.02 $156.11 

28293 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $812.56 $223.02 $162.51 

28294 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $812.56 $223.02 $162.51 

28296 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $812.56 $223.02 $162.51 

28297 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $812.56 $223.02 $162.51 

28298 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $812.56 $223.02 $162.51 

28299 ....... Correction of 

bunion.

.................. .................. .................. 28.0970 $1,115.12 $916.06 $223.02 $183.21 

28300 ....... Incision of heel 

bone.

.................. .................. .................. 41.2239 $1,636.10 $1,041.05 $327.22 $208.21 

28302 ....... Incision of ankle 

bone.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28304 ....... Incision of 

midfoot bones.

.................. .................. .................. 41.2239 $1,636.10 $1,041.05 $327.22 $208.21 

28305 ....... Incise/graft 

midfoot bones.

.................. .................. .................. 41.2239 $1,636.10 $1,073.05 $327.22 $214.61 

28306 ....... Incision of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28307 ....... Incision of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28308 ....... Incision of 

metatarsal.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49889 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

28309 ....... Incision of 

metatarsals.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28310 ....... Revision of big 

toe.

.................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28312 ....... Revision of toe .................. .................. .................. 20.2255 $802.71 $656.36 $160.54 $131.27 

28313 ....... Repair deformity 

of toe.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28315 ....... Removal of 

sesamoid 

bone.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28320 ....... Repair of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28322 ....... Repair of 

metatarsals.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28340 ....... Resect enlarged 

toe tissue.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28341 ....... Resect enlarged 

toe.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28344 ....... Repair extra 

toe(s).

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28345 ....... Repair webbed 

toe(s).

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28400 ....... Treatment of 

heel fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

28405 ....... Treatment of 

heel fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

28406 ....... Treatment of 

heel fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

28415 ....... Treat heel fracture................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28420 ....... Treat/graft heel 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

28430 ....... Treatment of 

ankle fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28435 ....... Treatment of 

ankle fracture.

.................. .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

28436 ....... Treatment of 

ankle fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

28445 ....... Treat ankle fracture................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28450 ....... Treat midfoot 

fracture, each.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28455 ....... Treat midfoot 

fracture, each.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28456 ....... Treat midfoot 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

28465 ....... Treat midfoot 

fracture, each.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28470 ....... Treat metatarsal 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28475 ....... Treat metatarsal 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28476 ....... Treat metatarsal 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

28485 ....... Treat metatarsal 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,060.50 $298.20 $212.10 

28490 ....... Treat big toe 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28495 ....... Treat big toe 

fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28496 ....... Treat big toe 

fracture.

.................. .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

28505 ....... Treat big toe 

fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28510 ....... Treatment of 

toe fracture.

Y .............. Y .............. Y .............. 1.3651 $54.18 $54.18 $10.84 $10.84 

28515 ....... Treatment of 

toe fracture.

Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 


sroberts on PROD1PC70 with PROPOSALS
49890 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

28525 ....... Treat toe fracture................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28530 ....... Treat sesamoid 

bone fracture.

Y .............. Y .............. Y .............. 1.3078 $51.90 $51.90 $10.38 $10.38 

28531 ....... Treat sesamoid 

bone fracture.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28540 ....... Treat foot dislocation.Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28545 ....... Treat foot dislocation................... .................. .................. 25.6702 $1,018.80 $675.90 $203.76 $135.18 

28546 ....... Treat foot dislocation................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

28555 ....... Repair foot dislocation................... .................. .................. 37.5680 $1,491.00 $968.50 $298.20 $193.70 

28570 ....... Treat foot dislocation.Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28575 ....... Treat foot dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

28576 ....... Treat foot dislocation................... .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

28585 ....... Repair foot dislocation................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28600 ....... Treat foot dislocation.Y .............. Y .............. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28605 ....... Treat foot dislocation................... .................. .................. 1.6914 $67.13 $85.62 $13.43 $17.12 

28606 ....... Treat foot dislocation................... .................. .................. 25.6702 $1,018.80 $732.40 $203.76 $146.48 

28615 ....... Repair foot dislocation................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28630 ....... Treat toe dislocation.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28635 ....... Treat toe dislocation................... .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

28636 ....... Treat toe dislocation................... .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

28645 ....... Repair toe dislocation................... .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28660 ....... Treat toe dislocation.Y .............. .................. .................. 1.6914 $67.13 $67.13 $13.43 $13.43 

28665 ....... Treat toe dislocation................... .................. .................. 14.5502 $577.47 $455.23 $115.49 $91.05 

28666 ....... Treat toe dislocation................... .................. .................. 25.6702 $1,018.80 $764.40 $203.76 $152.88 

28675 ....... Repair of toe 

dislocation.

.................. .................. .................. 37.5680 $1,491.00 $1,000.50 $298.20 $200.10 

28705 ....... Fusion of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28715 ....... Fusion of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28725 ....... Fusion of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28730 ....... Fusion of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28735 ....... Fusion of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28737 ....... Revision of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,176.55 $327.22 $235.31 

28740 ....... Fusion of foot 

bones.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28750 ....... Fusion of big 

toe joint.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28755 ....... Fusion of big 

toe joint.

.................. .................. .................. 20.2255 $802.71 $716.36 $160.54 $143.27 

28760 ....... Fusion of big 

toe joint.

.................. .................. .................. 41.2239 $1,636.10 $1,133.05 $327.22 $226.61 

28810 ....... Amputation toe 

& metatarsal.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49891 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

28820 ....... Amputation of 

toe.

.................. .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28825 ....... Partial amputation of toe................... .................. .................. 20.2255 $802.71 $624.36 $160.54 $124.87 

28890 ....... High energy 

eswt, plantar f.

Y .............. .................. .................. 25.0600 $994.58 $994.58 $198.92 $198.92 

29010 ....... Application of 

body cast.

Y .............. Y .............. .................. 2.2728 $90.20 $90.20 $18.04 $18.04 

29015 ....... Application of 

body cast.

Y .............. Y .............. .................. 2.2728 $90.20 $90.20 $18.04 $18.04 

29020 ....... Application of 

body cast.

Y .............. .................. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29025 ....... Application of 

body cast.

Y .............. Y .............. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29035 ....... Application of 

body cast.

Y .............. .................. .................. 2.2728 $90.20 $90.20 $18.04 $18.04 

29040 ....... Application of 

body cast.

Y .............. .................. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29044 ....... Application of 

body cast.

Y .............. Y .............. .................. 2.2728 $90.20 $90.20 $18.04 $18.04 

29049 ....... Application of 

figure eight.

Y .............. Y .............. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29055 ....... Application of 

shoulder cast.

Y .............. Y .............. .................. 2.2728 $90.20 $90.20 $18.04 $18.04 

29058 ....... Application of 

shoulder cast.

Y .............. Y .............. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29065 ....... Application of 

long arm cast.

Y .............. Y .............. Y .............. 1.1406 $45.27 $45.27 $9.05 $9.05 

29075 ....... Application of 

forearm cast.

Y .............. Y .............. Y .............. 1.0379 $41.19 $41.19 $8.24 $8.24 

29085 ....... Apply hand/wrist 

cast.

Y .............. Y .............. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29086 ....... Apply finger 

cast.

Y .............. Y .............. Y .............. 0.8720 $34.61 $34.61 $6.92 $6.92 

29105 ....... Apply long arm 

splint.

Y .............. Y .............. Y .............. 1.0024 $39.78 $39.78 $7.96 $7.96 

29125 ....... Apply forearm 

splint.

Y .............. Y .............. Y .............. 0.8527 $33.84 $33.84 $6.77 $6.77 

29126 ....... Apply forearm 

splint.

Y .............. Y .............. Y .............. 0.9572 $37.99 $37.99 $7.60 $7.60 

29130 ....... Application of 

finger splint.

Y .............. Y .............. Y .............. 0.3862 $15.33 $15.33 $3.07 $3.07 

29131 ....... Application of 

finger splint.

Y .............. Y .............. Y .............. 0.5869 $23.29 $23.29 $4.66 $4.66 

29200 ....... Strapping of 

chest.

Y .............. Y .............. Y .............. 0.5597 $22.21 $22.21 $4.44 $4.44 

29220 ....... Strapping of low 

back.

Y .............. Y .............. Y .............. 0.5669 $22.50 $22.50 $4.50 $4.50 

29240 ....... Strapping of 

shoulder.

Y .............. Y .............. Y .............. 0.6464 $25.66 $25.66 $5.13 $5.13 

29260 ....... Strapping of 

elbow or wrist.

Y .............. Y .............. Y .............. 0.5940 $23.58 $23.58 $4.72 $4.72 

29280 ....... Strapping of 

hand or finger.

Y .............. Y .............. Y .............. 0.6225 $24.70 $24.70 $4.94 $4.94 

29305 ....... Application of 

hip cast.

Y .............. .................. .................. 2.2728 $90.20 $90.20 $18.04 $18.04 

29325 ....... Application of 

hip casts.

Y .............. .................. .................. 2.2728 $90.20 $90.20 $18.04 $18.04 

29345 ....... Application of 

long leg cast.

Y .............. Y .............. Y .............. 1.5007 $59.56 $59.56 $11.91 $11.91 

29355 ....... Application of 

long leg cast.

Y .............. Y .............. Y .............. 1.4561 $57.79 $57.79 $11.56 $11.56 

29358 ....... Apply long leg 

cast brace.

Y .............. Y .............. Y .............. 1.7938 $71.19 $71.19 $14.24 $14.24 

29365 ....... Application of 

long leg cast.

Y .............. Y .............. Y .............. 1.4129 $56.08 $56.08 $11.22 $11.22 

29405 ....... Apply short leg 

cast.

Y .............. Y .............. Y .............. 1.0527 $41.78 $41.78 $8.36 $8.36 


sroberts on PROD1PC70 with PROPOSALS
49892 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

29425 ....... Apply short leg 

cast.

Y .............. Y .............. Y .............. 1.0639 $42.22 $42.22 $8.44 $8.44 

29435 ....... Apply short leg 

cast.

Y .............. Y .............. Y .............. 1.3502 $53.59 $53.59 $10.72 $10.72 

29440 ....... Addition of 

walker to cast.

Y .............. Y .............. Y .............. 0.5600 $22.23 $22.23 $4.45 $4.45 

29445 ....... Apply rigid leg 

cast.

Y .............. Y .............. Y .............. 1.4713 $58.39 $58.39 $11.68 $11.68 

29450 ....... Application of 

leg cast.

Y .............. Y .............. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29505 ....... Application, long 

leg splint.

Y .............. .................. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29515 ....... Application 

lower leg 

splint.

Y .............. .................. .................. 1.0504 $41.69 $41.69 $8.34 $8.34 

29520 ....... Strapping of hip Y .............. Y .............. Y .............. 0.6469 $25.67 $25.67 $5.13 $5.13 

29530 ....... Strapping of 

knee.

Y .............. Y .............. Y .............. 0.6104 $24.23 $24.23 $4.85 $4.85 

29540 ....... Strapping of 

ankle and/or 

ft.

Y .............. Y .............. Y .............. 0.4057 $16.10 $16.10 $3.22 $3.22 

29550 ....... Strapping of 

toes.

Y .............. Y .............. Y .............. 0.4128 $16.38 $16.38 $3.28 $3.28 

29580 ....... Application of 

paste boot.

Y .............. Y .............. Y .............. 0.5844 $23.19 $23.19 $4.64 $4.64 

29590 ....... Application of 

foot splint.

Y .............. Y .............. Y .............. 0.4639 $18.41 $18.41 $3.68 $3.68 

29700 ....... Removal/revision of cast.Y .............. Y .............. Y .............. 0.7997 $31.74 $31.74 $6.35 $6.35 

29705 ....... Removal/revision of cast.Y .............. Y .............. Y .............. 0.6912 $27.43 $27.43 $5.49 $5.49 

29710 ....... Removal/revision of cast.Y .............. Y .............. Y .............. 1.3029 $51.71 $51.71 $10.34 $10.34 

29715 ....... Removal/revision of cast.Y .............. Y .............. Y .............. 1.0504 $41.69 $41.69 $8.34 $8.34 

29720 ....... Repair of body 

cast.

Y .............. Y .............. Y .............. 1.0084 $40.02 $40.02 $8.00 $8.00 

29730 ....... Windowing of 

cast.

Y .............. Y .............. Y .............. 0.6775 $26.89 $26.89 $5.38 $5.38 

29740 ....... Wedging of cast Y .............. Y .............. Y .............. 0.9533 $37.83 $37.83 $7.57 $7.57 

29750 ....... Wedging of 

clubfoot cast.

Y .............. Y .............. Y .............. 0.8453 $33.55 $33.55 $6.71 $6.71 

29800 ....... Jaw arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29804 ....... Jaw arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29805 ....... Shoulder arthroscopy, dx................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29806 ....... Shoulder arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,149.25 $357.70 $229.85 

29807 ....... Shoulder arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,149.25 $357.70 $229.85 

29819 ....... Shoulder arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29820 ....... Shoulder arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29821 ....... Shoulder arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29822 ....... Shoulder arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49893 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

29823 ....... Shoulder arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29824 ....... Shoulder arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $926.59 $227.24 $185.32 

29825 ....... Shoulder arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29826 ....... Shoulder arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,149.25 $357.70 $229.85 

29827 ....... Arthroscop rotator cuff repr................... .................. .................. 45.0637 $1,788.49 $1,252.75 $357.70 $250.55 

29830 ....... Elbow arthroscopy................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29834 ....... Elbow arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29835 ....... Elbow arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29836 ....... Elbow arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29837 ....... Elbow arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29838 ....... Elbow arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29840 ....... Wrist arthroscopy................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29843 ....... Wrist arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29844 ....... Wrist arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29845 ....... Wrist arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29846 ....... Wrist arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29847 ....... Wrist arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29848 ....... Wrist endoscopy/surgery................... .................. .................. 28.6279 $1,136.19 $1,237.59 $227.24 $247.52 

29850 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29851 ....... Knee arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,209.25 $357.70 $241.85 

29855 ....... Tibial arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,209.25 $357.70 $241.85 

29856 ....... Tibial arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29860 ....... Hip arthroscopy, 

dx.

.................. .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29861 ....... Hip arthroscopy/ 

surgery.

.................. .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29862 ....... Hip arthroscopy/ 

surgery.

.................. .................. .................. 45.0637 $1,788.49 $1,563.75 $357.70 $312.75 

29863 ....... Hip arthroscopy/ 

surgery.

.................. .................. .................. 45.0637 $1,788.49 $1,209.25 $357.70 $241.85 

29866 ....... Autgrft implnt, 

knee w/scope.

Y .............. .................. .................. 45.0637 $1,788.49 $1,788.49 $357.70 $357.70 

29870 ....... Knee arthroscopy, dx................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29871 ....... Knee arthroscopy/drainage................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29873 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29874 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29875 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 


sroberts on PROD1PC70 with PROPOSALS
49894 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

29876 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29877 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29879 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29880 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29881 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $883.09 $227.24 $176.62 

29882 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29883 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29884 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29885 ....... Knee arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,149.25 $357.70 $229.85 

29886 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29887 ....... Knee arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29888 ....... Knee arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,149.25 $357.70 $229.85 

29889 ....... Knee arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,149.25 $357.70 $229.85 

29891 ....... Ankle arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29892 ....... Ankle arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29893 ....... Scope, plantar 

fasciotomy.

.................. .................. .................. 20.2255 $802.71 $1,023.81 $160.54 $204.76 

29894 ....... Ankle arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29895 ....... Ankle arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29897 ....... Ankle arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29898 ....... Ankle arthroscopy/surgery................... .................. .................. 28.6279 $1,136.19 $823.09 $227.24 $164.62 

29899 ....... Ankle arthroscopy/surgery................... .................. .................. 45.0637 $1,788.49 $1,149.25 $357.70 $229.85 

29900 ....... Mcp joint arthroscopy, dx................... .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

29901 ....... Mcp joint arthroscopy, 

surg.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

29902 ....... Mcp joint arthroscopy, 

surg.

.................. .................. .................. 16.0343 $636.37 $573.19 $127.27 $114.64 

30000 ....... Drainage of 

nose lesion.

Y .............. Y .............. .................. 2.3768 $94.33 $94.33 $18.87 $18.87 

30020 ....... Drainage of 

nose lesion.

Y .............. Y .............. .................. 2.3768 $94.33 $94.33 $18.87 $18.87 

30100 ....... Intranasal biopsy.Y .............. Y .............. Y .............. 1.9302 $76.60 $76.60 $15.32 $15.32 

30110 ....... Removal of 

nose polyp(s).

Y .............. Y .............. Y .............. 3.0207 $119.89 $119.89 $23.98 $23.98 

30115 ....... Removal of 

nose polyp(s).

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

30117 ....... Removal of 

intranasal lesion.

.................. .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

30118 ....... Removal of 

intranasal lesion.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

30120 ....... Revision of 

nose.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49895 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

30124 ....... Removal of 

nose lesion.

Y .............. Y .............. Y .............. 3.1426 $124.72 $124.72 $24.94 $24.94 

30125 ....... Removal of 

nose lesion.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

30130 ....... Excise inferior 

turbinate.

.................. .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

30140 ....... Resect inferior 

turbinate.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

30150 ....... Partial removal 

of nose.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

30160 ....... Removal of 

nose.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

30200 ....... Injection treatment of nose.Y .............. Y .............. Y .............. 1.5377 $61.03 $61.03 $12.21 $12.21 

30210 ....... Nasal sinus 

therapy.

Y .............. Y .............. Y .............. 1.9430 $77.11 $77.11 $15.42 $15.42 

30220 ....... Insert nasal 

septal button.

.................. .................. .................. 7.7261 $306.63 $391.09 $61.33 $78.22 

30300 ....... Remove nasal 

foreign body.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

30310 ....... Remove nasal 

foreign body.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

30320 ....... Remove nasal 

foreign body.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

30400 ....... Reconstruction 

of nose.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

30410 ....... Reconstruction 

of nose.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

30420 ....... Reconstruction 

of nose.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

30430 ....... Revision of 

nose.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

30435 ....... Revision of 

nose.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

30450 ....... Revision of 

nose.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

30460 ....... Revision of 

nose.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

30462 ....... Revision of 

nose.

.................. .................. .................. 37.7719 $1,499.09 $1,419.05 $299.82 $283.81 

30465 ....... Repair nasal 

stenosis.

.................. .................. .................. 37.7719 $1,499.09 $1,419.05 $299.82 $283.81 

30520 ....... Repair of nasal 

septum.

.................. .................. .................. 23.1564 $919.03 $774.52 $183.81 $154.90 

30540 ....... Repair nasal 

defect.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

30545 ....... Repair nasal 

defect.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

30560 ....... Release of 

nasal adhesions.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

30580 ....... Repair upper 

jaw fistula.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

30600 ....... Repair mouth/ 

nose fistula.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

30620 ....... Intranasal reconstruction................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

30630 ....... Repair nasal 

septum defect.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

30801 ....... Ablate inf turbinate, superf................... .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

30802 ....... Cauterization, 

inner nose.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

30901 ....... Control of nosebleed.Y .............. Y .............. Y .............. 1.1029 $43.77 $43.77 $8.75 $8.75 

30903 ....... Control of nosebleed................... .................. .................. 1.2021 $47.71 $60.85 $9.54 $12.17 


sroberts on PROD1PC70 with PROPOSALS
49896 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

30905 ....... Control of nosebleed................... .................. .................. 1.2021 $47.71 $60.85 $9.54 $12.17 

30906 ....... Repeat control 

of nosebleed.

.................. .................. .................. 1.2021 $47.71 $60.85 $9.54 $12.17 

30915 ....... Ligation, nasal 

sinus artery.

.................. .................. .................. 24.5817 $975.60 $710.80 $195.12 $142.16 

30920 ....... Ligation, upper 

jaw artery.

.................. .................. .................. 24.5817 $975.60 $742.80 $195.12 $148.56 

30930 ....... Ther fx, nasal 

inf turbinate.

.................. .................. .................. 16.4494 $652.85 $641.42 $130.57 $128.28 

31000 ....... Irrigation, maxillary sinus.Y .............. Y .............. .................. 2.3768 $94.33 $94.33 $18.87 $18.87 

31002 ....... Irrigation, sphenoid sinus.Y .............. Y .............. Y .............. 2.4899 $98.82 $98.82 $19.76 $19.76 

31020 ....... Exploration, 

maxillary 

sinus.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

31030 ....... Exploration, 

maxillary 

sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

31032 ....... Explore sinus, 

remove polyps.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31040 ....... Exploration behind upper 

jaw.

Y .............. Y .............. Y .............. 7.3501 $291.71 $291.71 $58.34 $58.34 

31050 ....... Exploration, 

sphenoid 

sinus.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31051 ....... Sphenoid sinus 

surgery.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31070 ....... Exploration of 

frontal sinus.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

31075 ....... Exploration of 

frontal sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31080 ....... Removal of 

frontal sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31081 ....... Removal of 

frontal sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31084 ....... Removal of 

frontal sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31085 ....... Removal of 

frontal sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31086 ....... Removal of 

frontal sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31087 ....... Removal of 

frontal sinus.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

31090 ....... Exploration of 

sinuses.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

31200 ....... Removal of ethmoid sinus................... .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31201 ....... Removal of ethmoid sinus................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

31205 ....... Removal of ethmoid sinus................... .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

31231 ....... Nasal endoscopy, dx.Y .............. Y .............. .................. 1.4038 $55.71 $55.71 $11.14 $11.14 

31233 ....... Nasal/sinus endoscopy, dx................... .................. .................. 1.4038 $55.71 $71.06 $11.14 $14.21 

31235 ....... Nasal/sinus endoscopy, dx................... .................. .................. 15.1300 $600.48 $466.74 $120.10 $93.35 

31237 ....... Nasal/sinus endoscopy, surg................... .................. .................. 15.1300 $600.48 $523.24 $120.10 $104.65 

31238 ....... Nasal/sinus endoscopy, surg................... .................. .................. 15.1300 $600.48 $466.74 $120.10 $93.35 

31239 ....... Nasal/sinus endoscopy, surg................... .................. .................. 21.8010 $865.24 $747.62 $173.05 $149.52 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49897 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

31240 ....... Nasal/sinus endoscopy, surg................... .................. .................. 15.1300 $600.48 $523.24 $120.10 $104.65 

31254 ....... Revision of ethmoid sinus................... .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31255 ....... Removal of ethmoid sinus................... .................. .................. 21.8010 $865.24 $791.12 $173.05 $158.22 

31256 ....... Exploration 

maxillary 

sinus.

.................. .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31267 ....... Endoscopy, 

maxillary 

sinus.

.................. .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31276 ....... Sinus endoscopy, surgical................... .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31287 ....... Nasal/sinus endoscopy, surg................... .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31288 ....... Nasal/sinus endoscopy, surg................... .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31300 ....... Removal of larynx lesion................... .................. .................. 23.1564 $919.03 $818.02 $183.81 $163.60 

31320 ....... Diagnostic incision, larynx................... .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31400 ....... Revision of larynx................... .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31420 ....... Removal of epiglottis................... .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31502 ....... Change of windpipe airway.Y .............. .................. .................. 2.3431 $92.99 $92.99 $18.60 $18.60 

31505 ....... Diagnostic laryngoscopy.Y .............. Y .............. .................. 0.7572 $30.05 $30.05 $6.01 $6.01 

31510 ....... Laryngoscopy 

with biopsy.

.................. .................. .................. 15.1300 $600.48 $523.24 $120.10 $104.65 

31511 ....... Remove foreign 

body, larynx.

.................. .................. .................. 1.4038 $55.71 $71.06 $11.14 $14.21 

31512 ....... Removal of larynx lesion................... .................. .................. 15.1300 $600.48 $523.24 $120.10 $104.65 

31513 ....... Injection into 

vocal cord.

.................. .................. .................. 1.4038 $55.71 $71.06 $11.14 $14.21 

31515 ....... Laryngoscopy 

for aspiration.

.................. .................. .................. 15.1300 $600.48 $466.74 $120.10 $93.35 

31520 ....... Diagnostic laryngoscopy.Y .............. .................. .................. 1.4038 $55.71 $55.71 $11.14 $11.14 

31525 ....... Dx laryngoscopy excl nb................... .................. .................. 15.1300 $600.48 $466.74 $120.10 $93.35 

31526 ....... Dx laryngoscopy w/oper 

scope.

.................. .................. .................. 21.8010 $865.24 $655.62 $173.05 $131.12 

31527 ....... Laryngoscopy 

for treatment.

.................. .................. .................. 21.8010 $865.24 $599.12 $173.05 $119.82 

31528 ....... Laryngoscopy 

and dilation.

.................. .................. .................. 15.1300 $600.48 $523.24 $120.10 $104.65 

31529 ....... Laryngoscopy 

and dilation.

.................. .................. .................. 15.1300 $600.48 $523.24 $120.10 $104.65 

31530 ....... Laryngoscopy 

w/fb removal.

.................. .................. .................. 21.8010 $865.24 $655.62 $173.05 $131.12 

31531 ....... Laryngoscopy 

w/fb & op 

scope.

.................. .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31535 ....... Laryngoscopy 

w/biopsy.

.................. .................. .................. 21.8010 $865.24 $655.62 $173.05 $131.12 

31536 ....... Laryngoscopy 

w/bx & op 

scope.

.................. .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 

31540 ....... Laryngoscopy 

w/exc of 

tumor.

.................. .................. .................. 21.8010 $865.24 $687.62 $173.05 $137.52 


sroberts on PROD1PC70 with PROPOSALS
49898 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

31541 ....... Larynscop w/ 

tumr exc + 

scope.

.................. .................. .................. 21.8010 $865.24 $747.62 $173.05 $149.52 

31545 ....... Remove vc lesion w/scope................... .................. .................. 21.8010 $865.24 $747.62 $173.05 $149.52 

31546 ....... Remove vc lesion scope/ 

graft.

.................. .................. .................. 21.8010 $865.24 $747.62 $173.05 $149.52 

31560 ....... Laryngoscop w/ 

arytenoidectom.

.................. .................. .................. 21.8010 $865.24 $791.12 $173.05 $158.22 

31561 ....... Larynscop, 

remve cart + 

scop.

.................. .................. .................. 21.8010 $865.24 $791.12 $173.05 $158.22 

31570 ....... Laryngoscope 

w/vc inj.

.................. .................. .................. 15.1300 $600.48 $523.24 $120.10 $104.65 

31571 ....... Laryngoscop w/ 

vc inj + scope.

.................. .................. .................. 21.8010 $865.24 $655.62 $173.05 $131.12 

31575 ....... Diagnostic laryngoscopy.Y .............. Y .............. .................. 1.4038 $55.71 $55.71 $11.14 $11.14 

31576 ....... Laryngoscopy 

with biopsy.

.................. .................. .................. 21.8010 $865.24 $655.62 $173.05 $131.12 

31577 ....... Remove foreign 

body, larynx.

.................. .................. .................. 3.8737 $153.74 $196.08 $30.75 $39.22 

31578 ....... Removal of larynx lesion................... .................. .................. 21.8010 $865.24 $655.62 $173.05 $131.12 

31579 ....... Diagnostic laryngoscopy.Y .............. Y .............. Y .............. 2.8542 $113.28 $113.28 $22.66 $22.66 

31580 ....... Revision of larynx................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

31582 ....... Revision of larynx................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

31588 ....... Revision of larynx................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

31590 ....... Reinnervate larynx................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

31595 ....... Larynx nerve 

surgery.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31603 ....... Incision of windpipe................... .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

31605 ....... Incision of windpipe.Y .............. .................. .................. 7.7261 $306.63 $306.63 $61.33 $61.33 

31611 ....... Surgery/speech 

prosthesis.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

31612 ....... Puncture/clear 

windpipe.

.................. .................. .................. 23.1564 $919.03 $626.02 $183.81 $125.20 

31613 ....... Repair windpipe 

opening.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

31614 ....... Repair windpipe 

opening.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31615 ....... Visualization of 

windpipe.

.................. .................. .................. 9.3905 $372.69 $352.85 $74.54 $70.57 

31620 ....... Endobronchial 

us add-on.

Y .............. .................. .................. 29.7322 $1,180.01 $1,180.01 $236.00 $236.00 

31622 ....... Dx bronchoscope/wash................... .................. .................. 9.3905 $372.69 $352.85 $74.54 $70.57 

31623 ....... Dx bronchoscope/brush................... .................. .................. 9.3905 $372.69 $409.35 $74.54 $81.87 

31624 ....... Dx bronchoscope/lavage................... .................. .................. 9.3905 $372.69 $409.35 $74.54 $81.87 

31625 ....... Bronchoscopy 

w/biopsy(s).

.................. .................. .................. 9.3905 $372.69 $409.35 $74.54 $81.87 

31628 ....... Bronchoscopy/ 

lung bx, each.

.................. .................. .................. 9.3905 $372.69 $409.35 $74.54 $81.87 

31629 ....... Bronchoscopy/ 

needle bx, 

each.

.................. .................. .................. 9.3905 $372.69 $409.35 $74.54 $81.87 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49899 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

31630 ....... Bronchoscopy 

dilate/fx repr.

.................. .................. .................. 21.8803 $868.39 $657.19 $173.68 $131.44 

31631 ....... Bronchoscopy, 

dilate w/stent.

.................. .................. .................. 21.8803 $868.39 $657.19 $173.68 $131.44 

31632 ....... Bronchoscopy/ 

lung bx, add’l.

Y .............. .................. .................. 9.3905 $372.69 $372.69 $74.54 $74.54 

31633 ....... Bronchoscopy/ 

needle bx 

add’l.

Y .............. .................. .................. 9.3905 $372.69 $372.69 $74.54 $74.54 

31635 ....... Bronchoscopy 

w/fb removal.

.................. .................. .................. 9.3905 $372.69 $409.35 $74.54 $81.87 

31636 ....... Bronchoscopy, 

bronch stents.

.................. .................. .................. 21.8803 $868.39 $657.19 $173.68 $131.44 

31637 ....... Bronchoscopy, 

stent add-on.

.................. .................. .................. 9.3905 $372.69 $352.85 $74.54 $70.57 

31638 ....... Bronchoscopy, 

revise stent.

.................. .................. .................. 21.8803 $868.39 $657.19 $173.68 $131.44 

31640 ....... Bronchoscopy 

w/tumor excise.

.................. .................. .................. 21.8803 $868.39 $657.19 $173.68 $131.44 

31641 ....... Bronchoscopy, 

treat blockage.

.................. .................. .................. 21.8803 $868.39 $657.19 $173.68 $131.44 

31643 ....... Diag bronchoscope/catheter................... .................. .................. 9.3905 $372.69 $409.35 $74.54 $81.87 

31645 ....... Bronchoscopy, 

clear airways.

.................. .................. .................. 9.3905 $372.69 $352.85 $74.54 $70.57 

31646 ....... Bronchoscopy, 

reclear airway.

.................. .................. .................. 9.3905 $372.69 $352.85 $74.54 $70.57 

31656 ....... Bronchoscopy, 

inj for x-ray.

.................. .................. .................. 9.3905 $372.69 $352.85 $74.54 $70.57 

31700 ....... Insertion of airway catheter................... .................. .................. 1.4038 $55.71 $71.06 $11.14 $14.21 

31717 ....... Bronchial brush 

biopsy.

.................. .................. .................. 3.8737 $153.74 $196.08 $30.75 $39.22 

31720 ....... Clearance of 

airways.

.................. .................. .................. 0.7572 $30.05 $38.33 $6.01 $7.67 

31730 ....... Intro, windpipe 

wire/tube.

.................. .................. .................. 3.8737 $153.74 $196.08 $30.75 $39.22 

31750 ....... Repair of windpipe................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

31755 ....... Repair of windpipe................... .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

31820 ....... Closure of windpipe lesion................... .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

31825 ....... Repair of windpipe defect................... .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

31830 ....... Revise windpipe 

scar.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

32000 ....... Drainage of 

chest.

.................. .................. .................. 3.6425 $144.56 $184.38 $28.91 $36.88 

32002 ....... Treatment of 

collapsed 

lung.

Y .............. .................. .................. 3.6425 $144.56 $144.56 $28.91 $28.91 

32019 ....... Insert pleural 

catheter.

Y .............. .................. .................. 29.2259 $1,159.92 $1,159.92 $231.98 $231.98 

32020 ....... Tube thoracostomy.Y .............. .................. .................. 3.6425 $144.56 $144.56 $28.91 $28.91 

32400 ....... Needle biopsy 

chest lining.

.................. .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 

32405 ....... Biopsy, lung or 

mediastinum.

.................. .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 

32420 ....... Puncture/clear 

lung.

.................. .................. .................. 3.6425 $144.56 $184.38 $28.91 $36.88 

32960 ....... Therapeutic 

pneumothorax.

Y .............. .................. .................. 3.6425 $144.56 $144.56 $28.91 $28.91 

33010 ....... Drainage of 

heart sac.

.................. .................. .................. 3.6425 $144.56 $184.38 $28.91 $36.88 


sroberts on PROD1PC70 with PROPOSALS
49900 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

33011 ....... Repeat drainage of heart 

sac.

.................. .................. .................. 3.6425 $144.56 $184.38 $28.91 $36.88 

33206 ....... Insertion of 

heart pacemaker.

Y .............. .................. .................. 121.9402 $4,839.57 $4,839.57 $967.91 $967.91 

33212 ....... Insertion of 

pulse generator.

.................. .................. .................. 97.8357 $3,882.91 $2,196.46 $776.58 $439.29 

33213 ....... Insertion of 

pulse generator.

.................. .................. .................. 112.2347 $4,454.38 $2,482.19 $890.88 $496.44 

33214 ....... Upgrade of 

pacemaker 

system.

Y .............. .................. .................. 153.1524 $6,078.33 $6,078.33 $1,215.67 $1,215.67 

33215 ....... Reposition pacing-defib lead.Y .............. .................. .................. 23.4666 $931.34 $931.34 $186.27 $186.27 

33216 ....... Insert lead 

pace-defib, 

one.

Y .............. .................. .................. 44.7574 $1,776.34 $1,776.34 $355.27 $355.27 

33217 ....... Insert lead 

pace-defib, 

dual.

Y .............. .................. .................. 44.7574 $1,776.34 $1,776.34 $355.27 $355.27 

33218 ....... Repair lead 

pace-defib, 

one.

Y .............. .................. .................. 44.7574 $1,776.34 $1,776.34 $355.27 $355.27 

33220 ....... Repair lead 

pace-defib, 

dual.

Y .............. .................. .................. 44.7574 $1,776.34 $1,776.34 $355.27 $355.27 

33222 ....... Revise pocket, 

pacemaker.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

33223 ....... Revise pocket, 

pacing-defib.

.................. .................. .................. 21.2645 $843.95 $644.97 $168.79 $128.99 

33224 ....... Insert pacing 

lead & connect.

Y .............. .................. .................. 267.8870 $10,631.92 $10,631.92 $2,126.38 $2,126.38 

33225 ....... L ventric pacing 

lead add-on.

Y .............. .................. .................. 267.8870 $10,631.92 $10,631.92 $2,126.38 $2,126.38 

33226 ....... Reposition l 

ventric lead.

Y .............. .................. .................. 23.4666 $931.34 $931.34 $186.27 $186.27 

33233 ....... Removal of 

pacemaker 

system.

.................. .................. .................. 23.4666 $931.34 $688.67 $186.27 $137.73 

33234 ....... Removal of 

pacemaker 

system.

Y .............. .................. .................. 23.4666 $931.34 $931.34 $186.27 $186.27 

33241 ....... Remove pulse 

generator.

Y .............. .................. .................. 23.4666 $931.34 $931.34 $186.27 $186.27 

33282 ....... Implant pat-active ht record.Y .............. .................. .................. 74.8877 $2,972.15 $2,972.15 $594.43 $594.43 

33284 ....... Remove pat-active ht record.Y .............. .................. .................. 10.9541 $434.75 $434.75 $86.95 $86.95 

35188 ....... Repair blood 

vessel lesion.

.................. .................. .................. 37.9652 $1,506.77 $1,068.38 $301.35 $213.68 

35207 ....... Repair blood 

vessel lesion.

.................. .................. .................. 37.9652 $1,506.77 $1,068.38 $301.35 $213.68 

35473 ....... Repair arterial 

blockage.

Y .............. .................. .................. 42.8894 $1,702.20 $1,702.20 $340.44 $340.44 

35474 ....... Repair arterial 

blockage.

Y .............. .................. .................. 42.8894 $1,702.20 $1,702.20 $340.44 $340.44 

35476 ....... Repair venous 

blockage.

Y .............. .................. .................. 42.8894 $1,702.20 $1,702.20 $340.44 $340.44 

35492 ....... Atherectomy, 

percutaneous.

Y .............. .................. .................. 42.8894 $1,702.20 $1,702.20 $340.44 $340.44 

35761 ....... Exploration of 

artery/vein.

Y .............. .................. .................. 29.4757 $1,169.83 $1,169.83 $233.97 $233.97 

35875 ....... Removal of clot 

in graft.

.................. .................. .................. 37.9652 $1,506.77 $1,422.88 $301.35 $284.58 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49901 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

35876 ....... Removal of clot 

in graft.

.................. .................. .................. 37.9652 $1,506.77 $1,422.88 $301.35 $284.58 

36002 ....... Pseudoaneurysm injection trt.Y .............. .................. .................. 2.5166 $99.88 $99.88 $19.98 $19.98 

36260 ....... Insertion of infusion pump................... .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 

36261 ....... Revision of infusion pump................... .................. .................. 28.4646 $1,129.71 $787.85 $225.94 $157.57 

36262 ....... Removal of infusion pump................... .................. .................. 22.6984 $900.86 $616.93 $180.17 $123.39 

36420 ....... Vein access 

cutdown < 1 

yr.

Y .............. .................. .................. 0.2016 $8.00 $8.00 $1.60 $1.60 

36425 ....... Vein access 

cutdown > 1 

yr.

Y .............. Y .............. Y .............. 0.1841 $7.31 $7.31 $1.46 $1.46 

36430 ....... Blood transfusion service.Y .............. Y .............. Y .............. 0.8269 $32.82 $32.82 $6.56 $6.56 

36440 ....... Bl push transfuse, 2 yr or.Y .............. Y .............. Y .............. 0.3133 $12.43 $12.43 $2.49 $2.49 

36450 ....... Bl exchange/ 

transfuse, nb.

Y .............. Y .............. .................. 0.6213 $24.66 $24.66 $4.93 $4.93 

36468 ....... Injection(s), spider veins.Y .............. Y .............. .................. 1.1035 $43.80 $43.80 $8.76 $8.76 

36469 ....... Injection(s), spider veins.Y .............. .................. .................. 1.1035 $43.80 $43.80 $8.76 $8.76 

36470 ....... Injection therapy 

of vein.

Y .............. Y .............. .................. 1.1035 $43.80 $43.80 $8.76 $8.76 

36471 ....... Injection therapy 

of veins.

Y .............. Y .............. .................. 1.1035 $43.80 $43.80 $8.76 $8.76 

36475 ....... Endovenous rf, 

1st vein.

.................. .................. .................. 34.6279 $1,374.32 $942.16 $274.86 $188.43 

36476 ....... Endovenous rf, 

vein add-on.

.................. .................. .................. 34.6279 $1,374.32 $942.16 $274.86 $188.43 

36478 ....... Endovenous 

laser, 1st vein.

.................. .................. .................. 24.5817 $975.60 $742.80 $195.12 $148.56 

36479 ....... Endovenous 

laser vein 

addon.

.................. .................. .................. 24.5817 $975.60 $742.80 $195.12 $148.56 

36511 ....... Apheresis wbc Y .............. .................. .................. 11.7005 $464.37 $464.37 $92.87 $92.87 

36512 ....... Apheresis rbc ... Y .............. .................. .................. 11.7005 $464.37 $464.37 $92.87 $92.87 

36513 ....... Apheresis platelets.Y .............. .................. .................. 11.7005 $464.37 $464.37 $92.87 $92.87 

36514 ....... Apheresis plasma.Y .............. .................. .................. 11.7005 $464.37 $464.37 $92.87 $92.87 

36515 ....... Apheresis, 

adsorp/reinfuse.

Y .............. .................. .................. 30.6602 $1,216.84 $1,216.84 $243.37 $243.37 

36516 ....... Apheresis, selective.Y .............. .................. .................. 30.6602 $1,216.84 $1,216.84 $243.37 $243.37 

36522 ....... Photopheresis .. Y .............. .................. .................. 30.6602 $1,216.84 $1,216.84 $243.37 $243.37 

36550 ....... Declot vascular 

device.

Y .............. Y .............. Y .............. 0.5176 $20.54 $20.54 $4.11 $4.11 

36555 ....... Insert non-tunnel cv cath................... .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36556 ....... Insert non-tunnel cv cath................... .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36557 ....... Insert tunneled 

cv cath.

.................. .................. .................. 22.6984 $900.86 $673.43 $180.17 $134.69 

36558 ....... Insert tunneled 

cv cath.

.................. .................. .................. 22.6984 $900.86 $673.43 $180.17 $134.69 

36560 ....... Insert tunneled 

cv cath.

.................. .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 

36561 ....... Insert tunneled 

cv cath.

.................. .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 

36563 ....... Insert tunneled 

cv cath.

.................. .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 


sroberts on PROD1PC70 with PROPOSALS
49902 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

36565 ....... Insert tunneled 

cv cath.

.................. .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 

36566 ....... Insert tunneled 

cv cath.

.................. .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 

36568 ....... Insert picc cath .................. .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36569 ....... Insert picc cath .................. .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36570 ....... Insert picvad 

cath.

.................. .................. .................. 22.6984 $900.86 $705.43 $180.17 $141.09 

36571 ....... Insert picvad 

cath.

.................. .................. .................. 22.6984 $900.86 $705.43 $180.17 $141.09 

36575 ....... Repair tunneled 

cv cath.

.................. .................. .................. 8.7841 $348.62 $397.31 $69.72 $79.46 

36576 ....... Repair tunneled 

cv cath.

.................. .................. .................. 8.7841 $348.62 $397.31 $69.72 $79.46 

36578 ....... Replace tunneled cv cath................... .................. .................. 22.6984 $900.86 $673.43 $180.17 $134.69 

36580 ....... Replace cvad 

cath.

.................. .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36581 ....... Replace tunneled cv cath................... .................. .................. 22.6984 $900.86 $673.43 $180.17 $134.69 

36582 ....... Replace tunneled cv cath................... .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 

36583 ....... Replace tunneled cv cath................... .................. .................. 28.4646 $1,129.71 $819.85 $225.94 $163.97 

36584 ....... Replace picc 

cath.

.................. .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36585 ....... Replace picvad 

cath.

.................. .................. .................. 22.6984 $900.86 $705.43 $180.17 $141.09 

36589 ....... Removal tunneled cv cath................... .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36590 ....... Removal tunneled cv cath................... .................. .................. 8.7841 $348.62 $340.81 $69.72 $68.16 

36595 ....... Mech remov 

tunneled cv 

cath.

Y .............. .................. .................. 22.6984 $900.86 $900.86 $180.17 $180.17 

36596 ....... Mech remov 

tunneled cv 

cath.

Y .............. .................. .................. 8.7841 $348.62 $348.62 $69.72 $69.72 

36598 ....... Inj w/fluor, eval 

cv device.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

36640 ....... Insertion catheter, artery................... .................. .................. 28.4646 $1,129.71 $731.35 $225.94 $146.27 

36680 ....... Insert needle, 

bone cavity.

Y .............. .................. .................. 1.0948 $43.45 $43.45 $8.69 $8.69 

36800 ....... Insertion of 

cannula.

.................. .................. .................. 29.4757 $1,169.83 $839.92 $233.97 $167.98 

36810 ....... Insertion of 

cannula.

.................. .................. .................. 29.4757 $1,169.83 $839.92 $233.97 $167.98 

36815 ....... Insertion of 

cannula.

.................. .................. .................. 29.4757 $1,169.83 $839.92 $233.97 $167.98 

36818 ....... Av fuse, uppr 

arm, cephalic.

Y .............. .................. .................. 37.9652 $1,506.77 $1,506.77 $301.35 $301.35 

36819 ....... Av fuse, uppr 

arm, basilic.

.................. .................. .................. 37.9652 $1,506.77 $1,008.38 $301.35 $201.68 

36820 ....... Av fusion/forearm vein................... .................. .................. 37.9652 $1,506.77 $1,008.38 $301.35 $201.68 

36821 ....... Av fusion direct 

any site.

.................. .................. .................. 37.9652 $1,506.77 $1,008.38 $301.35 $201.68 

36825 ....... Artery-vein 

autograft.

.................. .................. .................. 37.9652 $1,506.77 $1,068.38 $301.35 $213.68 

36830 ....... Artery-vein 

nonautograft.

.................. .................. .................. 37.9652 $1,506.77 $1,068.38 $301.35 $213.68 

36831 ....... Open thrombect 

av fistula.

.................. .................. .................. 37.9652 $1,506.77 $1,422.88 $301.35 $284.58 

36832 ....... Av fistula revision, open................... .................. .................. 37.9652 $1,506.77 $1,068.38 $301.35 $213.68 

36833 ....... Av fistula revision................... .................. .................. 37.9652 $1,506.77 $1,068.38 $301.35 $213.68 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49903 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

36834 ....... Repair a-v aneurysm................... .................. .................. 37.9652 $1,506.77 $1,008.38 $301.35 $201.68 

36835 ....... Artery to vein 

shunt.

.................. .................. .................. 29.4757 $1,169.83 $899.92 $233.97 $179.98 

36860 ....... External 

cannula 

declotting.

.................. .................. .................. 2.0612 $81.81 $104.34 $16.36 $20.87 

36861 ....... Cannula 

declotting.

.................. .................. .................. 29.4757 $1,169.83 $839.92 $233.97 $167.98 

36870 ....... Percut 

thrombect av 

fistula.

.................. .................. .................. 31.0004 $1,230.35 $1,284.67 $246.07 $256.93 

37184 ....... Prim art mech 

thrombectomy.

Y .............. .................. .................. 31.0004 $1,230.35 $1,230.35 $246.07 $246.07 

37185 ....... Prim art mthrombect 

add-on.

Y .............. .................. .................. 17.0436 $676.43 $676.43 $135.29 $135.29 

37186 ....... Sec art mthrombect 

add-on.

Y .............. .................. .................. 17.0436 $676.43 $676.43 $135.29 $135.29 

37187 ....... Venous mech 

thrombectomy.

Y .............. .................. .................. 31.0004 $1,230.35 $1,230.35 $246.07 $246.07 

37188 ....... Venous mthrombectomy 

add-on.

Y .............. .................. .................. 31.0004 $1,230.35 $1,230.35 $246.07 $246.07 

37200 ....... Transcatheter 

biopsy.

Y .............. .................. .................. 6.0729 $241.02 $241.02 $48.20 $48.20 

37203 ....... Transcatheter 

retrieval.

Y .............. .................. .................. 17.0436 $676.43 $676.43 $135.29 $135.29 

37205 ....... Transcath iv 

stent, percut.

Y .............. .................. .................. 66.0804 $2,622.60 $2,622.60 $524.52 $524.52 

37250 ....... Iv us first vessel 

add-on.

Y .............. .................. .................. 32.2182 $1,278.68 $1,278.68 $255.74 $255.74 

37251 ....... Iv us each add 

vessel add-on.

Y .............. .................. .................. 32.2182 $1,278.68 $1,278.68 $255.74 $255.74 

37500 ....... Endoscopy 

ligate perf 

veins.

.................. .................. .................. 34.6279 $1,374.32 $942.16 $274.86 $188.43 

37607 ....... Ligation of a-v 

fistula.

.................. .................. .................. 24.5817 $975.60 $742.80 $195.12 $148.56 

37609 ....... Temporal artery 

procedure.

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

37650 ....... Revision of 

major vein.

.................. .................. .................. 24.5817 $975.60 $710.80 $195.12 $142.16 

37700 ....... Revise leg vein .................. .................. .................. 34.6279 $1,374.32 $910.16 $274.86 $182.03 

37718 ....... Ligate/strip 

short leg vein.

.................. .................. .................. 34.6279 $1,374.32 $942.16 $274.86 $188.43 

37722 ....... Ligate/strip long 

leg vein.

.................. .................. .................. 34.6279 $1,374.32 $942.16 $274.86 $188.43 

37735 ....... Removal of leg 

veins/lesion.

.................. .................. .................. 34.6279 $1,374.32 $942.16 $274.86 $188.43 

37760 ....... Ligation, leg 

veins, open.

.................. .................. .................. 24.5817 $975.60 $742.80 $195.12 $148.56 

37765 ....... Phleb veins - 

extrem - to 20.

Y .............. Y .............. Y .............. 3.5230 $139.82 $139.82 $27.96 $27.96 

37766 ....... Phleb veins - 

extrem 20+.

Y .............. Y .............. Y .............. 4.0582 $161.06 $161.06 $32.21 $32.21 

37780 ....... Revision of leg 

vein.

.................. .................. .................. 24.5817 $975.60 $742.80 $195.12 $148.56 

37785 ....... Ligate/divide/excise vein................... .................. .................. 24.5817 $975.60 $742.80 $195.12 $148.56 

37790 ....... Penile venous 

occlusion.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

38205 ....... Harvest 

allogenic 

stem cells.

Y .............. .................. .................. 11.7005 $464.37 $464.37 $92.87 $92.87 

38206 ....... Harvest auto 

stem cells.

Y .............. .................. .................. 11.7005 $464.37 $464.37 $92.87 $92.87 


sroberts on PROD1PC70 with PROPOSALS
49904 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

38220 ....... Bone marrow 

aspiration.

Y .............. Y .............. .................. 2.4295 $96.42 $96.42 $19.28 $19.28 

38221 ....... Bone marrow 

biopsy.

Y .............. Y .............. .................. 2.4295 $96.42 $96.42 $19.28 $19.28 

38230 ....... Bone marrow 

collection.

Y .............. .................. .................. 23.2490 $922.71 $922.71 $184.54 $184.54 

38241 ....... Bone marrow/ 

stem transplant.

Y .............. .................. .................. 23.2490 $922.71 $922.71 $184.54 $184.54 

38242 ....... Lymphocyte infuse transplant.Y .............. Y .............. Y .............. 0.6143 $24.38 $24.38 $4.88 $4.88 

38300 ....... Drainage, lymph 

node lesion.

.................. .................. .................. 10.9184 $433.33 $383.17 $86.67 $76.63 

38305 ....... Drainage, lymph 

node lesion.

.................. .................. .................. 17.4686 $693.30 $569.65 $138.66 $113.93 

38308 ....... Incision of 

lymph channels.

.................. .................. .................. 21.3673 $848.03 $647.01 $169.61 $129.40 

38500 ....... Biopsy/removal, 

lymph nodes.

.................. .................. .................. 21.3673 $848.03 $647.01 $169.61 $129.40 

38505 ....... Needle biopsy, 

lymph nodes.

.................. .................. .................. 3.8051 $151.02 $192.61 $30.20 $38.52 

38510 ....... Biopsy/removal, 

lymph nodes.

.................. .................. .................. 21.3673 $848.03 $647.01 $169.61 $129.40 

38520 ....... Biopsy/removal, 

lymph nodes.

.................. .................. .................. 21.3673 $848.03 $647.01 $169.61 $129.40 

38525 ....... Biopsy/removal, 

lymph nodes.

.................. .................. .................. 21.3673 $848.03 $647.01 $169.61 $129.40 

38530 ....... Biopsy/removal, 

lymph nodes.

.................. .................. .................. 21.3673 $848.03 $647.01 $169.61 $129.40 

38542 ....... Explore deep 

node(s), neck.

.................. .................. .................. 37.1283 $1,473.55 $959.78 $294.71 $191.96 

38550 ....... Removal, neck/ 

armpit lesion.

.................. .................. .................. 21.3673 $848.03 $679.01 $169.61 $135.80 

38555 ....... Removal, neck/ 

armpit lesion.

.................. .................. .................. 21.3673 $848.03 $739.01 $169.61 $147.80 

38570 ....... Laparoscopy, 

lymph node 

biop.

.................. .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

38571 ....... Laparoscopy, 

lymphadenectomy.

.................. .................. .................. 70.8854 $2,813.31 $2,076.15 $562.66 $415.23 

38572 ....... Laparoscopy, 

lymphadenectomy.

.................. .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

38700 ....... Removal of 

lymph nodes, 

neck.

Y .............. .................. .................. 21.3673 $848.03 $848.03 $169.61 $169.61 

38740 ....... Remove armpit 

lymph nodes.

.................. .................. .................. 37.1283 $1,473.55 $959.78 $294.71 $191.96 

38745 ....... Remove armpit 

lymph nodes.

.................. .................. .................. 37.1283 $1,473.55 $1,051.78 $294.71 $210.36 

38760 ....... Remove groin 

lymph nodes.

.................. .................. .................. 21.3673 $848.03 $647.01 $169.61 $129.40 

40490 ....... Biopsy of lip ..... Y .............. Y .............. Y .............. 1.6094 $63.87 $63.87 $12.77 $12.77 

40500 ....... Partial excision 

of lip.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

40510 ....... Partial excision 

of lip.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

40520 ....... Partial excision 

of lip.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

40525 ....... Reconstruct lip 

with flap.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

40527 ....... Reconstruct lip 

with flap.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

40530 ....... Partial removal 

of lip.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49905 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

40650 ....... Repair lip .......... .................. .................. .................. 7.7261 $306.63 $391.09 $61.33 $78.22 

40652 ....... Repair lip .......... .................. .................. .................. 7.7261 $306.63 $391.09 $61.33 $78.22 

40654 ....... Repair lip .......... .................. .................. .................. 7.7261 $306.63 $391.09 $61.33 $78.22 

40700 ....... Repair cleft lip/ 

nasal.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

40701 ....... Repair cleft lip/ 

nasal.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

40702 ....... Repair cleft lip/ 

nasal.

Y .............. Y .............. Y .............. 6.6019 $262.02 $262.02 $52.40 $52.40 

40720 ....... Repair cleft lip/ 

nasal.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

40761 ....... Repair cleft lip/ 

nasal.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

40800 ....... Drainage of 

mouth lesion.

Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

40801 ....... Drainage of 

mouth lesion.

.................. .................. .................. 7.7261 $306.63 $376.32 $61.33 $75.26 

40804 ....... Removal, foreign body, 

mouth.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

40805 ....... Removal, foreign body, 

mouth.

Y .............. Y .............. Y .............. 4.1994 $166.66 $166.66 $33.33 $33.33 

40806 ....... Incision of lip 

fold.

Y .............. Y .............. Y .............. 1.8622 $73.91 $73.91 $14.78 $14.78 

40808 ....... Biopsy of mouth 

lesion.

Y .............. Y .............. .................. 2.3768 $94.33 $94.33 $18.87 $18.87 

40810 ....... Excision of 

mouth lesion.

Y .............. Y .............. Y .............. 2.8430 $112.83 $112.83 $22.57 $22.57 

40812 ....... Excise/repair 

mouth lesion.

Y .............. Y .............. Y .............. 3.6275 $143.97 $143.97 $28.79 $28.79 

40814 ....... Excise/repair 

mouth lesion.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

40816 ....... Excision of 

mouth lesion.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

40818 ....... Excise oral mucosa for graft................... .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

40819 ....... Excise lip or 

cheek fold.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

40820 ....... Treatment of 

mouth lesion.

Y .............. Y .............. Y .............. 3.9656 $157.39 $157.39 $31.48 $31.48 

40830 ....... Repair mouth 

laceration.

Y .............. .................. .................. 2.3768 $94.33 $94.33 $18.87 $18.87 

40831 ....... Repair mouth 

laceration.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

40840 ....... Reconstruction 

of mouth.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

40842 ....... Reconstruction 

of mouth.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

40843 ....... Reconstruction 

of mouth.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

40844 ....... Reconstruction 

of mouth.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

40845 ....... Reconstruction 

of mouth.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

41000 ....... Drainage of 

mouth lesion.

Y .............. Y .............. Y .............. 2.1048 $83.53 $83.53 $16.71 $16.71 

41005 ....... Drainage of 

mouth lesion.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

41006 ....... Drainage of 

mouth lesion.

.................. .................. .................. 23.1564 $919.03 $626.02 $183.81 $125.20 

41007 ....... Drainage of 

mouth lesion.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

41008 ....... Drainage of 

mouth lesion.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

41009 ....... Drainage of 

mouth lesion.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 


sroberts on PROD1PC70 with PROPOSALS
49906 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

41010 ....... Incision of 

tongue fold.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

41015 ....... Drainage of 

mouth lesion.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

41016 ....... Drainage of 

mouth lesion.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

41017 ....... Drainage of 

mouth lesion.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

41018 ....... Drainage of 

mouth lesion.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

41100 ....... Biopsy of 

tongue.

Y .............. Y .............. Y .............. 2.1907 $86.95 $86.95 $17.39 $17.39 

41105 ....... Biopsy of 

tongue.

Y .............. Y .............. Y .............. 2.1418 $85.00 $85.00 $17.00 $17.00 

41108 ....... Biopsy of floor 

of mouth.

Y .............. Y .............. Y .............. 1.9697 $78.17 $78.17 $15.63 $15.63 

41110 ....... Excision of 

tongue lesion.

Y .............. Y .............. Y .............. 2.8336 $112.46 $112.46 $22.49 $22.49 

41112 ....... Excision of 

tongue lesion.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

41113 ....... Excision of 

tongue lesion.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

41114 ....... Excision of 

tongue lesion.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

41115 ....... Excision of 

tongue fold.

Y .............. Y .............. Y .............. 3.3338 $132.31 $132.31 $26.46 $26.46 

41116 ....... Excision of 

mouth lesion.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

41120 ....... Partial removal 

of tongue.

.................. .................. .................. 23.1564 $919.03 $818.02 $183.81 $163.60 

41250 ....... Repair tongue 

laceration.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

41251 ....... Repair tongue 

laceration.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

41252 ....... Repair tongue 

laceration.

.................. .................. .................. 7.7261 $306.63 $376.32 $61.33 $75.26 

41500 ....... Fixation of 

tongue.

.................. .................. .................. 23.1564 $919.03 $626.02 $183.81 $125.20 

41510 ....... Tongue to lip 

surgery.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

41520 ....... Reconstruction, 

tongue fold.

.................. .................. .................. 7.7261 $306.63 $376.32 $61.33 $75.26 

41800 ....... Drainage of 

gum lesion.

.................. .................. .................. 1.4821 $58.82 $75.02 $11.76 $15.00 

41805 ....... Removal foreign 

body, gum.

Y .............. Y .............. Y .............. 3.2618 $129.45 $129.45 $25.89 $25.89 

41806 ....... Removal foreign 

body,jawbone.

Y .............. Y .............. Y .............. 4.1774 $165.79 $165.79 $33.16 $33.16 

41820 ....... Excision, gum, 

each quadrant.

Y .............. Y .............. .................. 7.7261 $306.63 $306.63 $61.33 $61.33 

41821 ....... Excision of gum 

flap.

Y .............. .................. .................. 7.7261 $306.63 $306.63 $61.33 $61.33 

41822 ....... Excision of gum 

lesion.

Y .............. Y .............. Y .............. 3.7793 $149.99 $149.99 $30.00 $30.00 

41823 ....... Excision of gum 

lesion.

Y .............. Y .............. Y .............. 5.3407 $211.96 $211.96 $42.39 $42.39 

41825 ....... Excision of gum 

lesion.

Y .............. Y .............. Y .............. 2.9473 $116.97 $116.97 $23.39 $23.39 

41826 ....... Excision of gum 

lesion.

Y .............. Y .............. Y .............. 3.3501 $132.96 $132.96 $26.59 $26.59 

41827 ....... Excision of gum 

lesion.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

41828 ....... Excision of gum 

lesion.

Y .............. Y .............. Y .............. 3.4999 $138.90 $138.90 $27.78 $27.78 

41830 ....... Removal of gum 

tissue.

Y .............. Y .............. Y .............. 4.8590 $192.84 $192.84 $38.57 $38.57 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49907 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

41850 ....... Treatment of 

gum lesion.

Y .............. Y .............. .................. 16.4494 $652.85 $652.85 $130.57 $130.57 

41870 ....... Gum graft ......... Y .............. .................. .................. 23.1564 $919.03 $919.03 $183.81 $183.81 

41872 ....... Repair gum ...... Y .............. Y .............. Y .............. 1.6239 $64.45 $64.45 $12.89 $12.89 

41874 ....... Repair tooth 

socket.

Y .............. Y .............. Y .............. 4.6763 $185.59 $185.59 $37.12 $37.12 

42000 ....... Drainage mouth 

roof lesion.

.................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

42100 ....... Biopsy roof of 

mouth.

Y .............. Y .............. Y .............. 1.8757 $74.44 $74.44 $14.89 $14.89 

42104 ....... Excision lesion, 

mouth roof.

Y .............. Y .............. Y .............. 2.6328 $104.49 $104.49 $20.90 $20.90 

42106 ....... Excision lesion, 

mouth roof.

Y .............. Y .............. Y .............. 3.3670 $133.63 $133.63 $26.73 $26.73 

42107 ....... Excision lesion, 

mouth roof.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

42120 ....... Remove palate/ 

lesion.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

42140 ....... Excision of 

uvula.

.................. .................. .................. 7.7261 $306.63 $376.32 $61.33 $75.26 

42145 ....... Repair palate, 

pharynx/uvula.

.................. .................. .................. 23.1564 $919.03 $818.02 $183.81 $163.60 

42160 ....... Treatment 

mouth roof lesion.

Y .............. Y .............. Y .............. 3.4534 $137.06 $137.06 $27.41 $27.41 

42180 ....... Repair palate ... .................. .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

42182 ....... Repair palate ... .................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

42200 ....... Reconstruct 

cleft palate.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

42205 ....... Reconstruct 

cleft palate.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

42210 ....... Reconstruct 

cleft palate.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

42215 ....... Reconstruct 

cleft palate.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

42220 ....... Reconstruct 

cleft palate.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

42226 ....... Lengthening of 

palate.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

42235 ....... Repair palate ... .................. .................. .................. 16.4494 $652.85 $684.92 $130.57 $136.98 

42260 ....... Repair nose to 

lip fistula.

.................. .................. .................. 23.1564 $919.03 $774.52 $183.81 $154.90 

42280 ....... Preparation, 

palate mold.

Y .............. Y .............. Y .............. 1.8635 $73.96 $73.96 $14.79 $14.79 

42281 ....... Insertion, palate 

prosthesis.

Y .............. .................. .................. 16.4494 $652.85 $652.85 $130.57 $130.57 

42300 ....... Drainage of salivary gland................... .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

42305 ....... Drainage of salivary gland................... .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

42310 ....... Drainage of salivary gland................... .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

42320 ....... Drainage of salivary gland................... .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

42330 ....... Removal of salivary stone.Y .............. Y .............. Y .............. 2.7864 $110.59 $110.59 $22.12 $22.12 

42335 ....... Removal of salivary stone.Y .............. Y .............. Y .............. 4.5522 $180.67 $180.67 $36.13 $36.13 

42340 ....... Removal of salivary stone................... .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

42400 ....... Biopsy of salivary gland.Y .............. Y .............. Y .............. 1.5674 $62.21 $62.21 $12.44 $12.44 

42405 ....... Biopsy of salivary gland................... .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

42408 ....... Excision of salivary cyst................... .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

42409 ....... Drainage of salivary cyst................... .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 


sroberts on PROD1PC70 with PROPOSALS
49908 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

42410 ....... Excise parotid 

gland/lesion.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

42415 ....... Excise parotid 

gland/lesion.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

42420 ....... Excise parotid 

gland/lesion.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

42425 ....... Excise parotid 

gland/lesion.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

42440 ....... Excise submaxillary gland................... .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

42450 ....... Excise sublingual gland................... .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

42500 ....... Repair salivary 

duct.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

42505 ....... Repair salivary 

duct.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

42507 ....... Parotid duct diversion................... .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

42508 ....... Parotid duct diversion................... .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

42509 ....... Parotid duct diversion................... .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

42510 ....... Parotid duct diversion................... .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

42600 ....... Closure of salivary fistula................... .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

42650 ....... Dilation of salivary duct.Y .............. Y .............. Y .............. 1.0121 $40.17 $40.17 $8.03 $8.03 

42660 ....... Dilation of salivary duct.Y .............. Y .............. Y .............. 1.2294 $48.79 $48.79 $9.76 $9.76 

42665 ....... Ligation of salivary duct................... .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

42700 ....... Drainage of tonsil abscess................... .................. .................. 2.3768 $94.33 $120.31 $18.87 $24.06 

42720 ....... Drainage of 

throat abscess.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

42725 ....... Drainage of 

throat abscess.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

42800 ....... Biopsy of throat Y .............. Y .............. Y .............. 1.9620 $77.87 $77.87 $15.57 $15.57 

42802 ....... Biopsy of throat .................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

42804 ....... Biopsy of upper 

nose/throat.

.................. .................. .................. 16.4494 $652.85 $492.92 $130.57 $98.58 

42806 ....... Biopsy of upper 

nose/throat.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

42808 ....... Excise pharynx 

lesion.

.................. .................. .................. 16.4494 $652.85 $549.42 $130.57 $109.88 

42809 ....... Remove pharynx foreign 

body.

Y .............. .................. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

42810 ....... Excision of neck 

cyst.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

42815 ....... Excision of neck 

cyst.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

42820 ....... Remove tonsils 

and adenoids.

.................. .................. .................. 22.7757 $903.92 $706.96 $180.78 $141.39 

42821 ....... Remove tonsils 

and adenoids.

.................. .................. .................. 22.7757 $903.92 $810.46 $180.78 $162.09 

42825 ....... Removal of tonsils................... .................. .................. 22.7757 $903.92 $766.96 $180.78 $153.39 

42826 ....... Removal of tonsils................... .................. .................. 22.7757 $903.92 $766.96 $180.78 $153.39 

42830 ....... Removal of adenoids................... .................. .................. 22.7757 $903.92 $766.96 $180.78 $153.39 

42831 ....... Removal of adenoids................... .................. .................. 22.7757 $903.92 $766.96 $180.78 $153.39 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49909 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

42835 ....... Removal of adenoids................... .................. .................. 22.7757 $903.92 $766.96 $180.78 $153.39 

42836 ....... Removal of adenoids................... .................. .................. 22.7757 $903.92 $766.96 $180.78 $153.39 

42860 ....... Excision of tonsil tags................... .................. .................. 22.7757 $903.92 $706.96 $180.78 $141.39 

42870 ....... Excision of lingual tonsil................... .................. .................. 22.7757 $903.92 $706.96 $180.78 $141.39 

42890 ....... Partial removal 

of pharynx.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

42892 ....... Revision of pharyngeal walls................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

42900 ....... Repair throat 

wound.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

42950 ....... Reconstruction 

of throat.

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

42955 ....... Surgical opening of throat................... .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

42960 ....... Control throat 

bleeding.

.................. .................. .................. 1.2021 $47.71 $60.85 $9.54 $12.17 

42962 ....... Control throat 

bleeding.

.................. .................. .................. 37.7719 $1,499.09 $972.55 $299.82 $194.51 

42970 ....... Control nose/ 

throat bleeding.

Y .............. Y .............. .................. 1.2021 $47.71 $47.71 $9.54 $9.54 

42972 ....... Control nose/ 

throat bleeding.

.................. .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

43030 ....... Throat muscle 

surgery.

Y .............. .................. .................. 16.4494 $652.85 $652.85 $130.57 $130.57 

43200 ....... Esophagus endoscopy................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43201 ....... Esoph scope w/ 

submucous 

inj.

.................. .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43202 ....... Esophagus endoscopy, biopsy................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43204 ....... Esoph scope w/ 

sclerosis inj.

.................. .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43205 ....... Esophagus endoscopy/ligation................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43215 ....... Esophagus endoscopy................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43216 ....... Esophagus endoscopy/lesion................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43217 ....... Esophagus endoscopy................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43219 ....... Esophagus endoscopy................... .................. .................. 22.6777 $900.03 $616.52 $180.01 $123.30 

43220 ....... Esoph endoscopy, dilation................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43226 ....... Esoph endoscopy, dilation................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43227 ....... Esoph endoscopy, repair................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43228 ....... Esoph endoscopy, ablation................... .................. .................. 27.5493 $1,093.38 $769.69 $218.68 $153.94 

43231 ....... Esoph endoscopy w/us 

exam.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43232 ....... Esoph endoscopy w/us fn 

bx.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43234 ....... Upper gi endoscopy, exam................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 


sroberts on PROD1PC70 with PROPOSALS
49910 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

43235 ....... Uppr gi endoscopy, diagnosis................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43236 ....... Uppr gi scope 

w/submuc inj.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43237 ....... Endoscopic us 

exam, esoph.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43238 ....... Uppr gi endoscopy w/us fn 

bx.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43239 ....... Upper gi endoscopy, biopsy................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43240 ....... Esoph endoscope w/drain 

cyst.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43241 ....... Upper gi endoscopy with 

tube.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43242 ....... Uppr gi endoscopy w/us fn 

bx.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43243 ....... Upper gi endoscopy & inject................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43244 ....... Upper gi endoscopy/ligation................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43245 ....... Uppr gi scope 

dilate strictr.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43246 ....... Place gastrostomy tube................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43247 ....... Operative upper 

gi endoscopy.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43248 ....... Uppr gi endoscopy/guide 

wire.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43249 ....... Esoph endoscopy, dilation................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43250 ....... Upper gi endoscopy/tumor................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43251 ....... Operative upper 

gi endoscopy.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43255 ....... Operative upper 

gi endoscopy.

.................. .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43256 ....... Uppr gi endoscopy w/stent................... .................. .................. 22.6777 $900.03 $705.02 $180.01 $141.00 

43257 ....... Uppr gi scope 

w/thrml txmnt.

Y .............. .................. .................. 27.5493 $1,093.38 $1,093.38 $218.68 $218.68 

43258 ....... Operative upper 

gi endoscopy.

.................. .................. .................. 8.3070 $329.69 $419.84 $65.94 $83.97 

43259 ....... Endoscopic 

ultrasound 

exam.

.................. .................. .................. 8.3070 $329.69 $419.84 $65.94 $83.97 

43260 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43261 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43262 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43263 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43264 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49911 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

43265 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43267 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43268 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 22.6777 $900.03 $673.02 $180.01 $134.60 

43269 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 22.6777 $900.03 $673.02 $180.01 $134.60 

43271 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43272 ....... Endo 

cholangiopancreatograph.

.................. .................. .................. 19.8125 $786.32 $616.16 $157.26 $123.23 

43450 ....... Dilate esophagus................... .................. .................. 5.3134 $210.88 $268.96 $42.18 $53.79 

43453 ....... Dilate esophagus................... .................. .................. 5.3134 $210.88 $268.96 $42.18 $53.79 

43456 ....... Dilate esophagus................... .................. .................. 5.3134 $210.88 $268.96 $42.18 $53.79 

43458 ....... Dilate esophagus................... .................. .................. 5.3134 $210.88 $268.96 $42.18 $53.79 

43600 ....... Biopsy of stomach................... .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43653 ....... Laparoscopy, 

gastrostomy.

.................. .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

43750 ....... Place gastrostomy tube................... .................. .................. 8.3070 $329.69 $387.84 $65.94 $77.57 

43760 ....... Change gastrostomy tube................... .................. .................. 2.3431 $92.99 $118.61 $18.60 $23.72 

43761 ....... Reposition gastrostomy tube.Y .............. .................. .................. 7.2859 $289.16 $289.16 $57.83 $57.83 

43870 ....... Repair stomach 

opening.

.................. .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

43886 ....... Revise gastric 

port, open.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

43887 ....... Remove gastric 

port, open.

Y .............. .................. .................. 5.0931 $202.14 $202.14 $40.43 $40.43 

43888 ....... Change gastric 

port, open.

Y .............. .................. .................. 13.3433 $529.57 $529.57 $105.91 $105.91 

44100 ....... Biopsy of bowel .................. .................. .................. 8.3070 $329.69 $331.34 $65.94 $66.27 

44312 ....... Revision of ileostomy................... .................. .................. 21.2645 $843.95 $588.47 $168.79 $117.69 

44340 ....... Revision of colostomy................... .................. .................. 21.2645 $843.95 $676.97 $168.79 $135.39 

44360 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44361 ....... Small bowel endoscopy/biopsy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44363 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44364 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44365 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44366 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44369 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44370 ....... Small bowel endoscopy/stent................... .................. .................. 22.6777 $900.03 $1,119.52 $180.01 $223.90 

44372 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 


sroberts on PROD1PC70 with PROPOSALS
49912 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

44373 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44376 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44377 ....... Small bowel endoscopy/biopsy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44378 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $409.29 $74.52 $81.86 

44379 ....... Sbowel endoscope w/stent................... .................. .................. 22.6777 $900.03 $1,119.52 $180.01 $223.90 

44380 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $352.79 $74.52 $70.56 

44382 ....... Small bowel endoscopy................... .................. .................. 9.3878 $372.58 $352.79 $74.52 $70.56 

44383 ....... Ileoscopy w/ 

stent.

.................. .................. .................. 22.6777 $900.03 $1,119.52 $180.01 $223.90 

44385 ....... Endoscopy of 

bowel pouch.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44386 ....... Endoscopy, 

bowel pouch/ 

biop.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44388 ....... Colonoscopy .... .................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44389 ....... Colonoscopy 

with biopsy.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44390 ....... Colonoscopy for 

foreign body.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44391 ....... Colonoscopy for 

bleeding.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44392 ....... Colonoscopy & 

polypectomy.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44393 ....... Colonoscopy, 

lesion removal.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44394 ....... Colonoscopy w/ 

snare.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

44397 ....... Colonoscopy w/ 

stent.

.................. .................. .................. 22.6777 $900.03 $616.52 $180.01 $123.30 

45000 ....... Drainage of pelvic abscess................... .................. .................. 4.8970 $194.35 $247.89 $38.87 $49.58 

45005 ....... Drainage of rectal abscess................... .................. .................. 12.8778 $511.10 $478.55 $102.22 $95.71 

45020 ....... Drainage of rectal abscess................... .................. .................. 12.8778 $511.10 $478.55 $102.22 $95.71 

45100 ....... Biopsy of rectum................... .................. .................. 22.2336 $882.41 $607.70 $176.48 $121.54 

45108 ....... Removal of 

anorectal lesion.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

45150 ....... Excision of rectal stricture................... .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

45160 ....... Excision of rectal lesion................... .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

45170 ....... Excision of rectal lesion................... .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

45190 ....... Destruction, rectal tumor................... .................. .................. 22.2336 $882.41 $1,110.70 $176.48 $222.14 

45300 ....... Proctosigmoidoscopy dx.Y .............. Y .............. Y .............. 1.5109 $59.96 $59.96 $11.99 $11.99 

45303 ....... Proctosigmoidoscopy dilate.Y .............. Y .............. .................. 8.5644 $339.90 $339.90 $67.98 $67.98 

45305 ....... Proctosigmoidoscopy w/bx................... .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45307 ....... Proctosigmoidoscopy fb................... .................. .................. 20.4902 $813.22 $573.11 $162.64 $114.62 

45308 ....... Proctosigmoidoscopy removal................... .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49913 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

45309 ....... Proctosigmoidoscopy removal................... .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45315 ....... Proctosigmoidoscopy removal................... .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45317 ....... Proctosigmoidoscopy bleed................... .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45320 ....... Proctosigmoidoscopy ablate................... .................. .................. 20.4902 $813.22 $573.11 $162.64 $114.62 

45321 ....... Proctosigmoidoscopy volvul................... .................. .................. 20.4902 $813.22 $573.11 $162.64 $114.62 

45327 ....... Proctosigmoidoscopy w/stent................... .................. .................. 22.6777 $900.03 $616.52 $180.01 $123.30 

45330 ....... Diagnostic 

sigmoidoscopy.

Y .............. Y .............. Y .............. 2.0624 $81.85 $81.85 $16.37 $16.37 

45331 ....... Sigmoidoscopy 

and biopsy.

.................. .................. .................. 4.8005 $190.52 $243.00 $38.10 $48.60 

45332 ....... Sigmoidoscopy 

w/fb removal.

.................. .................. .................. 4.8005 $190.52 $243.00 $38.10 $48.60 

45333 ....... Sigmoidoscopy 

& polypectomy.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45334 ....... Sigmoidoscopy 

for bleeding.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45335 ....... Sigmoidoscopy 

w/submuc inj.

.................. .................. .................. 4.8005 $190.52 $243.00 $38.10 $48.60 

45337 ....... Sigmoidoscopy 

& decompress.

.................. .................. .................. 4.8005 $190.52 $243.00 $38.10 $48.60 

45338 ....... Sigmoidoscopy 

w/tumr remove.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45339 ....... Sigmoidoscopy 

w/ablate tumr.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45340 ....... Sig w/balloon 

dilation.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45341 ....... Sigmoidoscopy 

w/ultrasound.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45342 ....... Sigmoidoscopy 

w/us guide bx.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

45345 ....... Sigmoidoscopy 

w/stent.

.................. .................. .................. 22.6777 $900.03 $616.52 $180.01 $123.30 

45355 ....... Surgical 

colonoscopy.

.................. .................. .................. 8.8143 $349.82 $341.41 $69.96 $68.28 

45378 ....... Diagnostic 

colonoscopy.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45379 ....... Colonoscopy w/ 

fb removal.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45380 ....... Colonoscopy 

and biopsy.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45381 ....... Colonoscopy, 

submucous 

inj.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45382 ....... Colonoscopy/ 

control bleeding.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45383 ....... Lesion removal 

colonoscopy.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45384 ....... Lesion remove 

colonoscopy.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45385 ....... Lesion removal 

colonoscopy.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45386 ....... Colonoscopy dilate stricture................... .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45387 ....... Colonoscopy w/ 

stent.

.................. .................. .................. 22.6777 $900.03 $616.52 $180.01 $123.30 


sroberts on PROD1PC70 with PROPOSALS
49914 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

45391 ....... Colonoscopy w/ 

endoscope us.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45392 ....... Colonoscopy w/ 

endoscopic 

fnb.

.................. .................. .................. 8.8143 $349.82 $397.91 $69.96 $79.58 

45500 ....... Repair of rectum................... .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

45505 ....... Repair of rectum................... .................. .................. 29.4386 $1,168.36 $807.18 $233.67 $161.44 

45520 ....... Treatment of 

rectal 

prolapse.

Y .............. Y .............. .................. 1.1035 $43.80 $43.80 $8.76 $8.76 

45560 ....... Repair of 

rectocele.

.................. .................. .................. 29.4386 $1,168.36 $807.18 $233.67 $161.44 

45900 ....... Reduction of 

rectal 

prolapse.

.................. .................. .................. 4.8970 $194.35 $247.89 $38.87 $49.58 

45905 ....... Dilation of anal 

sphincter.

.................. .................. .................. 22.2336 $882.41 $607.70 $176.48 $121.54 

45910 ....... Dilation of rectal 

narrowing.

.................. .................. .................. 22.2336 $882.41 $607.70 $176.48 $121.54 

45915 ....... Remove rectal 

obstruction.

.................. .................. .................. 4.8970 $194.35 $247.89 $38.87 $49.58 

45990 ....... Surg dx exam, 

anorectal.

.................. .................. .................. 4.8970 $194.35 $247.89 $38.87 $49.58 

46020 ....... Placement of 

seton.

.................. .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46030 ....... Removal of rectal marker................... .................. .................. 4.8970 $194.35 $247.89 $38.87 $49.58 

46040 ....... Incision of rectal 

abscess.

.................. .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46045 ....... Incision of rectal 

abscess.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

46050 ....... Incision of anal 

abscess.

.................. .................. .................. 4.8970 $194.35 $247.89 $38.87 $49.58 

46060 ....... Incision of rectal 

abscess.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

46070 ....... Incision of anal 

septum.

Y .............. .................. .................. 12.8778 $511.10 $511.10 $102.22 $102.22 

46080 ....... Incision of anal 

sphincter.

.................. .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46083 ....... Incise external 

hemorrhoid.

Y .............. Y .............. Y .............. 2.0708 $82.18 $82.18 $16.44 $16.44 

46200 ....... Removal of anal 

fissure.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

46210 ....... Removal of anal 

crypt.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

46211 ....... Removal of anal 

crypts.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

46220 ....... Removal of anal 

tag.

.................. .................. .................. 22.2336 $882.41 $607.70 $176.48 $121.54 

46221 ....... Ligation of hemorrhoid(s).Y .............. Y .............. Y .............. 2.7306 $108.37 $108.37 $21.67 $21.67 

46230 ....... Removal of anal 

tags.

.................. .................. .................. 22.2336 $882.41 $607.70 $176.48 $121.54 

46250 ....... Hemorrhoidectomy................... .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46255 ....... Hemorrhoidectomy................... .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46257 ....... Remove hemorrhoids & fissure................... .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46258 ....... Remove hemorrhoids & fistula................... .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46260 ....... Hemorrhoidectomy................... .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49915 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

46261 ....... Remove hemorrhoids & fissure................... .................. .................. 22.2336 $882.41 $756.20 $176.48 $151.24 

46262 ....... Remove hemorrhoids & fistula................... .................. .................. 22.2336 $882.41 $756.20 $176.48 $151.24 

46270 ....... Removal of anal 

fistula.

.................. .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46275 ....... Removal of anal 

fistula.

.................. .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46280 ....... Removal of anal 

fistula.

.................. .................. .................. 22.2336 $882.41 $756.20 $176.48 $151.24 

46285 ....... Removal of anal 

fistula.

.................. .................. .................. 22.2336 $882.41 $607.70 $176.48 $121.54 

46288 ....... Repair anal fistula................... .................. .................. 22.2336 $882.41 $756.20 $176.48 $151.24 

46320 ....... Removal of 

hemorrhoid 

clot.

Y .............. Y .............. Y .............. 1.9331 $76.72 $76.72 $15.34 $15.34 

46500 ....... Injection into 

hemorrhoid(s).

Y .............. Y .............. Y .............. 2.4529 $97.35 $97.35 $19.47 $19.47 

46505 ....... Chemodenervation anal 

musc.

Y .............. .................. .................. 4.8970 $194.35 $194.35 $38.87 $38.87 

46600 ....... Diagnostic 

anoscopy.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

46604 ....... Anoscopy and 

dilation.

Y .............. Y .............. .................. 8.5644 $339.90 $339.90 $67.98 $67.98 

46606 ....... Anoscopy and 

biopsy.

Y .............. Y .............. Y .............. 3.3278 $132.07 $132.07 $26.41 $26.41 

46608 ....... Anoscopy, remove for 

body.

.................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

46610 ....... Anoscopy, remove lesion................... .................. .................. 20.4902 $813.22 $573.11 $162.64 $114.62 

46611 ....... Anoscopy ......... .................. .................. .................. 8.5644 $339.90 $336.45 $67.98 $67.29 

46612 ....... Anoscopy, remove lesions................... .................. .................. 20.4902 $813.22 $573.11 $162.64 $114.62 

46614 ....... Anoscopy, control bleeding.Y .............. Y .............. Y .............. 2.1904 $86.93 $86.93 $17.39 $17.39 

46615 ....... Anoscopy ......... .................. .................. .................. 20.4902 $813.22 $629.61 $162.64 $125.92 

46700 ....... Repair of anal 

stricture.

.................. .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46706 ....... Repr of anal fistula w/glue................... .................. .................. 29.4386 $1,168.36 $750.68 $233.67 $150.14 

46750 ....... Repair of anal 

sphincter.

.................. .................. .................. 37.2425 $1,478.08 $994.04 $295.62 $198.81 

46753 ....... Reconstruction 

of anus.

.................. .................. .................. 22.2336 $882.41 $696.20 $176.48 $139.24 

46754 ....... Removal of suture from 

anus.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

46760 ....... Repair of anal 

sphincter.

.................. .................. .................. 37.2425 $1,478.08 $962.04 $295.62 $192.41 

46761 ....... Repair of anal 

sphincter.

.................. .................. .................. 37.2425 $1,478.08 $994.04 $295.62 $198.81 

46762 ....... Implant artificial 

sphincter.

.................. .................. .................. 37.2425 $1,478.08 $1,236.54 $295.62 $247.31 

46900 ....... Destruction, 

anal lesion(s).

Y .............. Y .............. .................. 2.6253 $104.19 $104.19 $20.84 $20.84 

46910 ....... Destruction, 

anal lesion(s).

Y .............. Y .............. Y .............. 2.9131 $115.62 $115.62 $23.12 $23.12 

46916 ....... Cryosurgery, 

anal lesion(s).

Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

46917 ....... Laser surgery, 

anal lesions.

.................. .................. .................. 20.5802 $816.79 $574.89 $163.36 $114.98 

46922 ....... Excision of anal 

lesion(s).

.................. .................. .................. 20.5802 $816.79 $574.89 $163.36 $114.98 


sroberts on PROD1PC70 with PROPOSALS
49916 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

46924 ....... Destruction, 

anal lesion(s).

.................. .................. .................. 20.5802 $816.79 $574.89 $163.36 $114.98 

46934 ....... Destruction of 

hemorrhoids.

Y .............. Y .............. Y .............. 4.4793 $177.78 $177.78 $35.56 $35.56 

46935 ....... Destruction of 

hemorrhoids.

Y .............. Y .............. Y .............. 3.0462 $120.90 $120.90 $24.18 $24.18 

46936 ....... Destruction of 

hemorrhoids.

Y .............. Y .............. Y .............. 4.7722 $189.40 $189.40 $37.88 $37.88 

46937 ....... Cryotherapy of 

rectal lesion.

.................. .................. .................. 22.2336 $882.41 $664.20 $176.48 $132.84 

46938 ....... Cryotherapy of 

rectal lesion.

.................. .................. .................. 29.4386 $1,168.36 $807.18 $233.67 $161.44 

46940 ....... Treatment of 

anal fissure.

Y .............. Y .............. Y .............. 2.0705 $82.17 $82.17 $16.43 $16.43 

46942 ....... Treatment of 

anal fissure.

Y .............. Y .............. Y .............. 1.9967 $79.25 $79.25 $15.85 $15.85 

46945 ....... Ligation of hemorrhoids.Y .............. Y .............. Y .............. 3.4793 $138.09 $138.09 $27.62 $27.62 

46946 ....... Ligation of hemorrhoids.Y .............. Y .............. Y .............. 3.6051 $143.08 $143.08 $28.62 $28.62 

46947 ....... Hemorrhoidopexy by stapling................... .................. .................. 29.4386 $1,168.36 $839.18 $233.67 $167.84 

47000 ....... Needle biopsy 

of liver.

.................. .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 

47382 ....... Percut ablate 

liver rf.

Y .............. .................. .................. 39.0235 $1,548.77 $1,548.77 $309.75 $309.75 

47510 ....... Insert catheter, 

bile duct.

.................. .................. .................. 19.4515 $771.99 $609.00 $154.40 $121.80 

47511 ....... Insert bile duct 

drain.

.................. .................. .................. 19.4515 $771.99 $984.63 $154.40 $196.93 

47525 ....... Change bile 

duct catheter.

.................. .................. .................. 11.5220 $457.29 $395.14 $91.46 $79.03 

47530 ....... Revise/reinsert 

bile tube.

.................. .................. .................. 11.5220 $457.29 $395.14 $91.46 $79.03 

47552 ....... Biliary endoscopy thru skin................... .................. .................. 19.4515 $771.99 $609.00 $154.40 $121.80 

47553 ....... Biliary endoscopy thru skin................... .................. .................. 19.4515 $771.99 $641.00 $154.40 $128.20 

47554 ....... Biliary endoscopy thru skin................... .................. .................. 19.4515 $771.99 $641.00 $154.40 $128.20 

47555 ....... Biliary endoscopy thru skin................... .................. .................. 19.4515 $771.99 $641.00 $154.40 $128.20 

47556 ....... Biliary endoscopy thru skin................... .................. .................. 19.4515 $771.99 $984.63 $154.40 $196.93 

47560 ....... Laparoscopy w/ 

cholangio.

.................. .................. .................. 31.9353 $1,267.45 $888.73 $253.49 $177.75 

47561 ....... Laparo w/ 

cholangio/biopsy.

.................. .................. .................. 31.9353 $1,267.45 $888.73 $253.49 $177.75 

47562 ....... Laparoscopic 

cholecystectomy.

Y .............. .................. .................. 43.5124 $1,726.92 $1,726.92 $345.38 $345.38 

47563 ....... Laparo cholecystectomy/ 

graph.

Y .............. .................. .................. 43.5124 $1,726.92 $1,726.92 $345.38 $345.38 

47630 ....... Remove bile 

duct stone.

.................. .................. .................. 19.4515 $771.99 $641.00 $154.40 $128.20 

48102 ....... Needle biopsy, 

pancreas.

.................. .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 

49080 ....... Puncture, peritoneal cavity................... .................. .................. 3.6425 $144.56 $184.38 $28.91 $36.88 

49081 ....... Removal of abdominal fluid................... .................. .................. 3.6425 $144.56 $184.38 $28.91 $36.88 

49085 ....... Remove abdomen foreign 

body.

.................. .................. .................. 22.1758 $880.12 $663.06 $176.02 $132.61 

49180 ....... Biopsy, abdominal mass................... .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49917 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

49250 ....... Excision of umbilicus................... .................. .................. 22.1758 $880.12 $755.06 $176.02 $151.01 

49320 ....... Diag laparo 

separate proc.

.................. .................. .................. 31.9353 $1,267.45 $888.73 $253.49 $177.75 

49321 ....... Laparoscopy, 

biopsy.

.................. .................. .................. 31.9353 $1,267.45 $948.73 $253.49 $189.75 

49322 ....... Laparoscopy, 

aspiration.

.................. .................. .................. 31.9353 $1,267.45 $948.73 $253.49 $189.75 

49419 ....... Insrt abdom 

cath for 

chemotx.

.................. .................. .................. 29.4757 $1,169.83 $751.42 $233.97 $150.28 

49420 ....... Insert abdom 

drain, temp.

.................. .................. .................. 29.2259 $1,159.92 $746.46 $231.98 $149.29 

49421 ....... Insert abdom 

drain, perm.

.................. .................. .................. 29.2259 $1,159.92 $746.46 $231.98 $149.29 

49422 ....... Remove perm 

cannula/catheter.

.................. .................. .................. 23.4666 $931.34 $632.17 $186.27 $126.43 

49423 ....... Exchange drainage catheter.Y .............. .................. .................. 11.5220 $457.29 $457.29 $91.46 $91.46 

49426 ....... Revise abdomen-venous 

shunt.

.................. .................. .................. 22.1758 $880.12 $663.06 $176.02 $132.61 

49429 ....... Removal of 

shunt.

Y .............. .................. .................. 23.4666 $931.34 $931.34 $186.27 $186.27 

49495 ....... Rpr ing hernia 

baby, reduc.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49496 ....... Rpr ing hernia 

baby, blocked.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49500 ....... Rpr ing hernia, 

init, reduce.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49501 ....... Rpr ing hernia, 

init blocked.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49505 ....... Prp i/hern init 

reduc ≤5 yr.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49507 ....... Prp i/hern init 

block ≤5 yr.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49520 ....... Rerepair ing 

hernia, reduce.

.................. .................. .................. 29.1491 $1,156.87 $1,075.94 $231.37 $215.19 

49521 ....... Rerepair ing 

hernia, 

blocked.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49525 ....... Repair ing hernia, sliding................... .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49540 ....... Repair lumbar 

hernia.

.................. .................. .................. 29.1491 $1,156.87 $801.44 $231.37 $160.29 

49550 ....... Rpr rem hernia, 

init, reduce.

.................. .................. .................. 29.1491 $1,156.87 $936.94 $231.37 $187.39 

49553 ....... Rpr fem hernia, 

init blocked.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49555 ....... Rerepair fem 

hernia, reduce.

.................. .................. .................. 29.1491 $1,156.87 $936.94 $231.37 $187.39 

49557 ....... Rerepair fem 

hernia, 

blocked.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49560 ....... Rpr ventral hern 

init, reduc.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49561 ....... Rpr ventral hern 

init, block.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49565 ....... Rerepair ventrl 

hern, reduce.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49566 ....... Rerepair ventrl 

hern, block.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49568 ....... Hernia repair w/ 

mesh.

.................. .................. .................. 29.1491 $1,156.87 $1,075.94 $231.37 $215.19 


sroberts on PROD1PC70 with PROPOSALS
49918 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

49570 ....... Rpr epigastric 

hern, reduce.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49572 ....... Rpr epigastric 

hern, blocked.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49580 ....... Rpr umbil hern, 

reduc < 5 yr.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49582 ....... Rpr umbil hern, 

block < 5 yr.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49585 ....... Rpr umbil hern, 

reduc > 5 yr.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49587 ....... Rpr umbil hern, 

block > 5 yr.

.................. .................. .................. 29.1491 $1,156.87 $1,247.94 $231.37 $249.59 

49590 ....... Repair spigelian 

hernia.

.................. .................. .................. 29.1491 $1,156.87 $833.44 $231.37 $166.69 

49600 ....... Repair umbilical 

lesion.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

49650 ....... Laparo hernia 

repair initial.

.................. .................. .................. 43.5124 $1,726.92 $1,178.46 $345.38 $235.69 

49651 ....... Laparo hernia 

repair recur.

.................. .................. .................. 43.5124 $1,726.92 $1,360.96 $345.38 $272.19 

50200 ....... Biopsy of kidney .................. .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 

50382 ....... Change ureter 

stent, percut.

Y .............. .................. .................. 19.2766 $765.05 $765.05 $153.01 $153.01 

50384 ....... Remove ureter 

stent, percut.

Y .............. .................. .................. 19.2766 $765.05 $765.05 $153.01 $153.01 

50387 ....... Change ext/int 

ureter stent.

Y .............. .................. .................. 7.2859 $289.16 $289.16 $57.83 $57.83 

50389 ....... Remove renal 

tube w/fluoro.

Y .............. .................. .................. 3.5688 $141.64 $141.64 $28.33 $28.33 

50390 ....... Drainage of kidney lesion................... .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 

50391 ....... Instll rx agnt 

into rnal tub.

Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

50392 ....... Insert kidney 

drain.

.................. .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50393 ....... Insert ureteral 

tube.

.................. .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50395 ....... Create passage 

to kidney.

.................. .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50396 ....... Measure kidney 

pressure.

.................. .................. .................. 2.1159 $83.98 $107.11 $16.80 $21.42 

50398 ....... Change kidney 

tube.

.................. .................. .................. 7.2859 $289.16 $311.08 $57.83 $62.22 

50551 ....... Kidney endoscopy................... .................. .................. 6.7325 $267.20 $300.10 $53.44 $60.02 

50553 ....... Kidney endoscopy................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50555 ....... Kidney endoscopy & biopsy................... .................. .................. 6.7325 $267.20 $300.10 $53.44 $60.02 

50557 ....... Kidney endoscopy & treatment................... .................. .................. 23.8562 $946.81 $639.90 $189.36 $127.98 

50561 ....... Kidney endoscopy & treatment................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50562 ....... Renal scope w/ 

tumor resect.

Y .............. .................. .................. 6.7325 $267.20 $267.20 $53.44 $53.44 

50570 ....... Kidney endoscopy.Y .............. .................. .................. 6.7325 $267.20 $267.20 $53.44 $53.44 

50572 ....... Kidney endoscopy.Y .............. .................. .................. 6.7325 $267.20 $267.20 $53.44 $53.44 

50574 ....... Kidney endoscopy & biopsy.Y .............. .................. .................. 6.7325 $267.20 $267.20 $53.44 $53.44 

50575 ....... Kidney endoscopy.Y .............. .................. .................. 35.1024 $1,393.15 $1,393.15 $278.63 $278.63 

50576 ....... Kidney endoscopy & treatment.Y .............. .................. .................. 19.2766 $765.05 $765.05 $153.01 $153.01 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49919 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

50590 ....... Fragmenting of 

kidney stone.

Y .............. .................. .................. 44.1144 $1,750.82 $1,750.82 $350.16 $350.16 

50592 ....... Perc rf ablate 

renal tumor.

Y .............. .................. .................. 39.0235 $1,548.77 $1,548.77 $309.75 $309.75 

50686 ....... Measure ureter 

pressure.

Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

50688 ....... Change of ureter tube/stent................... .................. .................. 7.2859 $289.16 $311.08 $57.83 $62.22 

50947 ....... Laparo new ureter/bladder................... .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

50948 ....... Laparo new ureter/bladder................... .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

50951 ....... Endoscopy of 

ureter.

.................. .................. .................. 6.7325 $267.20 $300.10 $53.44 $60.02 

50953 ....... Endoscopy of 

ureter.

.................. .................. .................. 6.7325 $267.20 $300.10 $53.44 $60.02 

50955 ....... Ureter endoscopy & biopsy................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50957 ....... Ureter endoscopy & treatment................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50961 ....... Ureter endoscopy & treatment................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50970 ....... Ureter endoscopy................... .................. .................. 6.7325 $267.20 $300.10 $53.44 $60.02 

50972 ....... Ureter endoscopy & catheter................... .................. .................. 6.7325 $267.20 $300.10 $53.44 $60.02 

50974 ....... Ureter endoscopy & biopsy................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50976 ....... Ureter endoscopy & treatment................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

50980 ....... Ureter endoscopy & treatment................... .................. .................. 19.2766 $765.05 $549.03 $153.01 $109.81 

51000 ....... Drainage of 

bladder.

Y .............. Y .............. Y .............. 1.2446 $49.40 $49.40 $9.88 $9.88 

51005 ....... Drainage of 

bladder.

Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

51010 ....... Drainage of 

bladder.

.................. .................. .................. 18.2333 $723.64 $528.32 $144.73 $105.66 

51020 ....... Incise & treat 

bladder.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

51030 ....... Incise & treat 

bladder.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

51040 ....... Incise & drain 

bladder.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

51045 ....... Incise bladder/ 

drain ureter.

.................. .................. .................. 6.7325 $267.20 $340.80 $53.44 $68.16 

51050 ....... Removal of 

bladder stone.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

51065 ....... Remove ureter 

calculus.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

51080 ....... Drainage of 

bladder abscess.

.................. .................. .................. 17.4686 $693.30 $513.15 $138.66 $102.63 

51500 ....... Removal of 

bladder cyst.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

51520 ....... Removal of 

bladder lesion.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

51700 ....... Irrigation of 

bladder.

Y .............. Y .............. Y .............. 1.3433 $53.31 $53.31 $10.66 $10.66 

51701 ....... Insert bladder 

catheter.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

51702 ....... Insert temp 

bladder cath.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 


sroberts on PROD1PC70 with PROPOSALS
49920 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

51703 ....... Insert bladder 

cath, complex.

Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

51705 ....... Change of bladder tube.Y .............. Y .............. Y .............. 1.8609 $73.85 $73.85 $14.77 $14.77 

51710 ....... Change of bladder tube................... .................. .................. 7.2859 $289.16 $311.08 $57.83 $62.22 

51715 ....... Endoscopic injection/implant................... .................. .................. 28.5971 $1,134.96 $822.48 $226.99 $164.50 

51720 ....... Treatment of 

bladder lesion.

Y .............. Y .............. Y .............. 1.4579 $57.86 $57.86 $11.57 $11.57 

51725 ....... Simple 

cystometrogram.

Y .............. Y .............. .................. 2.1159 $83.98 $83.98 $16.80 $16.80 

51726 ....... Complex 

cystometrogram.

.................. .................. .................. 3.5688 $141.64 $180.65 $28.33 $36.13 

51736 ....... Urine flow 

measurement.

Y .............. Y .............. Y .............. 0.6370 $25.28 $25.28 $5.06 $5.06 

51741 ....... Electrouroflowmetry, 

first.

Y .............. Y .............. Y .............. 0.8854 $35.14 $35.14 $7.03 $7.03 

51772 ....... Urethra pressure profile................... .................. .................. 2.1159 $83.98 $107.11 $16.80 $21.42 

51784 ....... Anal/urinary 

muscle study.

Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

51785 ....... Anal/urinary 

muscle study.

.................. .................. .................. 1.0844 $43.04 $54.89 $8.61 $10.98 

51792 ....... Urinary reflex 

study.

Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

51795 ....... Urine voiding 

pressure 

study.

Y .............. Y .............. .................. 2.1159 $83.98 $83.98 $16.80 $16.80 

51797 ....... Intraabdominal 

pressure test.

Y .............. Y .............. .................. 2.1159 $83.98 $83.98 $16.80 $16.80 

51798 ....... Us urine capacity measure.Y .............. Y .............. Y .............. 0.4057 $16.10 $16.10 $3.22 $3.22 

51880 ....... Repair of bladder opening................... .................. .................. 23.8562 $946.81 $639.90 $189.36 $127.98 

51992 ....... Laparo sling operation................... .................. .................. 43.5124 $1,726.92 $1,221.96 $345.38 $244.39 

52000 ....... Cystoscopy ...... .................. .................. .................. 6.7325 $267.20 $300.10 $53.44 $60.02 

52001 ....... Cystoscopy, removal of clots................... .................. .................. 6.7325 $267.20 $340.80 $53.44 $68.16 

52005 ....... Cystoscopy & 

ureter catheter.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52007 ....... Cystoscopy and 

biopsy.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52010 ....... Cystoscopy & 

duct catheter.

.................. .................. .................. 6.7325 $267.20 $340.80 $53.44 $68.16 

52204 ....... Cystoscopy ...... .................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52214 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52224 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52234 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52235 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52240 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52250 ....... Cystoscopy and 

radiotracer.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

52260 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52265 ....... Cystoscopy and 

treatment.

Y .............. Y .............. .................. 6.7325 $267.20 $267.20 $53.44 $53.44 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49921 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

52270 ....... Cystoscopy & 

revise urethra.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52275 ....... Cystoscopy & 

revise urethra.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52276 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $637.53 $153.01 $127.51 

52277 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52281 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52282 ....... Cystoscopy, implant stent................... .................. .................. 35.1024 $1,393.15 $1,366.07 $278.63 $273.21 

52283 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52285 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52290 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52300 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52301 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $637.53 $153.01 $127.51 

52305 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52310 ....... Cystoscopy and 

treatment.

.................. .................. .................. 6.7325 $267.20 $340.80 $53.44 $68.16 

52315 ....... Cystoscopy and 

treatment.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

52317 ....... Remove bladder 

stone.

.................. .................. .................. 23.8562 $946.81 $639.90 $189.36 $127.98 

52318 ....... Remove bladder 

stone.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52320 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $831.90 $189.36 $166.38 

52325 ....... Cystoscopy, 

stone removal.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

52327 ....... Cystoscopy, inject material................... .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52330 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52332 ....... Cystoscopy and 

treatment.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52334 ....... Create passage 

to kidney.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52341 ....... Cysto w/ureter 

stricture tx.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52342 ....... Cysto w/up 

stricture tx.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52343 ....... Cysto w/renal 

stricture tx.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52344 ....... Cysto/uretero, 

stricture tx.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52345 ....... Cysto/uretero w/ 

up stricture.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52346 ....... Cystouretero w/ 

renal strict.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52351 ....... Cystouretero & 

or pyeloscope.

.................. .................. .................. 19.2766 $765.05 $637.53 $153.01 $127.51 

52352 ....... Cystouretero w/ 

stone remove.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

52353 ....... Cystouretero w/ 

lithotripsy.

.................. .................. .................. 35.1024 $1,393.15 $1,011.57 $278.63 $202.31 

52354 ....... Cystouretero w/ 

biopsy.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

52355 ....... Cystouretero w/ 

excise tumor.

.................. .................. .................. 23.8562 $946.81 $788.40 $189.36 $157.68 

52400 ....... Cystouretero w/ 

congen repr.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 


sroberts on PROD1PC70 with PROPOSALS
49922 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

52402 ....... Cystourethro cut 

ejacul duct.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52450 ....... Incision of prostate................... .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52500 ....... Revision of 

bladder neck.

.................. .................. .................. 23.8562 $946.81 $728.40 $189.36 $145.68 

52510 ....... Dilation prostatic urethra................... .................. .................. 19.2766 $765.05 $637.53 $153.01 $127.51 

52601 ....... Prostatectomy 

(turp).

.................. .................. .................. 35.1024 $1,393.15 $1,011.57 $278.63 $202.31 

52606 ....... Control postop 

bleeding.

.................. .................. .................. 23.8562 $946.81 $639.90 $189.36 $127.98 

52612 ....... Prostatectomy, 

first stage.

.................. .................. .................. 35.1024 $1,393.15 $919.57 $278.63 $183.91 

52614 ....... Prostatectomy, 

second stage.

.................. .................. .................. 35.1024 $1,393.15 $863.07 $278.63 $172.61 

52620 ....... Remove residual prostate................... .................. .................. 35.1024 $1,393.15 $863.07 $278.63 $172.61 

52630 ....... Remove prostate regrowth................... .................. .................. 35.1024 $1,393.15 $919.57 $278.63 $183.91 

52640 ....... Relieve bladder 

contracture.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

52647 ....... Laser surgery of 

prostate.

.................. .................. .................. 42.9327 $1,703.92 $1,521.46 $340.78 $304.29 

52648 ....... Laser surgery of 

prostate.

.................. .................. .................. 42.9327 $1,703.92 $1,521.46 $340.78 $304.29 

52700 ....... Drainage of 

prostate abscess.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

53000 ....... Incision of urethra................... .................. .................. 18.5138 $734.78 $533.89 $146.96 $106.78 

53010 ....... Incision of urethra................... .................. .................. 18.5138 $734.78 $533.89 $146.96 $106.78 

53020 ....... Incision of urethra................... .................. .................. 18.5138 $734.78 $533.89 $146.96 $106.78 

53025 ....... Incision of urethra.Y .............. Y .............. Y .............. 0.3551 $14.09 $14.09 $2.82 $2.82 

53040 ....... Drainage of urethra abscess................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

53060 ....... Drainage of urethra abscess.Y .............. Y .............. Y .............. 1.7500 $69.45 $69.45 $13.89 $13.89 

53080 ....... Drainage of urinary leakage................... .................. .................. 18.5138 $734.78 $622.39 $146.96 $124.48 

53085 ....... Drainage of urinary leakage.Y .............. .................. .................. 18.5138 $734.78 $734.78 $146.96 $146.96 

53200 ....... Biopsy of urethra................... .................. .................. 18.5138 $734.78 $533.89 $146.96 $106.78 

53210 ....... Removal of urethra................... .................. .................. 28.5971 $1,134.96 $925.98 $226.99 $185.20 

53215 ....... Removal of urethra................... .................. .................. 18.5138 $734.78 $725.89 $146.96 $145.18 

53220 ....... Treatment of 

urethra lesion.

.................. .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53230 ....... Removal of urethra lesion................... .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53235 ....... Removal of urethra lesion................... .................. .................. 18.5138 $734.78 $622.39 $146.96 $124.48 

53240 ....... Surgery for urethra pouch................... .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53250 ....... Removal of urethra gland................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

53260 ....... Treatment of 

urethra lesion.

.................. .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

53265 ....... Treatment of 

urethra lesion.

.................. .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

53270 ....... Removal of urethra gland................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49923 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

53275 ....... Repair of urethra defect................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

53400 ....... Revise urethra, 

stage 1.

.................. .................. .................. 28.5971 $1,134.96 $822.48 $226.99 $164.50 

53405 ....... Revise urethra, 

stage 2.

.................. .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53410 ....... Reconstruction 

of urethra.

.................. .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53420 ....... Reconstruct 

urethra, stage 

1.

.................. .................. .................. 28.5971 $1,134.96 $822.48 $226.99 $164.50 

53425 ....... Reconstruct 

urethra, stage 

2.

.................. .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53430 ....... Reconstruction 

of urethra.

.................. .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53431 ....... Reconstruct 

urethra/bladder.

.................. .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53440 ....... Male sling procedure................... .................. .................. 79.3730 $3,150.16 $1,798.08 $630.03 $359.62 

53442 ....... Remove/revise 

male sling.

.................. .................. .................. 28.5971 $1,134.96 $733.98 $226.99 $146.80 

53444 ....... Insert tandem 

cuff.

.................. .................. .................. 79.3730 $3,150.16 $1,798.08 $630.03 $359.62 

53445 ....... Insert uro/ves 

nck sphincter.

.................. .................. .................. 135.7295 $5,386.84 $2,859.92 $1,077.37 $571.98 

53446 ....... Remove uro 

sphincter.

.................. .................. .................. 28.5971 $1,134.96 $733.98 $226.99 $146.80 

53447 ....... Remove/replace 

ur sphincter.

.................. .................. .................. 135.7295 $5,386.84 $2,859.92 $1,077.37 $571.98 

53449 ....... Repair uro 

sphincter.

.................. .................. .................. 28.5971 $1,134.96 $733.98 $226.99 $146.80 

53450 ....... Revision of urethra................... .................. .................. 28.5971 $1,134.96 $733.98 $226.99 $146.80 

53460 ....... Revision of urethra................... .................. .................. 18.5138 $734.78 $533.89 $146.96 $106.78 

53502 ....... Repair of urethra injury................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

53505 ....... Repair of urethra injury................... .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53510 ....... Repair of urethra injury................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

53515 ....... Repair of urethra injury................... .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53520 ....... Repair of urethra defect................... .................. .................. 28.5971 $1,134.96 $790.48 $226.99 $158.10 

53600 ....... Dilate urethra 

stricture.

Y .............. Y .............. Y .............. 0.9900 $39.29 $39.29 $7.86 $7.86 

53601 ....... Dilate urethra 

stricture.

Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

53605 ....... Dilate urethra 

stricture.

.................. .................. .................. 19.2766 $765.05 $605.53 $153.01 $121.11 

53620 ....... Dilate urethra 

stricture.

Y .............. Y .............. Y .............. 1.6003 $63.51 $63.51 $12.70 $12.70 

53621 ....... Dilate urethra 

stricture.

Y .............. Y .............. Y .............. 1.6839 $66.83 $66.83 $13.37 $13.37 

53660 ....... Dilation of urethra.Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

53661 ....... Dilation of urethra.Y .............. Y .............. .................. 1.0844 $43.04 $43.04 $8.61 $8.61 

53665 ....... Dilation of urethra................... .................. .................. 18.5138 $734.78 $533.89 $146.96 $106.78 

53850 ....... Prostatic microwave 

thermotx.

Y .............. Y .............. .................. 42.3176 $1,679.50 $1,679.50 $335.90 $335.90 

53852 ....... Prostatic rf 

thermotx.

Y .............. Y .............. .................. 42.3176 $1,679.50 $1,679.50 $335.90 $335.90 


sroberts on PROD1PC70 with PROPOSALS
49924 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

53853 ....... Prostatic water 

thermother.

Y .............. Y .............. .................. 23.8562 $946.81 $946.81 $189.36 $189.36 

54000 ....... Slitting of prepuce................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

54001 ....... Slitting of prepuce................... .................. .................. 18.5138 $734.78 $590.39 $146.96 $118.08 

54015 ....... Drain penis lesion................... .................. .................. 17.4686 $693.30 $661.65 $138.66 $132.33 

54050 ....... Destruction, 

penis lesion(s).

Y .............. Y .............. .................. 1.0876 $43.16 $43.16 $8.63 $8.63 

54055 ....... Destruction, 

penis lesion(s).

Y .............. Y .............. Y .............. 1.5372 $61.01 $61.01 $12.20 $12.20 

54056 ....... Cryosurgery, 

penis lesion(s).

Y .............. Y .............. .................. 0.8076 $32.05 $32.05 $6.41 $6.41 

54057 ....... Laser surg, 

penis lesion(s).

.................. .................. .................. 17.7392 $704.03 $518.52 $140.81 $103.70 

54060 ....... Excision of 

penis lesion(s).

.................. .................. .................. 17.7392 $704.03 $518.52 $140.81 $103.70 

54065 ....... Destruction, 

penis lesion(s).

.................. .................. .................. 20.5802 $816.79 $574.89 $163.36 $114.98 

54100 ....... Biopsy of penis .................. .................. .................. 14.9563 $593.59 $463.29 $118.72 $92.66 

54105 ....... Biopsy of penis .................. .................. .................. 19.9760 $792.81 $562.90 $158.56 $112.58 

54110 ....... Treatment of 

penis lesion.

.................. .................. .................. 32.9991 $1,309.67 $877.84 $261.93 $175.57 

54111 ....... Treat penis lesion, graft................... .................. .................. 32.9991 $1,309.67 $877.84 $261.93 $175.57 

54112 ....... Treat penis lesion, graft................... .................. .................. 32.9991 $1,309.67 $877.84 $261.93 $175.57 

54115 ....... Treatment of 

penis lesion.

.................. .................. .................. 17.4686 $693.30 $513.15 $138.66 $102.63 

54120 ....... Partial removal 

of penis.

.................. .................. .................. 32.9991 $1,309.67 $877.84 $261.93 $175.57 

54150 ....... Circumcision .... .................. .................. .................. 20.7418 $823.20 $578.10 $164.64 $115.62 

54152 ....... Circumcision .... .................. .................. .................. 20.7418 $823.20 $578.10 $164.64 $115.62 

54160 ....... Circumcision .... .................. .................. .................. 20.7418 $823.20 $634.60 $164.64 $126.92 

54161 ....... Circumcision .... .................. .................. .................. 20.7418 $823.20 $634.60 $164.64 $126.92 

54162 ....... Lysis penil 

circumic lesion.

.................. .................. .................. 20.7418 $823.20 $634.60 $164.64 $126.92 

54163 ....... Repair of circumcision................... .................. .................. 20.7418 $823.20 $634.60 $164.64 $126.92 

54164 ....... Frenulotomy of 

penis.

.................. .................. .................. 20.7418 $823.20 $634.60 $164.64 $126.92 

54200 ....... Treatment of 

penis lesion.

Y .............. Y .............. Y .............. 1.6501 $65.49 $65.49 $13.10 $13.10 

54205 ....... Treatment of 

penis lesion.

.................. .................. .................. 32.9991 $1,309.67 $969.84 $261.93 $193.97 

54220 ....... Treatment of 

penis lesion.

.................. .................. .................. 2.1159 $83.98 $107.11 $16.80 $21.42 

54231 ....... Dynamic 

cavernosometry.

Y .............. Y .............. Y .............. 1.3889 $55.12 $55.12 $11.02 $11.02 

54235 ....... Penile injection Y .............. Y .............. Y .............. 1.0170 $40.36 $40.36 $8.07 $8.07 

54240 ....... Penis study ...... Y .............. Y .............. Y .............. 1.0844 $43.04 $43.04 $8.61 $8.61 

54250 ....... Penis study ...... Y .............. Y .............. Y .............. 0.9079 $36.03 $36.03 $7.21 $7.21 

54300 ....... Revision of 

penis.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54304 ....... Revision of 

penis.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54308 ....... Reconstruction 

of urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49925 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

54312 ....... Reconstruction 

of urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54316 ....... Reconstruction 

of urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54318 ....... Reconstruction 

of urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54322 ....... Reconstruction 

of urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54324 ....... Reconstruction 

of urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54326 ....... Reconstruction 

of urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54328 ....... Revise penis/ 

urethra.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54340 ....... Secondary 

urethral surgery.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54344 ....... Secondary 

urethral surgery.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54348 ....... Secondary 

urethral surgery.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54352 ....... Reconstruct 

urethra/penis.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54360 ....... Penis plastic 

surgery.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54380 ....... Repair penis ..... .................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54385 ....... Repair penis ..... .................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54400 ....... Insert semi-rigid 

prosthesis.

.................. .................. .................. 79.3730 $3,150.16 $1,830.08 $630.03 $366.02 

54401 ....... Insert self-contd 

prosthesis.

.................. .................. .................. 135.7295 $5,386.84 $2,948.42 $1,077.37 $589.68 

54405 ....... Insert multicomp penis 

pros.

.................. .................. .................. 135.7295 $5,386.84 $2,948.42 $1,077.37 $589.68 

54406 ....... Remove muticomp penis 

pros.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54408 ....... Repair multicomp penis 

pros.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54410 ....... Remove/replace 

penis prosth.

.................. .................. .................. 135.7295 $5,386.84 $2,948.42 $1,077.37 $589.68 

54415 ....... Remove selfcontd penis 

pros.

.................. .................. .................. 32.9991 $1,309.67 $909.84 $261.93 $181.97 

54416 ....... Remv/repl penis 

contain pros.

.................. .................. .................. 135.7295 $5,386.84 $2,948.42 $1,077.37 $589.68 

54420 ....... Revision of 

penis.

.................. .................. .................. 32.9991 $1,309.67 $969.84 $261.93 $193.97 

54435 ....... Revision of 

penis.

.................. .................. .................. 32.9991 $1,309.67 $969.84 $261.93 $193.97 

54440 ....... Repair of penis .................. .................. .................. 32.9991 $1,309.67 $969.84 $261.93 $193.97 

54450 ....... Preputial 

stretching.

.................. .................. .................. 3.5688 $141.64 $180.65 $28.33 $36.13 

54500 ....... Biopsy of testis .................. .................. .................. 10.2616 $407.26 $370.13 $81.45 $74.03 

54505 ....... Biopsy of testis .................. .................. .................. 23.7072 $940.89 $636.95 $188.18 $127.39 

54512 ....... Excise lesion 

testis.

.................. .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

54520 ....... Removal of testis................... .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

54522 ....... Orchiectomy, 

partial.

.................. .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

54530 ....... Removal of testis................... .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

54550 ....... Exploration for 

testis.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 


sroberts on PROD1PC70 with PROPOSALS
49926 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

54560 ....... Exploration for 

testis.

Y .............. .................. .................. 23.7072 $940.89 $940.89 $188.18 $188.18 

54600 ....... Reduce testis 

torsion.

.................. .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 

54620 ....... Suspension of 

testis.

.................. .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

54640 ....... Suspension of 

testis.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

54660 ....... Revision of testis................... .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

54670 ....... Repair testis injury................... .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

54680 ....... Relocation of 

testis(es).

.................. .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

54690 ....... Laparoscopy, 

orchiectomy.

.................. .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

54700 ....... Drainage of 

scrotum.

.................. .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

54800 ....... Biopsy of epididymis................... .................. .................. 2.0863 $82.80 $105.61 $16.56 $21.12 

54820 ....... Exploration of 

epididymis.

.................. .................. .................. 23.7072 $940.89 $636.95 $188.18 $127.39 

54830 ....... Remove epididymis lesion................... .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

54840 ....... Remove epididymis lesion................... .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 

54860 ....... Removal of epididymis................... .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

54861 ....... Removal of epididymis................... .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 

54900 ....... Fusion of spermatic ducts................... .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 

54901 ....... Fusion of spermatic ducts................... .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 

55000 ....... Drainage of hydrocele.Y .............. Y .............. Y .............. 1.6905 $67.09 $67.09 $13.42 $13.42 

55040 ....... Removal of hydrocele................... .................. .................. 29.1491 $1,156.87 $833.44 $231.37 $166.69 

55041 ....... Removal of 

hydroceles.

.................. .................. .................. 29.1491 $1,156.87 $936.94 $231.37 $187.39 

55060 ....... Repair of hydrocele................... .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 

55100 ....... Drainage of 

scrotum abscess.

.................. .................. .................. 10.9184 $433.33 $383.17 $86.67 $76.63 

55110 ....... Explore scrotum .................. .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

55120 ....... Removal of 

scrotum lesion.

.................. .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

55150 ....... Removal of 

scrotum.

.................. .................. .................. 23.7072 $940.89 $636.95 $188.18 $127.39 

55175 ....... Revision of 

scrotum.

.................. .................. .................. 23.7072 $940.89 $636.95 $188.18 $127.39 

55180 ....... Revision of 

scrotum.

.................. .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

55200 ....... Incision of 

sperm duct.

.................. .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

55250 ....... Removal of 

sperm duct(s).

.................. .................. .................. 23.7072 $940.89 $693.45 $188.18 $138.69 

55400 ....... Repair of sperm 

duct.

.................. .................. .................. 23.7072 $940.89 $636.95 $188.18 $127.39 

55450 ....... Ligation of 

sperm duct.

Y .............. Y .............. Y .............. 5.6047 $222.44 $222.44 $44.49 $44.49 

55500 ....... Removal of hydrocele................... .................. .................. 23.7072 $940.89 $725.45 $188.18 $145.09 

55520 ....... Removal of 

sperm cord 

lesion.

.................. .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49927 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

55530 ....... Revise spermatic cord 

veins.

.................. .................. .................. 23.7072 $940.89 $785.45 $188.18 $157.09 

55535 ....... Revise spermatic cord 

veins.

.................. .................. .................. 29.1491 $1,156.87 $893.44 $231.37 $178.69 

55540 ....... Revise hernia & 

sperm veins.

.................. .................. .................. 29.1491 $1,156.87 $936.94 $231.37 $187.39 

55550 ....... Laparo ligate 

spermatic 

vein.

.................. .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

55559 ....... Laparo proc, 

spermatic 

cord.

Y .............. .................. .................. 31.9353 $1,267.45 $1,267.45 $253.49 $253.49 

55600 ....... Incise sperm 

duct pouch.

Y .............. Y .............. Y .............. 3.5462 $140.74 $140.74 $28.15 $28.15 

55680 ....... Remove sperm 

pouch lesion.

.................. .................. .................. 23.7072 $940.89 $636.95 $188.18 $127.39 

55700 ....... Biopsy of prostate................... .................. .................. 5.9892 $237.70 $303.17 $47.54 $60.63 

55705 ....... Biopsy of prostate................... .................. .................. 5.9892 $237.70 $303.17 $47.54 $60.63 

55720 ....... Drainage of 

prostate abscess.

.................. .................. .................. 23.8562 $946.81 $639.90 $189.36 $127.98 

55725 ....... Drainage of 

prostate abscess.

.................. .................. .................. 23.8562 $946.81 $696.40 $189.36 $139.28 

55859 ....... Percut/needle 

insert, pros.

.................. .................. .................. 35.1024 $1,393.15 $1,366.07 $278.63 $273.21 

55860 ....... Surgical exposure, prostate.Y .............. .................. .................. 18.2333 $723.64 $723.64 $144.73 $144.73 

55870 ....... Electroejaculation.Y .............. Y .............. Y .............. 1.7213 $68.32 $68.32 $13.66 $13.66 

55873 ....... Cryoablate 

prostate.

.................. .................. .................. 107.8298 $4,279.56 $2,809.28 $855.91 $561.86 

56405 ....... I & D of vulva/ 

perineum.

Y .............. Y .............. Y .............. 1.0685 $42.41 $42.41 $8.48 $8.48 

56420 ....... Drainage of 

gland abscess.

Y .............. Y .............. .................. 1.4050 $55.76 $55.76 $11.15 $11.15 

56440 ....... Surgery for 

vulva lesion.

.................. .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

56441 ....... Lysis of labial 

lesion(s).

.................. .................. .................. 14.7958 $587.22 $460.11 $117.44 $92.02 

56501 ....... Destroy, vulva 

lesions, sim.

Y .............. Y .............. Y .............. 1.4690 $58.30 $58.30 $11.66 $11.66 

56515 ....... Destroy vulva 

lesion/s compl.

.................. .................. .................. 20.5802 $816.79 $663.39 $163.36 $132.68 

56605 ....... Biopsy of vulva/ 

perineum.

Y .............. Y .............. Y .............. 0.8450 $33.54 $33.54 $6.71 $6.71 

56606 ....... Biopsy of vulva/ 

perineum.

Y .............. Y .............. Y .............. 0.3647 $14.47 $14.47 $2.89 $2.89 

56620 ....... Partial removal 

of vulva.

.................. .................. .................. 28.7410 $1,140.68 $928.84 $228.14 $185.77 

56625 ....... Complete removal of 

vulva.

.................. .................. .................. 28.7410 $1,140.68 $1,067.84 $228.14 $213.57 

56700 ....... Partial removal 

of hymen.

.................. .................. .................. 20.5113 $814.05 $573.53 $162.81 $114.71 

56720 ....... Incision of 

hymen.

.................. .................. .................. 14.7958 $587.22 $460.11 $117.44 $92.02 

56740 ....... Remove vagina 

gland lesion.

.................. .................. .................. 20.5113 $814.05 $662.03 $162.81 $132.41 

56800 ....... Repair of vagina .................. .................. .................. 20.5113 $814.05 $662.03 $162.81 $132.41 

56810 ....... Repair of perineum................... .................. .................. 20.5113 $814.05 $765.53 $162.81 $153.11 


sroberts on PROD1PC70 with PROPOSALS
49928 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

56820 ....... Exam of vulva 

w/scope.

Y .............. Y .............. Y .............. 1.0682 $42.39 $42.39 $8.48 $8.48 

56821 ....... Exam/biopsy of 

vulva w/scope.

Y .............. Y .............. Y .............. 1.4089 $55.92 $55.92 $11.18 $11.18 

57000 ....... Exploration of 

vagina.

.................. .................. .................. 14.7958 $587.22 $460.11 $117.44 $92.02 

57010 ....... Drainage of pelvic abscess................... .................. .................. 14.7958 $587.22 $516.61 $117.44 $103.32 

57020 ....... Drainage of pelvic fluid................... .................. .................. 6.9265 $274.90 $350.61 $54.98 $70.12 

57022 ....... I & d vaginal 

hematoma, 

pp.

Y .............. .................. .................. 10.9184 $433.33 $433.33 $86.67 $86.67 

57023 ....... I& d vag hematoma, non-ob................... .................. .................. 17.4686 $693.30 $513.15 $138.66 $102.63 

57061 ....... Destroy vag lesions, simple.Y .............. Y .............. Y .............. 1.3555 $53.80 $53.80 $10.76 $10.76 

57065 ....... Destroy vag lesions, complex................... .................. .................. 20.5113 $814.05 $573.53 $162.81 $114.71 

57100 ....... Biopsy of vagina.Y .............. Y .............. Y .............. 0.8573 $34.02 $34.02 $6.80 $6.80 

57105 ....... Biopsy of vagina................... .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

57130 ....... Remove vagina 

lesion.

.................. .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

57135 ....... Remove vagina 

lesion.

.................. .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

57150 ....... Treat vagina infection.Y .............. Y .............. .................. 0.1501 $5.96 $5.96 $1.19 $1.19 

57155 ....... Insert uteri 

tandems/ 

ovoids.

.................. .................. .................. 6.9265 $274.90 $350.61 $54.98 $70.12 

57160 ....... Insert pessary/ 

other device.

Y .............. Y .............. Y .............. 0.8815 $34.98 $34.98 $7.00 $7.00 

57170 ....... Fitting of diaphragm/cap.Y .............. Y .............. .................. 0.1501 $5.96 $5.96 $1.19 $1.19 

57180 ....... Treat vaginal 

bleeding.

.................. .................. .................. 2.9902 $118.68 $151.36 $23.74 $30.27 

57200 ....... Repair of vagina .................. .................. .................. 20.5113 $814.05 $573.53 $162.81 $114.71 

57210 ....... Repair vagina/ 

perineum.

.................. .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

57220 ....... Revision of urethra................... .................. .................. 42.8756 $1,701.65 $1,105.83 $340.33 $221.17 

57230 ....... Repair of 

urethral lesion.

.................. .................. .................. 28.7410 $1,140.68 $825.34 $228.14 $165.07 

57240 ....... Repair bladder 

& vagina.

.................. .................. .................. 28.7410 $1,140.68 $928.84 $228.14 $185.77 

57250 ....... Repair rectum & 

vagina.

.................. .................. .................. 28.7410 $1,140.68 $928.84 $228.14 $185.77 

57260 ....... Repair of vagina .................. .................. .................. 28.7410 $1,140.68 $928.84 $228.14 $185.77 

57265 ....... Extensive repair 

of vagina.

.................. .................. .................. 42.8756 $1,701.65 $1,348.33 $340.33 $269.67 

57268 ....... Repair of bowel 

bulge.

.................. .................. .................. 28.7410 $1,140.68 $825.34 $228.14 $165.07 

57287 ....... Revise/remove 

sling repair.

Y .............. .................. .................. 28.7410 $1,140.68 $1,140.68 $228.14 $228.14 

57288 ....... Repair bladder 

defect.

.................. .................. .................. 42.8756 $1,701.65 $1,209.33 $340.33 $241.87 

57289 ....... Repair bladder 

& vagina.

.................. .................. .................. 28.7410 $1,140.68 $928.84 $228.14 $185.77 

57291 ....... Construction of 

vagina.

.................. .................. .................. 28.7410 $1,140.68 $928.84 $228.14 $185.77 

57300 ....... Repair rectumvagina fistula................... .................. .................. 28.7410 $1,140.68 $825.34 $228.14 $165.07 

57320 ....... Repair bladdervagina lesion.Y .............. .................. .................. 28.7410 $1,140.68 $1,140.68 $228.14 $228.14 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49929 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

57400 ....... Dilation of vagina................... .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

57410 ....... Pelvic examination................... .................. .................. 14.7958 $587.22 $516.61 $117.44 $103.32 

57415 ....... Remove vaginal 

foreign body.

.................. .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

57420 ....... Exam of vagina 

w/scope.

Y .............. Y .............. Y .............. 1.1018 $43.73 $43.73 $8.75 $8.75 

57421 ....... Exam/biopsy of 

vag w/scope.

Y .............. Y .............. Y .............. 1.4710 $58.38 $58.38 $11.68 $11.68 

57452 ....... Examination of 

vagina.

Y .............. Y .............. Y .............. 1.0518 $41.75 $41.75 $8.35 $8.35 

57454 ....... Vagina examination & biopsy.Y .............. Y .............. Y .............. 1.2983 $51.53 $51.53 $10.31 $10.31 

57455 ....... Biopsy of cervix 

w/scope.

Y .............. Y .............. Y .............. 1.3775 $54.67 $54.67 $10.93 $10.93 

57456 ....... Endocerv 

curettage w/ 

scope.

Y .............. Y .............. Y .............. 1.3315 $52.85 $52.85 $10.57 $10.57 

57460 ....... Cervix excision Y .............. Y .............. Y .............. 4.3623 $173.13 $173.13 $34.63 $34.63 

57461 ....... Conz of cervix 

w/scope, leep.

Y .............. Y .............. Y .............. 4.6015 $182.62 $182.62 $36.52 $36.52 

57500 ....... Biopsy of cervix Y .............. Y .............. Y .............. 1.9587 $77.74 $77.74 $15.55 $15.55 

57505 ....... Endocervical 

curettage.

Y .............. Y .............. Y .............. 1.1880 $47.15 $47.15 $9.43 $9.43 

57510 ....... Cauterization of 

cervix.

Y .............. Y .............. Y .............. 1.2257 $48.65 $48.65 $9.73 $9.73 

57511 ....... Cryocautery of 

cervix.

Y .............. Y .............. .................. 1.4050 $55.76 $55.76 $11.15 $11.15 

57513 ....... Laser surgery of 

cervix.

.................. .................. .................. 14.7958 $587.22 $516.61 $117.44 $103.32 

57520 ....... Conization of 

cervix.

.................. .................. .................. 20.5113 $814.05 $630.03 $162.81 $126.01 

57522 ....... Conization of 

cervix.

.................. .................. .................. 28.7410 $1,140.68 $793.34 $228.14 $158.67 

57530 ....... Removal of cervix................... .................. .................. 28.7410 $1,140.68 $825.34 $228.14 $165.07 

57550 ....... Removal of residual cervix................... .................. .................. 28.7410 $1,140.68 $825.34 $228.14 $165.07 

57556 ....... Remove cervix, 

repair bowel.

.................. .................. .................. 42.8756 $1,701.65 $1,209.33 $340.33 $241.87 

57700 ....... Revision of cervix................... .................. .................. 20.5113 $814.05 $573.53 $162.81 $114.71 

57720 ....... Revision of cervix................... .................. .................. 20.5113 $814.05 $662.03 $162.81 $132.41 

57800 ....... Dilation of cervical canal.Y .............. Y .............. Y .............. 0.6280 $24.92 $24.92 $4.98 $4.98 

57820 ....... D& c of residual 

cervix.

.................. .................. .................. 17.7635 $705.00 $607.50 $141.00 $121.50 

58100 ....... Biopsy of uterus 

lining.

Y .............. Y .............. Y .............. 1.0495 $41.65 $41.65 $8.33 $8.33 

58110 ....... Bx done w/colposcopy addon.Y .............. Y .............. Y .............. 0.4041 $16.04 $16.04 $3.21 $3.21 

58120 ....... Dilation and 

curettage.

.................. .................. .................. 17.7635 $705.00 $575.50 $141.00 $115.10 

58145 ....... Myomectomy 

vag method.

.................. .................. .................. 28.7410 $1,140.68 $928.84 $228.14 $185.77 

58301 ....... Remove intrauterine device.Y .............. Y .............. Y .............. 1.0140 $40.24 $40.24 $8.05 $8.05 

58321 ....... Artificial insemination.Y .............. Y .............. Y .............. 0.9178 $36.42 $36.42 $7.28 $7.28 

58322 ....... Artificial insemination.Y .............. Y .............. Y .............. 0.9612 $38.15 $38.15 $7.63 $7.63 

58323 ....... Sperm washing Y .............. Y .............. Y .............. 0.2946 $11.69 $11.69 $2.34 $2.34 

58345 ....... Reopen fallopian tube.Y .............. Y .............. Y .............. 1.9449 $77.19 $77.19 $15.44 $15.44 


sroberts on PROD1PC70 with PROPOSALS
49930 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

58346 ....... Insert heyman 

uteri capsule.

.................. .................. .................. 14.7958 $587.22 $516.61 $117.44 $103.32 

58350 ....... Reopen fallopian tube................... .................. .................. 28.7410 $1,140.68 $825.34 $228.14 $165.07 

58353 ....... Endometr ablate, thermal................... .................. .................. 28.7410 $1,140.68 $885.34 $228.14 $177.07 

58356 ....... Endometrial 

cryoablation.

Y .............. Y .............. .................. 42.8756 $1,701.65 $1,701.65 $340.33 $340.33 

58545 ....... Laparoscopic 

myomectomy.

.................. .................. .................. 31.9353 $1,267.45 $1,303.23 $253.49 $260.65 

58546 ....... Laparomyomectomy, 

complex.

.................. .................. .................. 43.5124 $1,726.92 $1,532.96 $345.38 $306.59 

58550 ....... Laparo-asst vag 

hysterectomy.

.................. .................. .................. 70.8854 $2,813.31 $2,076.15 $562.66 $415.23 

58552 ....... Laparo-vag hyst 

incl t/o.

Y .............. .................. .................. 43.5124 $1,726.92 $1,726.92 $345.38 $345.38 

58555 ....... Hysteroscopy, 

dx, sep proc.

.................. .................. .................. 21.4199 $850.11 $591.56 $170.02 $118.31 

58558 ....... Hysteroscopy, 

biopsy.

.................. .................. .................. 21.4199 $850.11 $680.06 $170.02 $136.01 

58559 ....... Hysteroscopy, 

lysis.

.................. .................. .................. 21.4199 $850.11 $648.06 $170.02 $129.61 

58560 ....... Hysteroscopy, 

resect septum.

.................. .................. .................. 33.3029 $1,321.73 $915.86 $264.35 $183.17 

58561 ....... Hysteroscopy, 

remove 

myoma.

.................. .................. .................. 33.3029 $1,321.73 $915.86 $264.35 $183.17 

58562 ....... Hysteroscopy, 

remove fb.

.................. .................. .................. 21.4199 $850.11 $680.06 $170.02 $136.01 

58563 ....... Hysteroscopy, 

ablation.

.................. .................. .................. 33.3029 $1,321.73 $975.86 $264.35 $195.17 

58565 ....... Hysteroscopy, 

sterilization.

.................. .................. .................. 42.8756 $1,701.65 $1,165.83 $340.33 $233.17 

58600 ....... Division of fallopian tube.Y .............. .................. .................. 28.7410 $1,140.68 $1,140.68 $228.14 $228.14 

58615 ....... Occlude fallopian tube(s).Y .............. .................. .................. 20.5113 $814.05 $814.05 $162.81 $162.81 

58660 ....... Laparoscopy, 

lysis.

.................. .................. .................. 43.5124 $1,726.92 $1,221.96 $345.38 $244.39 

58661 ....... Laparoscopy, 

remove 

adnexa.

.................. .................. .................. 43.5124 $1,726.92 $1,221.96 $345.38 $244.39 

58662 ....... Laparoscopy, 

excise lesions.

.................. .................. .................. 43.5124 $1,726.92 $1,221.96 $345.38 $244.39 

58670 ....... Laparoscopy, 

tubal cautery.

.................. .................. .................. 43.5124 $1,726.92 $1,118.46 $345.38 $223.69 

58671 ....... Laparoscopy, 

tubal block.

.................. .................. .................. 43.5124 $1,726.92 $1,118.46 $345.38 $223.69 

58672 ....... Laparoscopy, 

fimbrioplasty.

.................. .................. .................. 43.5124 $1,726.92 $1,221.96 $345.38 $244.39 

58673 ....... Laparoscopy, 

salpingostomy.

.................. .................. .................. 43.5124 $1,726.92 $1,221.96 $345.38 $244.39 

58800 ....... Drainage of 

ovarian 

cyst(s).

.................. .................. .................. 14.7958 $587.22 $548.61 $117.44 $109.72 

58820 ....... Drain ovary abscess, open................... .................. .................. 28.7410 $1,140.68 $825.34 $228.14 $165.07 

58900 ....... Biopsy of 

ovary(s).

.................. .................. .................. 14.7958 $587.22 $548.61 $117.44 $109.72 

58970 ....... Retrieval of oocyte................... .................. .................. 4.4108 $175.06 $223.27 $35.01 $44.65 

58974 ....... Transfer of embryo................... .................. .................. 4.4108 $175.06 $223.27 $35.01 $44.65 

58976 ....... Transfer of embryo................... .................. .................. 4.4108 $175.06 $223.27 $35.01 $44.65 

59000 ....... Amniocentesis, 

diagnostic.

Y .............. Y .............. .................. 1.4026 $55.67 $55.67 $11.13 $11.13 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49931 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

59001 ....... Amniocentesis, 

therapeutic.

Y .............. Y .............. Y .............. 1.0624 $42.16 $42.16 $8.43 $8.43 

59012 ....... Fetal cord puncture,prenatal.Y .............. .................. .................. 1.4026 $55.67 $55.67 $11.13 $11.13 

59015 ....... Chorion biopsy Y .............. Y .............. Y .............. 1.2728 $50.52 $50.52 $10.10 $10.10 

59020 ....... Fetal contract 

stress test.

Y .............. Y .............. Y .............. 0.7961 $31.60 $31.60 $6.32 $6.32 

59025 ....... Fetal non-stress 

test.

Y .............. Y .............. Y .............. 0.4581 $18.18 $18.18 $3.64 $3.64 

59070 ....... Transabdom 

amnioinfus w/ 

us.

Y .............. .................. .................. 1.4026 $55.67 $55.67 $11.13 $11.13 

59072 ....... Umbilical cord 

occlud w/us.

Y .............. .................. .................. 1.4026 $55.67 $55.67 $11.13 $11.13 

59076 ....... Fetal shunt 

placement, w/ 

us.

Y .............. .................. .................. 1.4026 $55.67 $55.67 $11.13 $11.13 

59100 ....... Remove uterus 

lesion.

Y .............. Y .............. Y .............. 5.2552 $208.57 $208.57 $41.71 $41.71 

59150 ....... Treat ectopic 

pregnancy.

Y .............. .................. .................. 43.5124 $1,726.92 $1,726.92 $345.38 $345.38 

59151 ....... Treat ectopic 

pregnancy.

Y .............. .................. .................. 43.5124 $1,726.92 $1,726.92 $345.38 $345.38 

59160 ....... D& c after delivery................... .................. .................. 17.7635 $705.00 $607.50 $141.00 $121.50 

59200 ....... Insert cervical 

dilator.

Y .............. Y .............. Y .............. 0.9139 $36.27 $36.27 $7.25 $7.25 

59300 ....... Episiotomy or 

vaginal repair.

Y .............. Y .............. Y .............. 1.8766 $74.48 $74.48 $14.90 $14.90 

59320 ....... Revision of cervix................... .................. .................. 20.5113 $814.05 $573.53 $162.81 $114.71 

59412 ....... Antepartum manipulation.Y .............. .................. .................. 2.8011 $111.17 $111.17 $22.23 $22.23 

59812 ....... Treatment of 

miscarriage.

.................. .................. .................. 18.5251 $735.23 $726.11 $147.05 $145.22 

59820 ....... Care of miscarriage................... .................. .................. 18.5251 $735.23 $726.11 $147.05 $145.22 

59821 ....... Treatment of 

miscarriage.

.................. .................. .................. 18.5251 $735.23 $726.11 $147.05 $145.22 

59840 ....... Abortion ............ .................. .................. .................. 17.2607 $685.04 $701.02 $137.01 $140.20 

59841 ....... Abortion ............ .................. .................. .................. 17.2607 $685.04 $701.02 $137.01 $140.20 

59866 ....... Abortion (mpr) .. Y .............. .................. .................. 1.4026 $55.67 $55.67 $11.13 $11.13 

59870 ....... Evacuate mole 

of uterus.

.................. .................. .................. 18.5251 $735.23 $726.11 $147.05 $145.22 

59871 ....... Remove 

cerclage suture.

.................. .................. .................. 20.5113 $814.05 $765.53 $162.81 $153.11 

60000 ....... Drain thyroid/ 

tongue cyst.

.................. .................. .................. 7.7261 $306.63 $319.82 $61.33 $63.96 

60001 ....... Aspirate/inject 

thyriod cyst.

Y .............. Y .............. Y .............. 1.4633 $58.08 $58.08 $11.62 $11.62 

60100 ....... Biopsy of thyroid.Y .............. Y .............. Y .............. 1.1901 $47.23 $47.23 $9.45 $9.45 

60200 ....... Remove thyroid 

lesion.

.................. .................. .................. 37.1283 $1,473.55 $959.78 $294.71 $191.96 

60280 ....... Remove thyroid 

duct lesion.

.................. .................. .................. 37.1283 $1,473.55 $1,051.78 $294.71 $210.36 

60281 ....... Remove thyroid 

duct lesion.

.................. .................. .................. 37.1283 $1,473.55 $1,051.78 $294.71 $210.36 

61000 ....... Remove cranial 

cavity fluid.

Y .............. Y .............. Y .............. 0.9167 $36.38 $36.38 $7.28 $7.28 

61001 ....... Remove cranial 

cavity fluid.

Y .............. Y .............. Y .............. 0.9655 $38.32 $38.32 $7.66 $7.66 

61020 ....... Remove brain 

cavity fluid.

.................. .................. .................. 3.0383 $120.58 $153.80 $24.12 $30.76 

61026 ....... Injection into 

brain canal.

.................. .................. .................. 3.0383 $120.58 $153.80 $24.12 $30.76 


sroberts on PROD1PC70 with PROPOSALS
49932 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

61050 ....... Remove brain 

canal fluid.

.................. .................. .................. 3.0383 $120.58 $153.80 $24.12 $30.76 

61055 ....... Injection into 

brain canal.

.................. .................. .................. 3.0383 $120.58 $153.80 $24.12 $30.76 

61070 ....... Brain canal 

shunt procedure.

.................. .................. .................. 3.0383 $120.58 $153.80 $24.12 $30.76 

61215 ....... Insert brain-fluid 

device.

.................. .................. .................. 45.6712 $1,812.60 $1,161.30 $362.52 $232.26 

61330 ....... Decompress 

eye socket.

Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

61334 ....... Explore orbit/remove object.Y .............. .................. .................. 37.7719 $1,499.09 $1,499.09 $299.82 $299.82 

61790 ....... Treat trigeminal 

nerve.

.................. .................. .................. 17.7609 $704.90 $607.45 $140.98 $121.49 

61791 ....... Treat trigeminal 

tract.

.................. .................. .................. 5.5439 $220.03 $280.63 $44.01 $56.13 

61795 ....... Brain surgery 

using computer.

Y .............. .................. .................. 5.5005 $218.30 $218.30 $43.66 $43.66 

61880 ....... Revise/remove 

neuroelectrode.

Y .............. .................. .................. 17.1830 $681.96 $681.96 $136.39 $136.39 

61885 ....... Insrt/redo 

neurostim 1 

array.

.................. .................. .................. 175.9328 $6,982.44 $3,714.22 $1,396.49 $742.84 

61886 ....... Implant 

neurostim arrays.

.................. .................. .................. 235.5774 $9,349.62 $4,929.81 $1,869.92 $985.96 

61888 ....... Revise/remove 

neuroreceiver.

.................. .................. .................. 33.9521 $1,347.49 $840.25 $269.50 $168.05 

62194 ....... Replace/irrigate 

catheter.

.................. .................. .................. 11.5220 $457.29 $395.14 $91.46 $79.03 

62225 ....... Replace/irrigate 

catheter.

.................. .................. .................. 11.5220 $457.29 $395.14 $91.46 $79.03 

62230 ....... Replace/revise 

brain shunt.

.................. .................. .................. 45.6712 $1,812.60 $1,129.30 $362.52 $225.86 

62252 ....... Csf shunt reprogram.Y .............. Y .............. Y .............. 1.1258 $44.68 $44.68 $8.94 $8.94 

62263 ....... Epidural lysis 

mult sessions.

.................. .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

62264 ....... Epidural lysis on 

single day.

.................. .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

62268 ....... Drain spinal 

cord cyst.

.................. .................. .................. 3.0383 $120.58 $153.80 $24.12 $30.76 

62269 ....... Needle biopsy, 

spinal cord.

.................. .................. .................. 6.0729 $241.02 $287.01 $48.20 $57.40 

62270 ....... Spinal fluid tap, 

diagnostic.

.................. .................. .................. 2.2491 $89.26 $113.85 $17.85 $22.77 

62272 ....... Drain cerebro 

spinal fluid.

.................. .................. .................. 2.2491 $89.26 $113.85 $17.85 $22.77 

62273 ....... Inject epidural 

patch.

.................. .................. .................. 5.5439 $220.03 $276.51 $44.01 $55.30 

62280 ....... Treat spinal 

cord lesion.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

62281 ....... Treat spinal 

cord lesion.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

62282 ....... Treat spinal 

canal lesion.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

62287 ....... Percutaneous 

diskectomy.

.................. .................. .................. 33.3035 $1,321.75 $1,330.38 $264.35 $266.08 

62292 ....... Injection into 

disk lesion.

Y .............. .................. .................. 3.0383 $120.58 $120.58 $24.12 $24.12 

62294 ....... Injection into 

spinal artery.

.................. .................. .................. 3.0383 $120.58 $153.80 $24.12 $30.76 

62310 ....... Inject spine c/t .. .................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

62311 ....... Inject spine l/s 

(cd).

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49933 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

62318 ....... Inject spine w/ 

cath, c/t.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

62319 ....... Inject spine w/ 

cath l/s (cd).

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

62350 ....... Implant spinal 

canal cath.

.................. .................. .................. 29.2931 $1,162.59 $804.29 $232.52 $160.86 

62355 ....... Remove spinal 

canal catheter.

.................. .................. .................. 12.4432 $493.85 $469.92 $98.77 $93.98 

62360 ....... Insert spine infusion device................... .................. .................. 112.0147 $4,445.65 $2,445.82 $889.13 $489.16 

62361 ....... Implant spine 

infusion pump.

.................. .................. .................. 183.1974 $7,270.75 $3,858.38 $1,454.15 $771.68 

62362 ....... Implant spine 

infusion pump.

.................. .................. .................. 183.1974 $7,270.75 $3,858.38 $1,454.15 $771.68 

62365 ....... Remove spine 

infusion device.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

62367 ....... Analyze spine 

infusion pump.

Y .............. Y .............. Y .............. 0.4369 $17.34 $17.34 $3.47 $3.47 

62368 ....... Analyze spine 

infusion pump.

Y .............. Y .............. Y .............. 0.5519 $21.90 $21.90 $4.38 $4.38 

63600 ....... Remove spinal 

cord lesion.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

63610 ....... Stimulation of 

spinal cord.

.................. .................. .................. 17.7609 $704.90 $518.95 $140.98 $103.79 

63615 ....... Remove lesion 

of spinal cord.

Y .............. Y .............. Y .............. 6.2719 $248.92 $248.92 $49.78 $49.78 

63650 ....... Implant 

neuroelectrodes.

.................. .................. .................. 56.3855 $2,237.83 $1,341.92 $447.57 $268.38 

63655 ....... Implant 

neuroelectrodes.

Y .............. .................. .................. 84.2373 $3,343.22 $3,343.22 $668.64 $668.64 

63660 ....... Revise/remove 

neuroelectrode.

.................. .................. .................. 17.1830 $681.96 $507.48 $136.39 $101.50 

63685 ....... Insrt/redo spine 

n generator.

.................. .................. .................. 178.1307 $7,069.67 $3,757.83 $1,413.93 $751.57 

63688 ....... Revise/remove 

neuroreceiver.

.................. .................. .................. 33.9521 $1,347.49 $840.25 $269.50 $168.05 

63744 ....... Revision of spinal shunt................... .................. .................. 36.1603 $1,435.13 $972.57 $287.03 $194.51 

63746 ....... Removal of spinal shunt................... .................. .................. 10.9541 $434.75 $440.37 $86.95 $88.07 

64400 ....... N block inj, 

trigeminal.

Y .............. Y .............. Y .............. 1.4194 $56.33 $56.33 $11.27 $11.27 

64402 ....... N block inj, facial.Y .............. Y .............. Y .............. 1.3219 $52.46 $52.46 $10.49 $10.49 

64405 ....... N block inj, occipital.Y .............. Y .............. Y .............. 1.1245 $44.63 $44.63 $8.93 $8.93 

64408 ....... N block inj, 

vagus.

Y .............. Y .............. Y .............. 1.3388 $53.13 $53.13 $10.63 $10.63 

64410 ....... Nblock inj, 

phrenic.

.................. .................. .................. 5.5439 $220.03 $276.51 $44.01 $55.30 

64412 ....... N block inj, spinal accessor.Y .............. Y .............. Y .............. 2.0074 $79.67 $79.67 $15.93 $15.93 

64413 ....... N block inj, cervical plexus.Y .............. Y .............. Y .............. 1.3483 $53.51 $53.51 $10.70 $10.70 

64415 ....... Nblock inj, 

brachial plexus.

.................. .................. .................. 2.2491 $89.26 $113.85 $17.85 $22.77 

64416 ....... N block cont infuse, b plex.Y .............. .................. .................. 2.2491 $89.26 $89.26 $17.85 $17.85 

64417 ....... Nblock inj, axillary................... .................. .................. 2.2491 $89.26 $113.85 $17.85 $22.77 

64418 ....... N block inj, 

suprascapular.

Y .............. Y .............. Y .............. 1.9395 $76.98 $76.98 $15.40 $15.40 


sroberts on PROD1PC70 with PROPOSALS
49934 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

64420 ....... Nblock inj, 

intercost, sng.

.................. .................. .................. 2.2491 $89.26 $113.85 $17.85 $22.77 

64421 ....... Nblock inj, 

intercost, mlt.

.................. .................. .................. 5.5439 $220.03 $276.51 $44.01 $55.30 

64425 ....... N block inj ilioing/hypogi.Y .............. Y .............. Y .............. 1.2794 $50.78 $50.78 $10.16 $10.16 

64430 ....... Nblock inj, pudendal................... .................. .................. 2.2491 $89.26 $113.85 $17.85 $22.77 

64435 ....... N block inj, 

paracervical.

Y .............. Y .............. Y .............. 1.9447 $77.18 $77.18 $15.44 $15.44 

64445 ....... Injection for 

nerve block.

Y .............. Y .............. Y .............. 1.8559 $73.66 $73.66 $14.73 $14.73 

64450 ....... N block, other 

peripheral.

Y .............. Y .............. Y .............. 1.0671 $42.35 $42.35 $8.47 $8.47 

64470 ....... Inj paravertebral 

c/t.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64472 ....... Inj paravertebral 

c/t add-on.

.................. .................. .................. 5.5439 $220.03 $276.51 $44.01 $55.30 

64475 ....... Inj paravertebral 

l/s.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64476 ....... Inj paravertebral 

l/s add-on.

.................. .................. .................. 5.5439 $220.03 $276.51 $44.01 $55.30 

64479 ....... Inj foramen epidural c/t................... .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64480 ....... Inj foramen epidural add-on................... .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64483 ....... Inj foramen epidural l/s................... .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64484 ....... Inj foramen epidural add-on................... .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64505 ....... N block, 

spenopalatine 

gangl.

Y .............. Y .............. Y .............. 1.0101 $40.09 $40.09 $8.02 $8.02 

64508 ....... N block, carotid 

sinus s/p.

Y .............. Y .............. Y .............. 2.2491 $89.26 $89.26 $17.85 $17.85 

64510 ....... Nblock, stellate 

ganglion.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64517 ....... Nblock inj, 

hypogas plxs.

.................. .................. .................. 2.2491 $89.26 $113.85 $17.85 $22.77 

64520 ....... Nblock, lumbar/ 

thoracic.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64530 ....... Nblock inj, celiac pelus................... .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64553 ....... Implant 

neuroelectrodes.

.................. .................. .................. 234.1628 $9,293.47 $4,813.24 $1,858.69 $962.65 

64555 ....... Implant 

neuroelectrodes.

Y .............. Y .............. Y .............. 2.4298 $96.44 $96.44 $19.29 $19.29 

64560 ....... Implant 

neuroelectrodes.

Y .............. .................. .................. 56.3855 $2,237.83 $2,237.83 $447.57 $447.57 

64561 ....... Implant 

neuroelectrodes.

.................. .................. .................. 56.3855 $2,237.83 $1,373.92 $447.57 $274.78 

64565 ....... Implant 

neuroelectrodes.

Y .............. Y .............. Y .............. 2.4267 $96.31 $96.31 $19.26 $19.26 

64573 ....... Implant 

neuroelectrodes.

.................. .................. .................. 234.1628 $9,293.47 $4,813.24 $1,858.69 $962.65 

64575 ....... Implant 

neuroelectrodes.

.................. .................. .................. 84.2373 $3,343.22 $1,838.11 $668.64 $367.62 

64577 ....... Implant 

neuroelectrodes.

.................. .................. .................. 84.2373 $3,343.22 $1,838.11 $668.64 $367.62 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49935 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

64580 ....... Implant 

neuroelectrodes.

.................. .................. .................. 84.2373 $3,343.22 $1,838.11 $668.64 $367.62 

64581 ....... Implant 

neuroelectrodes.

.................. .................. .................. 84.2373 $3,343.22 $1,926.61 $668.64 $385.32 

64585 ....... Revise/remove 

neuroelectrode.

.................. .................. .................. 17.1830 $681.96 $507.48 $136.39 $101.50 

64590 ....... Insrt/redo perph 

n generator.

.................. .................. .................. 178.1307 $7,069.67 $3,757.83 $1,413.93 $751.57 

64595 ....... Revise/remove 

neuroreceiver.

.................. .................. .................. 33.9521 $1,347.49 $840.25 $269.50 $168.05 

64600 ....... Injection treatment of nerve................... .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

64605 ....... Injection treatment of nerve................... .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

64610 ....... Injection treatment of nerve................... .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

64612 ....... Destroy nerve, 

face muscle.

Y .............. Y .............. Y .............. 1.7396 $69.04 $69.04 $13.81 $13.81 

64613 ....... Destroy nerve, 

spine muscle.

Y .............. Y .............. Y .............. 1.8356 $72.85 $72.85 $14.57 $14.57 

64614 ....... Destroy nerve, 

extrem musc.

Y .............. Y .............. Y .............. 2.0569 $81.63 $81.63 $16.33 $16.33 

64620 ....... Injection treatment of nerve................... .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

64622 ....... Destr 

paravertebrl 

nerve l/s.

.................. .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

64623 ....... Destr 

paravertebral 

n add-on.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64626 ....... Destr 

paravertebrl 

nerve c/t.

.................. .................. .................. 12.4432 $493.85 $413.42 $98.77 $82.68 

64627 ....... Destr 

paravertebral 

n add-on.

.................. .................. .................. 6.3788 $253.16 $293.08 $50.63 $58.62 

64630 ....... Injection treatment of nerve................... .................. .................. 5.5439 $220.03 $280.63 $44.01 $56.13 

64640 ....... Injection treatment of nerve.Y .............. Y .............. Y .............. 2.8054 $111.34 $111.34 $22.27 $22.27 

64650 ....... Chemodenerv 

eccrine 

glands.

Y .............. .................. .................. 2.2491 $89.26 $89.26 $17.85 $17.85 

64653 ....... Chemodenerv 

eccrine 

glands.

Y .............. .................. .................. 2.2491 $89.26 $89.26 $17.85 $17.85 

64680 ....... Injection treatment of nerve................... .................. .................. 6.3788 $253.16 $322.89 $50.63 $64.58 

64681 ....... Injection treatment of nerve................... .................. .................. 12.4432 $493.85 $469.92 $98.77 $93.98 

64702 ....... Revise finger/ 

toe nerve.

.................. .................. .................. 17.7609 $704.90 $518.95 $140.98 $103.79 

64704 ....... Revise hand/ 

foot nerve.

.................. .................. .................. 17.7609 $704.90 $518.95 $140.98 $103.79 

64708 ....... Revise arm/leg 

nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64712 ....... Revision of sciatic nerve................... .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64713 ....... Revision of arm 

nerve(s).

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64714 ....... Revise low back 

nerve(s).

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64716 ....... Revision of cranial nerve................... .................. .................. 17.7609 $704.90 $607.45 $140.98 $121.49 


sroberts on PROD1PC70 with PROPOSALS
49936 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

64718 ....... Revise ulnar 

nerve at 

elbow.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64719 ....... Revise ulnar 

nerve at wrist.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64721 ....... Carpal tunnel 

surgery.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64722 ....... Relieve pressure on 

nerve(s).

.................. .................. .................. 17.7609 $704.90 $518.95 $140.98 $103.79 

64726 ....... Release foot/toe 

nerve.

.................. .................. .................. 17.7609 $704.90 $518.95 $140.98 $103.79 

64727 ....... Internal nerve 

revision.

.................. .................. .................. 17.7609 $704.90 $518.95 $140.98 $103.79 

64732 ....... Incision of brow 

nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64734 ....... Incision of 

cheek nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64736 ....... Incision of chin 

nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64738 ....... Incision of jaw 

nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64740 ....... Incision of 

tongue nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64742 ....... Incision of facial 

nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64744 ....... Incise nerve, 

back of head.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64746 ....... Incise diaphragm nerve................... .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64761 ....... Incision of pelvis nerve.Y .............. .................. .................. 17.7609 $704.90 $704.90 $140.98 $140.98 

64763 ....... Incise hip/thigh 

nerve.

Y .............. .................. .................. 17.7609 $704.90 $704.90 $140.98 $140.98 

64766 ....... Incise hip/thigh 

nerve.

Y .............. .................. .................. 33.3035 $1,321.75 $1,321.75 $264.35 $264.35 

64771 ....... Sever cranial 

nerve.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64772 ....... Incision of spinal nerve................... .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64774 ....... Remove skin 

nerve lesion.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64776 ....... Remove digit 

nerve lesion.

.................. .................. .................. 17.7609 $704.90 $607.45 $140.98 $121.49 

64778 ....... Digit nerve surgery add-on................... .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64782 ....... Remove limb 

nerve lesion.

.................. .................. .................. 17.7609 $704.90 $607.45 $140.98 $121.49 

64783 ....... Limb nerve surgery add-on................... .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64784 ....... Remove nerve 

lesion.

.................. .................. .................. 17.7609 $704.90 $607.45 $140.98 $121.49 

64786 ....... Remove sciatic 

nerve lesion.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64787 ....... Implant nerve 

end.

.................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64788 ....... Remove skin 

nerve lesion.

.................. .................. .................. 17.7609 $704.90 $607.45 $140.98 $121.49 

64790 ....... Removal of 

nerve lesion.

.................. .................. .................. 17.7609 $704.90 $607.45 $140.98 $121.49 

64792 ....... Removal of 

nerve lesion.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64795 ....... Biopsy of nerve .................. .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64802 ....... Remove sympathetic nerves................... .................. .................. 17.7609 $704.90 $575.45 $140.98 $115.09 

64820 ....... Remove sympathetic nerves.Y .............. .................. .................. 17.7609 $704.90 $704.90 $140.98 $140.98 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49937 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

64821 ....... Remove sympathetic nerves................... .................. .................. 25.8425 $1,025.64 $827.82 $205.13 $165.56 

64822 ....... Remove sympathetic nerves.Y .............. .................. .................. 25.8425 $1,025.64 $1,025.64 $205.13 $205.13 

64823 ....... Remove sympathetic nerves.Y .............. .................. .................. 25.8425 $1,025.64 $1,025.64 $205.13 $205.13 

64831 ....... Repair of digit 

nerve.

.................. .................. .................. 33.3035 $1,321.75 $975.88 $264.35 $195.18 

64832 ....... Repair nerve 

add-on.

.................. .................. .................. 33.3035 $1,321.75 $827.38 $264.35 $165.48 

64834 ....... Repair of hand 

or foot nerve.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64835 ....... Repair of hand 

or foot nerve.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64836 ....... Repair of hand 

or foot nerve.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64837 ....... Repair nerve 

add-on.

.................. .................. .................. 33.3035 $1,321.75 $827.38 $264.35 $165.48 

64840 ....... Repair of leg 

nerve.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64856 ....... Repair/transpose nerve................... .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64857 ....... Repair arm/leg 

nerve.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64858 ....... Repair sciatic 

nerve.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64859 ....... Nerve surgery .. .................. .................. .................. 33.3035 $1,321.75 $827.38 $264.35 $165.48 

64861 ....... Repair of arm 

nerves.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64862 ....... Repair of low 

back nerves.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64864 ....... Repair of facial 

nerve.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64865 ....... Repair of facial 

nerve.

.................. .................. .................. 33.3035 $1,321.75 $975.88 $264.35 $195.18 

64870 ....... Fusion of facial/ 

other nerve.

.................. .................. .................. 33.3035 $1,321.75 $975.88 $264.35 $195.18 

64872 ....... Subsequent repair of nerve................... .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64874 ....... Repair & revise 

nerve add-on.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64876 ....... Repair nerve/ 

shorten bone.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64885 ....... Nerve graft, 

head or neck.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64886 ....... Nerve graft, 

head or neck.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64890 ....... Nerve graft, 

hand or foot.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64891 ....... Nerve graft, 

hand or foot.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64892 ....... Nerve graft, arm 

or leg.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64893 ....... Nerve graft, arm 

or leg.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64895 ....... Nerve graft, 

hand or foot.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64896 ....... Nerve graft, 

hand or foot.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64897 ....... Nerve graft, arm 

or leg.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64898 ....... Nerve graft, arm 

or leg.

.................. .................. .................. 33.3035 $1,321.75 $915.88 $264.35 $183.18 

64901 ....... Nerve graft addon................... .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64902 ....... Nerve graft addon................... .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 


sroberts on PROD1PC70 with PROPOSALS
49938 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

64905 ....... Nerve pedicle 

transfer.

.................. .................. .................. 33.3035 $1,321.75 $883.88 $264.35 $176.78 

64907 ....... Nerve pedicle 

transfer.

.................. .................. .................. 33.3035 $1,321.75 $827.38 $264.35 $165.48 

65091 ....... Revise eye ....... .................. .................. .................. 35.5217 $1,409.79 $959.89 $281.96 $191.98 

65093 ....... Revise eye with 

implant.

.................. .................. .................. 35.5217 $1,409.79 $959.89 $281.96 $191.98 

65101 ....... Removal of eye .................. .................. .................. 35.5217 $1,409.79 $959.89 $281.96 $191.98 

65103 ....... Remove eye/insert implant................... .................. .................. 35.5217 $1,409.79 $959.89 $281.96 $191.98 

65105 ....... Remove eye/attach implant................... .................. .................. 35.5217 $1,409.79 $1,019.89 $281.96 $203.98 

65110 ....... Removal of eye .................. .................. .................. 35.5217 $1,409.79 $1,063.39 $281.96 $212.68 

65112 ....... Remove eye/revise socket................... .................. .................. 35.5217 $1,409.79 $1,202.39 $281.96 $240.48 

65114 ....... Remove eye/revise socket................... .................. .................. 35.5217 $1,409.79 $1,202.39 $281.96 $240.48 

65125 ....... Revise ocular 

implant.

Y .............. .................. .................. 17.0126 $675.20 $675.20 $135.04 $135.04 

65130 ....... Insert ocular implant................... .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

65135 ....... Insert ocular implant................... .................. .................. 24.8502 $986.26 $716.13 $197.25 $143.23 

65140 ....... Attach ocular 

implant.

.................. .................. .................. 35.5217 $1,409.79 $959.89 $281.96 $191.98 

65150 ....... Revise ocular 

implant.

.................. .................. .................. 24.8502 $986.26 $716.13 $197.25 $143.23 

65155 ....... Reinsert ocular 

implant.

.................. .................. .................. 35.5217 $1,409.79 $959.89 $281.96 $191.98 

65175 ....... Removal of ocular implant................... .................. .................. 17.0126 $675.20 $504.10 $135.04 $100.82 

65205 ....... Remove foreign 

body from 

eye.

Y .............. Y .............. Y .............. 0.5328 $21.15 $21.15 $4.23 $4.23 

65210 ....... Remove foreign 

body from 

eye.

Y .............. Y .............. Y .............. 0.6756 $26.81 $26.81 $5.36 $5.36 

65220 ....... Remove foreign 

body from 

eye.

Y .............. .................. .................. 1.2244 $48.59 $48.59 $9.72 $9.72 

65222 ....... Remove foreign 

body from 

eye.

Y .............. Y .............. Y .............. 0.7394 $29.35 $29.35 $5.87 $5.87 

65235 ....... Remove foreign 

body from 

eye.

.................. .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

65260 ....... Remove foreign 

body from 

eye.

.................. .................. .................. 16.3433 $648.63 $579.32 $129.73 $115.86 

65265 ....... Remove foreign 

body from 

eye.

.................. .................. .................. 26.9305 $1,068.82 $849.41 $213.76 $169.88 

65270 ....... Repair of eye 

wound.

.................. .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

65272 ....... Repair of eye 

wound.

.................. .................. .................. 22.9479 $910.76 $678.38 $182.15 $135.68 

65275 ....... Repair of eye 

wound.

.................. .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

65280 ....... Repair of eye 

wound.

.................. .................. .................. 16.3433 $648.63 $639.32 $129.73 $127.86 

65285 ....... Repair of eye 

wound.

.................. .................. .................. 36.8820 $1,463.78 $1,046.89 $292.76 $209.38 

65286 ....... Repair of eye 

wound.

Y .............. Y .............. .................. 5.9800 $237.33 $237.33 $47.47 $47.47 

65290 ....... Repair of eye 

socket wound.

.................. .................. .................. 21.2885 $844.90 $677.45 $168.98 $135.49 

65400 ....... Removal of eye 

lesion.

.................. .................. .................. 14.9969 $595.20 $464.10 $119.04 $92.82 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49939 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

65410 ....... Biopsy of cornea................... .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

65420 ....... Removal of eye 

lesion.

.................. .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

65426 ....... Removal of eye 

lesion.

.................. .................. .................. 22.9479 $910.76 $813.88 $182.15 $162.78 

65430 ....... Corneal smear Y .............. Y .............. Y .............. 1.0593 $42.04 $42.04 $8.41 $8.41 

65435 ....... Curette/treat 

cornea.

Y .............. Y .............. Y .............. 0.8260 $32.78 $32.78 $6.56 $6.56 

65436 ....... Curette/treat 

cornea.

Y .............. .................. .................. 14.9969 $595.20 $595.20 $119.04 $119.04 

65450 ....... Treatment of 

corneal lesion.

Y .............. .................. .................. 2.1934 $87.05 $87.05 $17.41 $17.41 

65600 ....... Revision of cornea.Y .............. Y .............. Y .............. 4.1704 $165.51 $165.51 $33.10 $33.10 

65710 ....... Corneal transplant................... .................. .................. 37.9446 $1,505.95 $1,250.47 $301.19 $250.09 

65730 ....... Corneal transplant................... .................. .................. 37.9446 $1,505.95 $1,250.47 $301.19 $250.09 

65750 ....... Corneal transplant................... .................. .................. 37.9446 $1,505.95 $1,250.47 $301.19 $250.09 

65755 ....... Corneal transplant................... .................. .................. 37.9446 $1,505.95 $1,250.47 $301.19 $250.09 

65770 ....... Revise cornea 

with implant.

.................. .................. .................. 50.6347 $2,009.59 $1,502.30 $401.92 $300.46 

65772 ....... Correction of 

astigmatism.

.................. .................. .................. 14.9969 $595.20 $612.60 $119.04 $122.52 

65775 ....... Correction of 

astigmatism.

.................. .................. .................. 14.9969 $595.20 $612.60 $119.04 $122.52 

65780 ....... Ocular reconst, 

transplant.

.................. .................. .................. 37.9446 $1,505.95 $1,111.47 $301.19 $222.29 

65781 ....... Ocular reconst, 

transplant.

.................. .................. .................. 37.9446 $1,505.95 $1,111.47 $301.19 $222.29 

65782 ....... Ocular reconst, 

transplant.

.................. .................. .................. 37.9446 $1,505.95 $1,111.47 $301.19 $222.29 

65800 ....... Drainage of eye .................. .................. .................. 14.9969 $595.20 $464.10 $119.04 $92.82 

65805 ....... Drainage of eye .................. .................. .................. 14.9969 $595.20 $464.10 $119.04 $92.82 

65810 ....... Drainage of eye .................. .................. .................. 22.9479 $910.76 $710.38 $182.15 $142.08 

65815 ....... Drainage of eye .................. .................. .................. 22.9479 $910.76 $678.38 $182.15 $135.68 

65820 ....... Relieve inner 

eye pressure.

.................. .................. .................. 5.9800 $237.33 $285.17 $47.47 $57.03 

65850 ....... Incision of eye .. .................. .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

65855 ....... Laser surgery of 

eye.

Y .............. Y .............. Y .............. 3.4882 $138.44 $138.44 $27.69 $27.69 

65860 ....... Incise inner eye 

adhesions.

Y .............. Y .............. Y .............. 3.2701 $129.78 $129.78 $25.96 $25.96 

65865 ....... Incise inner eye 

adhesions.

.................. .................. .................. 14.9969 $595.20 $464.10 $119.04 $92.82 

65870 ....... Incise inner eye 

adhesions.

.................. .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

65875 ....... Incise inner eye 

adhesions.

.................. .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

65880 ....... Incise inner eye 

adhesions.

.................. .................. .................. 14.9969 $595.20 $612.60 $119.04 $122.52 

65900 ....... Remove eye lesion................... .................. .................. 14.9969 $595.20 $656.10 $119.04 $131.22 

65920 ....... Remove implant 

of eye.

.................. .................. .................. 22.9479 $910.76 $952.88 $182.15 $190.58 

65930 ....... Remove blood 

clot from eye.

.................. .................. .................. 22.9479 $910.76 $813.88 $182.15 $162.78 

66020 ....... Injection treatment of eye................... .................. .................. 14.9969 $595.20 $464.10 $119.04 $92.82 

66030 ....... Injection treatment of eye................... .................. .................. 5.9800 $237.33 $285.17 $47.47 $57.03 

66130 ....... Remove eye lesion................... .................. .................. 22.9479 $910.76 $952.88 $182.15 $190.58 

66150 ....... Glaucoma surgery................... .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 


sroberts on PROD1PC70 with PROPOSALS
49940 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

66155 ....... Glaucoma surgery................... .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

66160 ....... Glaucoma surgery................... .................. .................. 22.9479 $910.76 $678.38 $182.15 $135.68 

66165 ....... Glaucoma surgery................... .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

66170 ....... Glaucoma surgery................... .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

66172 ....... Incision of eye .. .................. .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

66180 ....... Implant eye 

shunt.

.................. .................. .................. 37.3057 $1,480.59 $1,098.80 $296.12 $219.76 

66185 ....... Revise eye 

shunt.

.................. .................. .................. 37.3057 $1,480.59 $963.30 $296.12 $192.66 

66220 ....... Repair eye lesion................... .................. .................. 36.8820 $1,463.78 $986.89 $292.76 $197.38 

66225 ....... Repair/graft eye 

lesion.

.................. .................. .................. 37.3057 $1,480.59 $1,055.30 $296.12 $211.06 

66250 ....... Follow-up surgery of eye................... .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

66500 ....... Incision of iris ... .................. .................. .................. 5.9800 $237.33 $285.17 $47.47 $57.03 

66505 ....... Incision of iris ... .................. .................. .................. 5.9800 $237.33 $285.17 $47.47 $57.03 

66600 ....... Remove iris and 

lesion.

.................. .................. .................. 22.9479 $910.76 $710.38 $182.15 $142.08 

66605 ....... Removal of iris .................. .................. .................. 22.9479 $910.76 $710.38 $182.15 $142.08 

66625 ....... Removal of iris .................. .................. .................. 5.9800 $237.33 $302.70 $47.47 $60.54 

66630 ....... Removal of iris .................. .................. .................. 22.9479 $910.76 $710.38 $182.15 $142.08 

66635 ....... Removal of iris .................. .................. .................. 22.9479 $910.76 $710.38 $182.15 $142.08 

66680 ....... Repair iris & ciliary body................... .................. .................. 22.9479 $910.76 $710.38 $182.15 $142.08 

66682 ....... Repair iris & ciliary body................... .................. .................. 22.9479 $910.76 $678.38 $182.15 $135.68 

66700 ....... Destruction, ciliary body................... .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

66710 ....... Ciliary 

transsleral 

therapy.

.................. .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

66711 ....... Ciliary 

endoscopic 

ablation.

.................. .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

66720 ....... Destruction, ciliary body................... .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

66740 ....... Destruction, ciliary body................... .................. .................. 22.9479 $910.76 $678.38 $182.15 $135.68 

66761 ....... Revision of iris Y .............. Y .............. Y .............. 4.6821 $185.82 $185.82 $37.16 $37.16 

66762 ....... Revision of iris Y .............. Y .............. Y .............. 4.7458 $188.35 $188.35 $37.67 $37.67 

66770 ....... Removal of 

inner eye lesion.

Y .............. Y .............. Y .............. 5.1266 $203.46 $203.46 $40.69 $40.69 

66820 ....... Incision, secondary cataract.Y .............. .................. .................. 5.9800 $237.33 $237.33 $47.47 $47.47 

66821 ....... After cataract 

laser surgery.

.................. .................. .................. 5.1266 $203.46 $259.51 $40.69 $51.90 

66825 ....... Reposition intraocular lens................... .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

66830 ....... Removal of lens 

lesion.

.................. .................. .................. 5.9800 $237.33 $302.70 $47.47 $60.54 

66840 ....... Removal of lens 

material.

.................. .................. .................. 14.5427 $577.17 $603.59 $115.43 $120.72 

66850 ....... Removal of lens 

material.

.................. .................. .................. 28.5043 $1,131.28 $1,063.14 $226.26 $212.63 

66852 ....... Removal of lens 

material.

.................. .................. .................. 28.5043 $1,131.28 $880.64 $226.26 $176.13 

66920 ....... Extraction of 

lens.

.................. .................. .................. 28.5043 $1,131.28 $880.64 $226.26 $176.13 

66930 ....... Extraction of 

lens.

.................. .................. .................. 28.5043 $1,131.28 $924.14 $226.26 $184.83 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49941 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

66940 ....... Extraction of 

lens.

.................. .................. .................. 14.5427 $577.17 $647.09 $115.43 $129.42 

66982 ....... Cataract surgery, complex................... .................. .................. 23.5664 $935.31 $954.15 $187.06 $190.83 

66983 ....... Cataract surg w/ 

iol, 1 stage.

.................. .................. .................. 23.5664 $935.31 $954.15 $187.06 $190.83 

66984 ....... Cataract surg w/ 

iol, 1 stage.

.................. .................. .................. 23.5664 $935.31 $954.15 $187.06 $190.83 

66985 ....... Insert lens prosthesis................... .................. .................. 23.5664 $935.31 $880.65 $187.06 $176.13 

66986 ....... Exchange lens 

prosthesis.

.................. .................. .................. 23.5664 $935.31 $880.65 $187.06 $176.13 

67005 ....... Partial removal 

of eye fluid.

.................. .................. .................. 26.9305 $1,068.82 $849.41 $213.76 $169.88 

67010 ....... Partial removal 

of eye fluid.

.................. .................. .................. 26.9305 $1,068.82 $849.41 $213.76 $169.88 

67015 ....... Release of eye 

fluid.

.................. .................. .................. 26.9305 $1,068.82 $700.91 $213.76 $140.18 

67025 ....... Replace eye 

fluid.

.................. .................. .................. 26.9305 $1,068.82 $700.91 $213.76 $140.18 

67027 ....... Implant eye 

drug system.

.................. .................. .................. 36.8820 $1,463.78 $1,046.89 $292.76 $209.38 

67028 ....... Injection eye 

drug.

Y .............. Y .............. Y .............. 2.1499 $85.32 $85.32 $17.06 $17.06 

67030 ....... Incise inner eye 

strands.

.................. .................. .................. 16.3433 $648.63 $490.82 $129.73 $98.16 

67031 ....... Laser surgery, 

eye strands.

.................. .................. .................. 5.1266 $203.46 $259.51 $40.69 $51.90 

67036 ....... Removal of 

inner eye fluid.

.................. .................. .................. 36.8820 $1,463.78 $1,046.89 $292.76 $209.38 

67038 ....... Strip retinal 

membrane.

.................. .................. .................. 36.8820 $1,463.78 $1,090.39 $292.76 $218.08 

67039 ....... Laser treatment 

of retina.

.................. .................. .................. 36.8820 $1,463.78 $1,229.39 $292.76 $245.88 

67040 ....... Laser treatment 

of retina.

.................. .................. .................. 36.8820 $1,463.78 $1,229.39 $292.76 $245.88 

67101 ....... Repair detached 

retina.

Y .............. Y .............. Y .............. 7.7847 $308.96 $308.96 $61.79 $61.79 

67105 ....... Repair detached 

retina.

Y .............. Y .............. .................. 5.0285 $199.57 $199.57 $39.91 $39.91 

67107 ....... Repair detached 

retina.

.................. .................. .................. 36.8820 $1,463.78 $1,090.39 $292.76 $218.08 

67108 ....... Repair detached 

retina.

.................. .................. .................. 36.8820 $1,463.78 $1,229.39 $292.76 $245.88 

67110 ....... Repair detached 

retina.

Y .............. Y .............. Y .............. 8.4635 $335.90 $335.90 $67.18 $67.18 

67112 ....... Rerepair detached retina................... .................. .................. 36.8820 $1,463.78 $1,229.39 $292.76 $245.88 

67115 ....... Release encircling material................... .................. .................. 16.3433 $648.63 $547.32 $129.73 $109.46 

67120 ....... Remove eye implant material................... .................. .................. 16.3433 $648.63 $547.32 $129.73 $109.46 

67121 ....... Remove eye implant material................... .................. .................. 26.9305 $1,068.82 $757.41 $213.76 $151.48 

67141 ....... Treatment of 

retina.

.................. .................. .................. 4.0750 $161.73 $206.27 $32.35 $41.25 

67145 ....... Treatment of 

retina.

Y .............. Y .............. Y .............. 4.8836 $193.82 $193.82 $38.76 $38.76 

67208 ....... Treatment of 

retinal lesion.

Y .............. Y .............. Y .............. 5.2064 $206.63 $206.63 $41.33 $41.33 

67210 ....... Treatment of 

retinal lesion.

Y .............. Y .............. .................. 5.0285 $199.57 $199.57 $39.91 $39.91 

67218 ....... Treatment of 

retinal lesion.

.................. .................. .................. 16.3433 $648.63 $682.82 $129.73 $136.56 

67220 ....... Treatment of 

choroid lesion.

Y .............. Y .............. .................. 4.0750 $161.73 $161.73 $32.35 $32.35 


sroberts on PROD1PC70 with PROPOSALS
49942 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

67221 ....... Ocular 

photodynamic 

ther.

Y .............. Y .............. Y .............. 3.3107 $131.39 $131.39 $26.28 $26.28 

67225 ....... Eye 

photodynamic 

ther add-on.

Y .............. Y .............. Y .............. 0.2131 $8.46 $8.46 $1.69 $1.69 

67227 ....... Treatment of 

retinal lesion.

.................. .................. .................. 26.9305 $1,068.82 $700.91 $213.76 $140.18 

67228 ....... Treatment of 

retinal lesion.

Y .............. Y .............. .................. 5.0285 $199.57 $199.57 $39.91 $39.91 

67250 ....... Reinforce eye 

wall.

.................. .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

67255 ....... Reinforce/graft 

eye wall.

.................. .................. .................. 26.9305 $1,068.82 $789.41 $213.76 $157.88 

67311 ....... Revise eye 

muscle.

.................. .................. .................. 21.2885 $844.90 $677.45 $168.98 $135.49 

67312 ....... Revise two eye 

muscles.

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67314 ....... Revise eye 

muscle.

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67316 ....... Revise two eye 

muscles.

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67318 ....... Revise eye 

muscle(s).

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67320 ....... Revise eye 

muscle(s) 

add-on.

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67331 ....... Eye surgery follow-up add-on................... .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67332 ....... Rerevise eye 

muscles addon.

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67334 ....... Revise eye 

muscle w/suture.

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67335 ....... Eye suture during surgery................... .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67340 ....... Revise eye 

muscle addon.

.................. .................. .................. 21.2885 $844.90 $737.45 $168.98 $147.49 

67343 ....... Release eye tissue................... .................. .................. 21.2885 $844.90 $919.95 $168.98 $183.99 

67345 ....... Destroy nerve 

of eye muscle.

Y .............. Y .............. Y .............. 2.1183 $84.07 $84.07 $16.81 $16.81 

67350 ....... Biopsy eye 

muscle.

.................. .................. .................. 13.9509 $553.68 $443.34 $110.74 $88.67 

67400 ....... Explore/biopsy 

eye socket.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

67405 ....... Explore/drain 

eye socket.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

67412 ....... Explore/treat 

eye socket.

.................. .................. .................. 24.8502 $986.26 $851.63 $197.25 $170.33 

67413 ....... Explore/treat 

eye socket.

.................. .................. .................. 24.8502 $986.26 $851.63 $197.25 $170.33 

67414 ....... Explr/decompress eye 

socket.

Y .............. .................. .................. 35.5217 $1,409.79 $1,409.79 $281.96 $281.96 

67415 ....... Aspiration, orbital contents................... .................. .................. 17.0126 $675.20 $504.10 $135.04 $100.82 

67420 ....... Explore/treat 

eye socket.

.................. .................. .................. 35.5217 $1,409.79 $1,063.39 $281.96 $212.68 

67430 ....... Explore/treat 

eye socket.

.................. .................. .................. 35.5217 $1,409.79 $1,063.39 $281.96 $212.68 

67440 ....... Explore/drain 

eye socket.

.................. .................. .................. 35.5217 $1,409.79 $1,063.39 $281.96 $212.68 

67445 ....... Explr/decompress eye 

socket.

.................. .................. .................. 35.5217 $1,409.79 $1,063.39 $281.96 $212.68 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49943 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

67450 ....... Explore/biopsy 

eye socket.

.................. .................. .................. 35.5217 $1,409.79 $1,063.39 $281.96 $212.68 

67500 ....... Inject/treat eye 

socket.

Y .............. .................. .................. 2.1934 $87.05 $87.05 $17.41 $17.41 

67505 ....... Inject/treat eye 

socket.

Y .............. .................. .................. 2.8099 $111.52 $111.52 $22.30 $22.30 

67515 ....... Inject/treat eye 

socket.

Y .............. Y .............. Y .............. 0.6151 $24.41 $24.41 $4.88 $4.88 

67550 ....... Insert eye socket implant................... .................. .................. 35.5217 $1,409.79 $1,019.89 $281.96 $203.98 

67560 ....... Revise eye 

socket implant.

.................. .................. .................. 24.8502 $986.26 $716.13 $197.25 $143.23 

67570 ....... Decompress 

optic nerve.

.................. .................. .................. 35.5217 $1,409.79 $1,019.89 $281.96 $203.98 

67700 ....... Drainage of 

eyelid abscess.

Y .............. Y .............. .................. 2.8099 $111.52 $111.52 $22.30 $22.30 

67710 ....... Incision of eyelid.Y .............. Y .............. Y .............. 4.0013 $158.80 $158.80 $31.76 $31.76 

67715 ....... Incision of eyelid fold................... .................. .................. 17.0126 $675.20 $504.10 $135.04 $100.82 

67800 ....... Remove eyelid 

lesion.

Y .............. Y .............. Y .............. 1.3373 $53.08 $53.08 $10.62 $10.62 

67801 ....... Remove eyelid 

lesions.

Y .............. Y .............. Y .............. 1.6194 $64.27 $64.27 $12.85 $12.85 

67805 ....... Remove eyelid 

lesions.

Y .............. Y .............. Y .............. 2.0923 $83.04 $83.04 $16.61 $16.61 

67808 ....... Remove eyelid 

lesion(s).

.................. .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

67810 ....... Biopsy of eyelid Y .............. Y .............. .................. 2.8099 $111.52 $111.52 $22.30 $22.30 

67820 ....... Revise eyelashes.Y .............. Y .............. Y .............. 0.4905 $19.47 $19.47 $3.89 $3.89 

67825 ....... Revise eyelashes.Y .............. Y .............. Y .............. 1.3893 $55.14 $55.14 $11.03 $11.03 

67830 ....... Revise eyelashes................... .................. .................. 6.9354 $275.25 $351.07 $55.05 $70.21 

67835 ....... Revise eyelashes................... .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

67840 ....... Remove eyelid 

lesion.

Y .............. Y .............. Y .............. 4.1405 $164.33 $164.33 $32.87 $32.87 

67850 ....... Treat eyelid lesion.Y .............. Y .............. Y .............. 2.9051 $115.30 $115.30 $23.06 $23.06 

67875 ....... Closure of eyelid by suture.Y .............. .................. .................. 6.9354 $275.25 $275.25 $55.05 $55.05 

67880 ....... Revision of eyelid................... .................. .................. 14.9969 $595.20 $552.60 $119.04 $110.52 

67882 ....... Revision of eyelid................... .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

67900 ....... Repair brow defect................... .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67901 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $696.10 $135.04 $139.22 

67902 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $696.10 $135.04 $139.22 

67903 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67904 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67906 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $696.10 $135.04 $139.22 

67908 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67909 ....... Revise eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67911 ....... Revise eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 


sroberts on PROD1PC70 with PROPOSALS
49944 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

67912 ....... Correction eyelid w/implant................... .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

67914 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

67915 ....... Repair eyelid 

defect.

Y .............. Y .............. Y .............. 4.5979 $182.48 $182.48 $36.50 $36.50 

67916 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67917 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67921 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

67922 ....... Repair eyelid 

defect.

Y .............. Y .............. Y .............. 4.5261 $179.63 $179.63 $35.93 $35.93 

67923 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67924 ....... Repair eyelid 

defect.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

67930 ....... Repair eyelid 

wound.

Y .............. Y .............. Y .............. 4.4580 $176.93 $176.93 $35.39 $35.39 

67935 ....... Repair eyelid 

wound.

.................. .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

67938 ....... Remove eyelid 

foreign body.

Y .............. Y .............. .................. 1.2244 $48.59 $48.59 $9.72 $9.72 

67950 ....... Revision of eyelid................... .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

67961 ....... Revision of eyelid................... .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

67966 ....... Revision of eyelid................... .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

67971 ....... Reconstruction 

of eyelid.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

67973 ....... Reconstruction 

of eyelid.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

67974 ....... Reconstruction 

of eyelid.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

67975 ....... Reconstruction 

of eyelid.

.................. .................. .................. 17.0126 $675.20 $592.60 $135.04 $118.52 

68020 ....... Incise/drain eyelid lining.Y .............. Y .............. Y .............. 1.1738 $46.59 $46.59 $9.32 $9.32 

68040 ....... Treatment of 

eyelid lesions.

Y .............. Y .............. Y .............. 0.5826 $23.12 $23.12 $4.62 $4.62 

68100 ....... Biopsy of eyelid 

lining.

Y .............. Y .............. Y .............. 2.4727 $98.14 $98.14 $19.63 $19.63 

68110 ....... Remove eyelid 

lining lesion.

Y .............. Y .............. Y .............. 3.1702 $125.82 $125.82 $25.16 $25.16 

68115 ....... Remove eyelid 

lining lesion.

.................. .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

68130 ....... Remove eyelid 

lining lesion.

.................. .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

68135 ....... Remove eyelid 

lining lesion.

Y .............. Y .............. Y .............. 1.5122 $60.01 $60.01 $12.00 $12.00 

68200 ....... Treat eyelid by 

injection.

Y .............. Y .............. Y .............. 0.4396 $17.45 $17.45 $3.49 $3.49 

68320 ....... Revise/graft 

eyelid lining.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

68325 ....... Revise/graft 

eyelid lining.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

68326 ....... Revise/graft 

eyelid lining.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

68328 ....... Revise/graft 

eyelid lining.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

68330 ....... Revise eyelid 

lining.

.................. .................. .................. 22.9479 $910.76 $770.38 $182.15 $154.08 

68335 ....... Revise/graft 

eyelid lining.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

68340 ....... Separate eyelid 

adhesions.

.................. .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49945 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

68360 ....... Revise eyelid 

lining.

.................. .................. .................. 22.9479 $910.76 $678.38 $182.15 $135.68 

68362 ....... Revise eyelid 

lining.

.................. .................. .................. 22.9479 $910.76 $678.38 $182.15 $135.68 

68371 ....... Harvest eye tissue, alograft................... .................. .................. 14.9969 $595.20 $520.60 $119.04 $104.12 

68400 ....... Incise/drain tear 

gland.

Y .............. Y .............. .................. 2.8099 $111.52 $111.52 $22.30 $22.30 

68420 ....... Incise/drain tear 

sac.

Y .............. Y .............. Y .............. 4.7254 $187.54 $187.54 $37.51 $37.51 

68440 ....... Incise tear duct 

opening.

Y .............. Y .............. Y .............. 1.4355 $56.97 $56.97 $11.39 $11.39 

68500 ....... Removal of tear 

gland.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

68505 ....... Partial removal, 

tear gland.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

68510 ....... Biopsy of tear 

gland.

.................. .................. .................. 17.0126 $675.20 $504.10 $135.04 $100.82 

68520 ....... Removal of tear 

sac.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

68525 ....... Biopsy of tear 

sac.

.................. .................. .................. 17.0126 $675.20 $504.10 $135.04 $100.82 

68530 ....... Clearance of 

tear duct.

Y .............. Y .............. Y .............. 6.0445 $239.89 $239.89 $47.98 $47.98 

68540 ....... Remove tear 

gland lesion.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

68550 ....... Remove tear 

gland lesion.

.................. .................. .................. 24.8502 $986.26 $748.13 $197.25 $149.63 

68700 ....... Repair tear 

ducts.

.................. .................. .................. 24.8502 $986.26 $716.13 $197.25 $143.23 

68705 ....... Revise tear duct 

opening.

Y .............. Y .............. .................. 2.8099 $111.52 $111.52 $22.30 $22.30 

68720 ....... Create tear sac 

drain.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

68745 ....... Create tear duct 

drain.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

68750 ....... Create tear duct 

drain.

.................. .................. .................. 24.8502 $986.26 $808.13 $197.25 $161.63 

68760 ....... Close tear duct 

opening.

Y .............. Y .............. .................. 2.1934 $87.05 $87.05 $17.41 $17.41 

68761 ....... Close tear duct 

opening.

Y .............. Y .............. Y .............. 1.8117 $71.90 $71.90 $14.38 $14.38 

68770 ....... Close tear system fistula................... .................. .................. 17.0126 $675.20 $652.60 $135.04 $130.52 

68801 ....... Dilate tear duct 

opening.

Y .............. Y .............. .................. 1.2244 $48.59 $48.59 $9.72 $9.72 

68810 ....... Probe 

nasolacrimal 

duct.

.................. .................. .................. 2.1934 $87.05 $111.03 $17.41 $22.21 

68811 ....... Probe 

nasolacrimal 

duct.

.................. .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

68815 ....... Probe 

nasolacrimal 

duct.

.................. .................. .................. 17.0126 $675.20 $560.60 $135.04 $112.12 

68840 ....... Explore/irrigate 

tear ducts.

Y .............. Y .............. .................. 1.2244 $48.59 $48.59 $9.72 $9.72 

69000 ....... Drain external 

ear lesion.

Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

69005 ....... Drain external 

ear lesion.

Y .............. Y .............. Y .............. 2.4802 $98.44 $98.44 $19.69 $19.69 

69020 ....... Drain outer ear 

canal lesion.

Y .............. Y .............. .................. 1.4821 $58.82 $58.82 $11.76 $11.76 

69100 ....... Biopsy of external ear.Y .............. Y .............. Y .............. 1.5436 $61.26 $61.26 $12.25 $12.25 

69105 ....... Biopsy of external ear canal.Y .............. Y .............. Y .............. 2.1216 $84.20 $84.20 $16.84 $16.84 


sroberts on PROD1PC70 with PROPOSALS
49946 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

69110 ....... Remove external ear, partial................... .................. .................. 14.9563 $593.59 $463.29 $118.72 $92.66 

69120 ....... Removal of external ear................... .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

69140 ....... Remove ear 

canal lesion(s).

.................. .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

69145 ....... Remove ear 

canal lesion(s).

.................. .................. .................. 14.9563 $593.59 $519.79 $118.72 $103.96 

69150 ....... Extensive ear 

canal surgery.

.................. .................. .................. 7.7261 $306.63 $391.09 $61.33 $78.22 

69200 ....... Clear outer ear 

canal.

Y .............. Y .............. .................. 0.6211 $24.65 $24.65 $4.93 $4.93 

69205 ....... Clear outer ear 

canal.

.................. .................. .................. 19.9760 $792.81 $562.90 $158.56 $112.58 

69210 ....... Remove impacted ear 

wax.

Y .............. Y .............. Y .............. 0.5077 $20.15 $20.15 $4.03 $4.03 

69220 ....... Clean out mastoid cavity.Y .............. Y .............. .................. 0.8076 $32.05 $32.05 $6.41 $6.41 

69222 ....... Clean out mastoid cavity.Y .............. Y .............. Y .............. 3.3054 $131.19 $131.19 $26.24 $26.24 

69300 ....... Revise external 

ear.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

69310 ....... Rebuild outer 

ear canal.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

69320 ....... Rebuild outer 

ear canal.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69400 ....... Inflate middle 

ear canal.

Y .............. Y .............. Y .............. 2.1026 $83.45 $83.45 $16.69 $16.69 

69401 ....... Inflate middle 

ear canal.

Y .............. Y .............. Y .............. 1.1906 $47.25 $47.25 $9.45 $9.45 

69405 ....... Catheterize middle ear canal.Y .............. Y .............. Y .............. 3.0530 $121.17 $121.17 $24.23 $24.23 

69420 ....... Incision of eardrum.Y .............. Y .............. .................. 2.3768 $94.33 $94.33 $18.87 $18.87 

69421 ....... Incision of eardrum................... .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

69424 ....... Remove ventilating tube.Y .............. Y .............. Y .............. 1.9136 $75.95 $75.95 $15.19 $15.19 

69433 ....... Create eardrum 

opening.

Y .............. Y .............. Y .............. 2.7076 $107.46 $107.46 $21.49 $21.49 

69436 ....... Create eardrum 

opening.

.................. .................. .................. 16.4494 $652.85 $581.42 $130.57 $116.28 

69440 ....... Exploration of 

middle ear.

.................. .................. .................. 23.1564 $919.03 $714.52 $183.81 $142.90 

69450 ....... Eardrum revision................... .................. .................. 37.7719 $1,499.09 $916.05 $299.82 $183.21 

69501 ....... Mastoidectomy .................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69502 ....... Mastoidectomy .................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

69505 ....... Remove mastoid structures................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69511 ....... Extensive mastoid surgery................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69530 ....... Extensive mastoid surgery................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69540 ....... Remove ear lesion.Y .............. Y .............. Y .............. 3.2334 $128.33 $128.33 $25.67 $25.67 

69550 ....... Remove ear lesion................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69552 ....... Remove ear lesion................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69601 ....... Mastoid surgery 

revision.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69602 ....... Mastoid surgery 

revision.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49947 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

69603 ....... Mastoid surgery 

revision.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69604 ....... Mastoid surgery 

revision.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69605 ....... Mastoid surgery 

revision.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69610 ....... Repair of eardrum.Y .............. Y .............. Y .............. 4.4163 $175.28 $175.28 $35.06 $35.06 

69620 ....... Repair of eardrum................... .................. .................. 23.1564 $919.03 $682.52 $183.81 $136.50 

69631 ....... Repair eardrum 

structures.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69632 ....... Rebuild eardrum structures................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69633 ....... Rebuild eardrum structures................... .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69635 ....... Repair eardrum 

structures.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69636 ....... Rebuild eardrum structures................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69637 ....... Rebuild eardrum structures................... .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69641 ....... Revise middle 

ear & mastoid.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69642 ....... Revise middle 

ear & mastoid.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69643 ....... Revise middle 

ear & mastoid.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69644 ....... Revise middle 

ear & mastoid.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69645 ....... Revise middle 

ear & mastoid.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69646 ....... Revise middle 

ear & mastoid.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69650 ....... Release middle 

ear bone.

.................. .................. .................. 23.1564 $919.03 $957.02 $183.81 $191.40 

69660 ....... Revise middle 

ear bone.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69661 ....... Revise middle 

ear bone.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69662 ....... Revise middle 

ear bone.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69666 ....... Repair middle 

ear structures.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

69667 ....... Repair middle 

ear structures.

.................. .................. .................. 37.7719 $1,499.09 $1,064.55 $299.82 $212.91 

69670 ....... Remove mastoid air cells................... .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

69676 ....... Remove middle 

ear nerve.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

69700 ....... Close mastoid 

fistula.

.................. .................. .................. 37.7719 $1,499.09 $1,004.55 $299.82 $200.91 

69711 ....... Remove/repair 

hearing aid.

.................. .................. .................. 37.7719 $1,499.09 $916.05 $299.82 $183.21 

69714 ....... Implant temple 

bone w/stimul.

.................. .................. .................. 37.7719 $1,499.09 $1,419.05 $299.82 $283.81 

69715 ....... Temple bne 

implnt w/ 

stimulat.

.................. .................. .................. 37.7719 $1,499.09 $1,419.05 $299.82 $283.81 

69717 ....... Temple bone 

implant revision.

.................. .................. .................. 37.7719 $1,499.09 $1,419.05 $299.82 $283.81 

69718 ....... Revise temple 

bone implant.

.................. .................. .................. 37.7719 $1,499.09 $1,419.05 $299.82 $283.81 


sroberts on PROD1PC70 with PROPOSALS
49948 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM BB.—PROPOSED LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2008 WITH ADDITIONS AND

PAYMENT RATES—Continued 

HCPCS Short Description 

New 2008 

ASC approved 

procedure 

Designated 

as office 

based 

Payment 

capped at 

MPFS rate 

CY 08 ASC 

relative payment weight 

CY 08 payment without 50/50 

transition 

CY 08 payment with 

50/50 transition 

CY 08 copayment 

without 50/ 

50 transition 

CY 08 copayment 

with 50/50 

transition 

69720 ....... Release facial 

nerve.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69740 ....... Repair facial 

nerve.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69745 ....... Repair facial 

nerve.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69801 ....... Incise inner ear .................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69802 ....... Incise inner ear .................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69805 ....... Explore inner 

ear.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69806 ....... Explore inner 

ear.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69820 ....... Establish inner 

ear window.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69840 ....... Revise inner ear 

window.

.................. .................. .................. 37.7719 $1,499.09 $1,108.05 $299.82 $221.61 

69905 ....... Remove inner 

ear.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69910 ....... Remove inner 

ear & mastoid.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69915 ....... Incise inner ear 

nerve.

.................. .................. .................. 37.7719 $1,499.09 $1,247.05 $299.82 $249.41 

69930 ....... Implant cochlear 

device.

.................. .................. .................. 406.8232 $16,146.03 $8,570.52 $3,229.21 $1,714.10 

G0104 ...... CA screen;flexi 

sigmoidscope.

Y .............. Y .............. .................. 1.7292 $68.63 $68.63 $13.73 $13.73 

G0105 ...... Colorectal scrn; 

hi risk ind.

.................. .................. .................. 7.8134 $310.10 $378.05 $62.02 $75.61 

G0121 ...... Colon ca scrn; 

not high rsk.

.................. .................. .................. 7.8134 $310.10 $378.05 $62.02 $75.61 

G0127 ...... Trim nail(s) ....... Y .............. Y .............. .................. 0.2665 $10.58 $10.58 $2.12 $2.12 

G0186 ...... Dstry eye 

lesn,fdr vssl 

tech.

Y .............. Y .............. .................. 4.0750 $161.73 $161.73 $32.35 $32.35 

G0260 ...... Inj for sacroiliac 

jt anesth.

.................. .................. .................. 5.5439 $220.03 $276.51 $44.01 $55.30 

G0268 ...... Removal of impacted wax 

md.

Y .............. Y .............. .................. 0.5409 $21.47 $21.47 $4.29 $4.29 

G0364 ...... Bone marrow 

aspirate & 

biops.

Y .............. Y .............. .................. 0.1293 $5.13 $5.13 $1.03 $1.03 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT 

HCPCS Short Description 

10021 ....... Fna w/o image 

10040 ....... Acne surgery 

10060 ....... Drainage of skin abscess 

10061 ....... Drainage of skin abscess 

10080 ....... Drainage of pilonidal cyst 

10081 ....... Drainage of pilonidal cyst 

10120 ....... Remove foreign body 

10140 ....... Drainage of hematoma/fluid 

10160 ....... Puncture drainage of lesion 

11000 ....... Debride infected skin 

11001 ....... Debride infected skin add-on 

11040 ....... Debride skin, partial 

11041 ....... Debride skin, full 

11055 ....... Trim skin lesion 

11056 ....... Trim skin lesions, 2 to 4 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

11057 ....... Trim skin lesions, over 4 

11100 ....... Biopsy, skin lesion 

11101 ....... Biopsy, skin add-on 

11200 ....... Removal of skin tags 

11201 ....... Remove skin tags add-on 

11300 ....... Shave skin lesion 

11301 ....... Shave skin lesion 

11302 ....... Shave skin lesion 

11303 ....... Shave skin lesion 

11305 ....... Shave skin lesion 

11306 ....... Shave skin lesion 

11307 ....... Shave skin lesion 

11308 ....... Shave skin lesion 

11310 ....... Shave skin lesion 

11311 ....... Shave skin lesion 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

11312 ....... Shave skin lesion 

11313 ....... Shave skin lesion 

11400 ....... Exc tr-ext b9+marg 0.5 < cm 

11401 ....... Exc tr-ext b9+marg 0.6-1 cm 

11402 ....... Exc tr-ext b9+marg 1.1-2 cm 

11403 ....... Exc tr-ext b9+marg 2.1-3 cm 

11420 ....... Exc h-f-nk-sp b9+marg 0.5 > 

11421 ....... Exc h-f-nk-sp b9+marg 0.6-1 

11422 ....... Exc h-f-nk-sp b9+marg 1.1-2 

11423 ....... Exc h-f-nk-sp b9+marg 2.1-3 

11440 ....... Exc face-mm b9+marg 0.5 < cm 

11441 ....... Exc face-mm b9+marg 0.6-1 cm 

11442 ....... Exc face-mm b9+marg 1.1-2 cm 

11443 ....... Exc face-mm b9+marg 2.1-3 cm 

11600 ....... Exc tr-ext mlg+marg 0.5 < cm 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49949 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

11601 ....... Exc tr-ext mlg+marg 0.6-1 cm 

11602 ....... Exc tr-ext mlg+marg 1.1-2 cm 

11603 ....... Exc tr-ext mlg+marg 2.1-3 cm 

11620 ....... Exc h-f-nk-sp mlg+marg 0.5 > 

11621 ....... Exc h-f-nk-sp mlg+marg 0.6-1 

11622 ....... Exc h-f-nk-sp mlg+marg 1.1-2 

11623 ....... Exc h-f-nk-sp mlg+marg 2.1-3 

11640 ....... Exc face-mm malig+marg 0.5 

11641 ....... Exc face-mm malig+marg 0.6-1 

11642 ....... Exc face-mm malig+marg 1.1-2 

11643 ....... Exc face-mm malig+marg 2.1-3 

11719 ....... Trim nail(s) 

11720 ....... Debride nail, 1-5 

11721 ....... Debride nail, 6 or more 

11730 ....... Removal of nail plate 

11732 ....... Remove nail plate, add-on 

11740 ....... Drain blood from under nail 

11750 ....... Removal of nail bed 

11752 ....... Remove nail bed/finger tip 

11755 ....... Biopsy, nail unit 

11762 ....... Reconstruction of nail bed 

11765 ....... Excision of nail fold, toe 

11900 ....... Injection into skin lesions 

11901 ....... Added skin lesions injection 

11920 ....... Correct skin color defects 

11921 ....... Correct skin color defects 

11922 ....... Correct skin color defects 

11950 ....... Therapy for contour defects 

11951 ....... Therapy for contour defects 

11952 ....... Therapy for contour defects 

11954 ....... Therapy for contour defects 

11976 ....... Removal of contraceptive cap 

11980 ....... Implant hormone pellet(s) 

11981 ....... Insert drug implant device 

11982 ....... Remove drug implant device 

11983 ....... Remove/insert drug implant 

12001 ....... Repair superficial wound(s) 

12002 ....... Repair superficial wound(s) 

12004 ....... Repair superficial wound(s) 

12011 ....... Repair superficial wound(s) 

12013 ....... Repair superficial wound(s) 

12014 ....... Repair superficial wound(s) 

12031 ....... Layer closure of wound(s) 

12032 ....... Layer closure of wound(s) 

12041 ....... Layer closure of wound(s) 

12042 ....... Layer closure of wound(s) 

12051 ....... Layer closure of wound(s) 

12052 ....... Layer closure of wound(s) 

12053 ....... Layer closure of wound(s) 

13133 ....... Repair wound/lesion add-on 

15340 ....... Apply cult skin substitute 

15780 ....... Abrasion treatment of skin 

15781 ....... Abrasion treatment of skin 

15782 ....... Abrasion treatment of skin 

15783 ....... Abrasion treatment of skin 

15786 ....... Abrasion, lesion, single 

15787 ....... Abrasion, lesions, add-on 

15788 ....... Chemical peel, face, epiderm 

15789 ....... Chemical peel, face, dermal 

15792 ....... Chemical peel, nonfacial 

15793 ....... Chemical peel, nonfacial 

15851 ....... Removal of sutures 

16000 ....... Initial treatment of burn(s) 

16020 ....... Dress/debrid p-thick burn, s 

17000 ....... Destroy benign/premlg lesion 

17003 ....... Destroy lesions, 2-14 

17004 ....... Destroy lesions, 15 or more 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

17106 ....... Destruction of skin lesions 

17107 ....... Destruction of skin lesions 

17108 ....... Destruction of skin lesions 

17110 ....... Destruct lesion, 1-14 

17111 ....... Destruct lesion, 15 or more 

17250 ....... Chemical cautery, tissue 

17260 ....... Destruction of skin lesions 

17261 ....... Destruction of skin lesions 

17262 ....... Destruction of skin lesions 

17263 ....... Destruction of skin lesions 

17264 ....... Destruction of skin lesions 

17266 ....... Destruction of skin lesions 

17270 ....... Destruction of skin lesions 

17271 ....... Destruction of skin lesions 

17272 ....... Destruction of skin lesions 

17273 ....... Destruction of skin lesions 

17274 ....... Destruction of skin lesions 

17276 ....... Destruction of skin lesions 

17280 ....... Destruction of skin lesions 

17281 ....... Destruction of skin lesions 

17282 ....... Destruction of skin lesions 

17283 ....... Destruction of skin lesions 

17284 ....... Destruction of skin lesions 

17286 ....... Destruction of skin lesions 

17304 ....... 1 stage mohs, up to 5 spec 

17305 ....... 2 stage mohs, up to 5 spec 

17306 ....... 3 stage mohs, up to 5 spec 

17307 ....... Mohs addl stage up to 5 spec 

17310 ....... Mohs any stage > 5 spec each 

17340 ....... Cryotherapy of skin 

17360 ....... Skin peel therapy 

17380 ....... Hair removal by electrolysis 

19000 ....... Drainage of breast lesion 

19001 ....... Drain breast lesion add-on 

20000 ....... Incision of abscess 

20500 ....... Injection of sinus tract 

20520 ....... Removal of foreign body 

20526 ....... Ther injection, carp tunnel 

20550 ....... Inj tendon sheath/ligament 

20551 ....... Inj tendon origin/insertion 

20552 ....... Inj trigger point, 1/2 muscl 

20553 ....... Inject trigger points, =/≤ 3 

20600 ....... Drain/inject, joint/bursa 

20605 ....... Drain/inject, joint/bursa 

20610 ....... Drain/inject, joint/bursa 

20612 ....... Aspirate/inj ganglion cyst 

20615 ....... Treatment of bone cyst 

20662 ....... Application of pelvis brace 

20663 ....... Application of thigh brace 

20973 ....... Bone/skin graft, great toe 

20974 ....... Electrical bone stimulation 

20979 ....... Us bone stimulation 

21030 ....... Excise max/zygoma b9 tumor 

21031 ....... Remove exostosis, mandible 

21032 ....... Remove exostosis, maxilla 

21048 ....... Remove maxilla cyst complex 

21076 ....... Prepare face/oral prosthesis 

21077 ....... Prepare face/oral prosthesis 

21079 ....... Prepare face/oral prosthesis 

21080 ....... Prepare face/oral prosthesis 

21081 ....... Prepare face/oral prosthesis 

21082 ....... Prepare face/oral prosthesis 

21083 ....... Prepare face/oral prosthesis 

21084 ....... Prepare face/oral prosthesis 

21085 ....... Prepare face/oral prosthesis 

21086 ....... Prepare face/oral prosthesis 

21087 ....... Prepare face/oral prosthesis 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

21088 ....... Prepare face/oral prosthesis 

21089 ....... Prepare face/oral prosthesis 

21110 ....... Interdental fixation 

21440 ....... Treat dental ridge fracture 

21920 ....... Biopsy soft tissue of back 

23065 ....... Biopsy shoulder tissues 

23600 ....... Treat humerus fracture 

23620 ....... Treat humerus fracture 

24065 ....... Biopsy arm/elbow soft tissue 

24200 ....... Removal of arm foreign body 

24650 ....... Treat radius fracture 

25065 ....... Biopsy forearm soft tissues 

25500 ....... Treat fracture of radius 

25530 ....... Treat fracture of ulna 

25560 ....... Treat fracture radiusamp; ulna 

25600 ....... Treat fracture radius/ulna 

25622 ....... Treat wrist bone fracture 

25630 ....... Treat wrist bone fracture 

25650 ....... Treat wrist bone fracture 

26010 ....... Drainage of finger abscess 

26600 ....... Treat metacarpal fracture 

26720 ....... Treat finger fracture, each 

26725 ....... Treat finger fracture, each 

26740 ....... Treat finger fracture, each 

26750 ....... Treat finger fracture, each 

27200 ....... Treat tail bone fracture 

27613 ....... Biopsy lower leg soft tissue 

28001 ....... Drainage of bursa of foot 

28010 ....... Incision of toe tendon 

28124 ....... Partial removal of toe 

28190 ....... Removal of foot foreign body 

28220 ....... Release of foot tendon 

28230 ....... Incision of foot tendon(s) 

28232 ....... Incision of toe tendon 

28272 ....... Release of toe joint, each 

28430 ....... Treatment of ankle fracture 

28450 ....... Treat midfoot fracture, each 

28455 ....... Treat midfoot fracture, each 

28470 ....... Treat metatarsal fracture 

28475 ....... Treat metatarsal fracture 

28490 ....... Treat big toe fracture 

28495 ....... Treat big toe fracture 

28510 ....... Treatment of toe fracture 

28515 ....... Treatment of toe fracture 

28530 ....... Treat sesamoid bone fracture 

28540 ....... Treat foot dislocation 

28570 ....... Treat foot dislocation 

28600 ....... Treat foot dislocation 

29010 ....... Application of body cast 

29015 ....... Application of body cast 

29025 ....... Application of body cast 

29049 ....... Application of figure eight 

29055 ....... Application of shoulder cast 

29058 ....... Application of shoulder cast 

29065 ....... Application of long arm cast 

29075 ....... Application of forearm cast 

29085 ....... Apply hand/wrist cast 

29086 ....... Apply finger cast 

29105 ....... Apply long arm splint 

29125 ....... Apply forearm splint 

29126 ....... Apply forearm splint 

29130 ....... Application of finger splint 

29131 ....... Application of finger splint 

29200 ....... Strapping of chest 

29220 ....... Strapping of low back 

29240 ....... Strapping of shoulder 

29260 ....... Strapping of elbow or wrist 


sroberts on PROD1PC70 with PROPOSALS
49950 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

29280 ....... Strapping of hand or finger 

29345 ....... Application of long leg cast 

29355 ....... Application of long leg cast 

29358 ....... Apply long leg cast brace 

29365 ....... Application of long leg cast 

29405 ....... Apply short leg cast 

29425 ....... Apply short leg cast 

29435 ....... Apply short leg cast 

29440 ....... Addition of walker to cast 

29445 ....... Apply rigid leg cast 

29450 ....... Application of leg cast 

29520 ....... Strapping of hip 

29530 ....... Strapping of knee 

29540 ....... Strapping of ankle and/or ft 

29550 ....... Strapping of toes 

29580 ....... Application of paste boot 

29590 ....... Application of foot splint 

29700 ....... Removal/revision of cast 

29705 ....... Removal/revision of cast 

29710 ....... Removal/revision of cast 

29715 ....... Removal/revision of cast 

29720 ....... Repair of body cast 

29730 ....... Windowing of cast 

29740 ....... Wedging of cast 

29750 ....... Wedging of clubfoot cast 

30000 ....... Drainage of nose lesion 

30020 ....... Drainage of nose lesion 

30100 ....... Intranasal biopsy 

30110 ....... Removal of nose polyp(s) 

30124 ....... Removal of nose lesion 

30200 ....... Injection treatment of nose 

30210 ....... Nasal sinus therapy 

30300 ....... Remove nasal foreign body 

30901 ....... Control of nosebleed 

31000 ....... Irrigation, maxillary sinus 

31002 ....... Irrigation, sphenoid sinus 

31040 ....... Exploration behind upper jaw 

31231 ....... Nasal endoscopy, dx 

31505 ....... Diagnostic laryngoscopy 

31575 ....... Diagnostic laryngoscopy 

31579 ....... Diagnostic laryngoscopy 

36425 ....... Vein access cutdown > 1 yr 

36430 ....... Blood transfusion service 

36440 ....... Bl push transfuse, 2 yr or lgt; 

36468 ....... Injection(s), spider veins 

36470 ....... Injection therapy of vein 

36471 ....... Injection therapy of veins 

36550 ....... Declot vascular device 

36598 ....... Inj w/fluor, eval cv device 

37765 ....... Phleb veins - extrem - to 20 

37766 ....... Phleb veins - extrem 20+ 

38220 ....... Bone marrow aspiration 

38221 ....... Bone marrow biopsy 

38242 ....... Lymphocyte infuse transplant 

40490 ....... Biopsy of lip 

40702 ....... Repair cleft lip/nasal 

40800 ....... Drainage of mouth lesion 

40804 ....... Removal, foreign body, mouth 

40805 ....... Removal, foreign body, mouth 

40806 ....... Incision of lip fold 

40808 ....... Biopsy of mouth lesion 

40810 ....... Excision of mouth lesion 

40812 ....... Excise/repair mouth lesion 

40820 ....... Treatment of mouth lesion 

41000 ....... Drainage of mouth lesion 

41100 ....... Biopsy of tongue 

41105 ....... Biopsy of tongue 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

41108 ....... Biopsy of floor of mouth 

41110 ....... Excision of tongue lesion 

41115 ....... Excision of tongue fold 

41805 ....... Removal foreign body, gum 

41806 ....... Removal foreign body,jawbone 

41820 ....... Excision, gum, each quadrant 

41822 ....... Excision of gum lesion 

41823 ....... Excision of gum lesion 

41825 ....... Excision of gum lesion 

41826 ....... Excision of gum lesion 

41828 ....... Excision of gum lesion 

41830 ....... Removal of gum tissue 

41850 ....... Treatment of gum lesion 

41872 ....... Repair gum 

41874 ....... Repair tooth socket 

42100 ....... Biopsy roof of mouth 

42104 ....... Excision lesion, mouth roof 

42106 ....... Excision lesion, mouth roof 

42160 ....... Treatment mouth roof lesion 

42280 ....... Preparation, palate mold 

42330 ....... Removal of salivary stone 

42335 ....... Removal of salivary stone 

42400 ....... Biopsy of salivary gland 

42650 ....... Dilation of salivary duct 

42660 ....... Dilation of salivary duct 

42800 ....... Biopsy of throat 

42970 ....... Control nose/throat bleeding 

45300 ....... Proctosigmoidoscopy dx 

45303 ....... Proctosigmoidoscopy dilate 

45330 ....... Diagnostic sigmoidoscopy 

45520 ....... Treatment of rectal prolapse 

46083 ....... Incise external hemorrhoid 

46221 ....... Ligation of hemorrhoid(s) 

46320 ....... Removal of hemorrhoid clot 

46500 ....... Injection into hemorrhoid(s) 

46600 ....... Diagnostic anoscopy 

46604 ....... Anoscopy and dilation 

46606 ....... Anoscopy and biopsy 

46614 ....... Anoscopy, control bleeding 

46900 ....... Destruction, anal lesion(s) 

46910 ....... Destruction, anal lesion(s) 

46916 ....... Cryosurgery, anal lesion(s) 

46934 ....... Destruction of hemorrhoids 

46935 ....... Destruction of hemorrhoids 

46936 ....... Destruction of hemorrhoids 

46940 ....... Treatment of anal fissure 

46942 ....... Treatment of anal fissure 

46945 ....... Ligation of hemorrhoids 

46946 ....... Ligation of hemorrhoids 

50391 ....... Instll rx agnt into rnal tub 

50686 ....... Measure ureter pressure 

51000 ....... Drainage of bladder 

51005 ....... Drainage of bladder 

51700 ....... Irrigation of bladder 

51701 ....... Insert bladder catheter 

51702 ....... Insert temp bladder cath 

51703 ....... Insert bladder cath, complex 

51705 ....... Change of bladder tube 

51720 ....... Treatment of bladder lesion 

51725 ....... Simple cystometrogram 

51736 ....... Urine flow measurement 

51741 ....... Electro-uroflowmetry, first 

51784 ....... Anal/urinary muscle study 

51792 ....... Urinary reflex study 

51795 ....... Urine voiding pressure study 

51797 ....... Intraabdominal pressure test 

51798 ....... Us urine capacity measure 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

52265 ....... Cystoscopy and treatment 

53025 ....... Incision of urethra 

53060 ....... Drainage of urethra abscess 

53600 ....... Dilate urethra stricture 

53601 ....... Dilate urethra stricture 

53620 ....... Dilate urethra stricture 

53621 ....... Dilate urethra stricture 

53660 ....... Dilation of urethra 

53661 ....... Dilation of urethra 

53850 ....... Prostatic microwave thermotx 

53852 ....... Prostatic rf thermotx 

53853 ....... Prostatic water thermother 

54050 ....... Destruction, penis lesion(s) 

54055 ....... Destruction, penis lesion(s) 

54056 ....... Cryosurgery, penis lesion(s) 

54200 ....... Treatment of penis lesion 

54231 ....... Dynamic cavernosometry 

54235 ....... Penile injection 

54240 ....... Penis study 

54250 ....... Penis study 

55000 ....... Drainage of hydrocele 

55450 ....... Ligation of sperm duct 

55600 ....... Incise sperm duct pouch 

55870 ....... Electroejaculation 

56405 ....... I & D of vulva/perineum 

56420 ....... Drainage of gland abscess 

56501 ....... Destroy, vulva lesions, sim 

56605 ....... Biopsy of vulva/perineum 

56606 ....... Biopsy of vulva/perineum 

56820 ....... Exam of vulva w/scope 

56821 ....... Exam/biopsy of vulva w/scope 

57061 ....... Destroy vag lesions, simple 

57100 ....... Biopsy of vagina 

57150 ....... Treat vagina infection 

57160 ....... Insert pessary/other device 

57170 ....... Fitting of diaphragm/cap 

57420 ....... Exam of vagina w/scope 

57421 ....... Exam/biopsy of vag w/scope 

57452 ....... Exam of cervix w/scope 

57454 ....... Bx/curett of cervix w/scope 

57455 ....... Biopsy of cervix w/scope 

57456 ....... Endocerv curettage w/scope 

57460 ....... Bx of cervix w/scope, leep 

57461 ....... Conz of cervix w/scope, leep 

57500 ....... Biopsy of cervix 

57505 ....... Endocervical curettage 

57510 ....... Cauterization of cervix 

57511 ....... Cryocautery of cervix 

57800 ....... Dilation of cervical canal 

58100 ....... Biopsy of uterus lining 

58110 ....... Bx done w/colposcopy add-on 

58300 ....... Insert intrauterine device 

58301 ....... Remove intrauterine device 

58321 ....... Artificial insemination 

58322 ....... Artificial insemination 

58323 ....... Sperm washing 

58345 ....... Reopen fallopian tube 

58356 ....... Endometrial cryoablation 

59000 ....... Amniocentesis, diagnostic 

59001 ....... Amniocentesis, therapeutic 

59015 ....... Chorion biopsy 

59020 ....... Fetal contract stress test 

59025 ....... Fetal non-stress test 

59100 ....... Remove uterus lesion 

59200 ....... Insert cervical dilator 

59300 ....... Episiotomy or vaginal repair 

60001 ....... Aspirate/inject thyriod cyst 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49951 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

60100 ....... Biopsy of thyroid 

61000 ....... Remove cranial cavity fluid 

61001 ....... Remove cranial cavity fluid 

62252 ....... Csf shunt reprogram 

62367 ....... Analyze spine infusion pump 

62368 ....... Analyze spine infusion pump 

63615 ....... Remove lesion of spinal cord 

64400 ....... N block inj, trigeminal 

64402 ....... N block inj, facial 

64405 ....... N block inj, occipital 

64408 ....... N block inj, vagus 

64412 ....... N block inj, spinal accessor 

64413 ....... N block inj, cervical plexus 

64418 ....... N block inj, suprascapular 

64425 ....... N block inj, ilio-ing/hypogi 

64435 ....... N block inj, paracervical 

64445 ....... N block inj, sciatic, sng 

64450 ....... N block, other peripheral 

64505 ....... N block, spenopalatine gangl 

64508 ....... N block, carotid sinus s/p 

64550 ....... Apply neurostimulator 

64555 ....... Implant neuroelectrodes 

64565 ....... Implant neuroelectrodes 

64612 ....... Destroy nerve, face muscle 

64613 ....... Destroy nerve, neck muscle 

64614 ....... Destroy nerve, extrem musc 

64640 ....... Injection treatment of nerve 

65205 ....... Remove foreign body from eye 

65210 ....... Remove foreign body from eye 

65222 ....... Remove foreign body from eye 

65286 ....... Repair of eye wound 

65430 ....... Corneal smear 

65435 ....... Curette/treat cornea 

65600 ....... Revision of cornea 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

65855 ....... Laser surgery of eye 

65860 ....... Incise inner eye adhesions 

66761 ....... Revision of iris 

66762 ....... Revision of iris 

66770 ....... Removal of inner eye lesion 

67028 ....... Injection eye drug 

67101 ....... Repair detached retina 

67105 ....... Repair detached retina 

67110 ....... Repair detached retina 

67145 ....... Treatment of retina 

67208 ....... Treatment of retinal lesion 

67210 ....... Treatment of retinal lesion 

67220 ....... Treatment of choroid lesion 

67221 ....... Ocular photodynamic ther 

67225 ....... Eye photodynamic ther add-on 

67228 ....... Treatment of retinal lesion 

67345 ....... Destroy nerve of eye muscle 

67515 ....... Inject/treat eye socket 

67700 ....... Drainage of eyelid abscess 

67710 ....... Incision of eyelid 

67800 ....... Remove eyelid lesion 

67801 ....... Remove eyelid lesions 

67805 ....... Remove eyelid lesions 

67810 ....... Biopsy of eyelid 

67820 ....... Revise eyelashes 

67825 ....... Revise eyelashes 

67840 ....... Remove eyelid lesion 

67850 ....... Treat eyelid lesion 

67915 ....... Repair eyelid defect 

67922 ....... Repair eyelid defect 

67930 ....... Repair eyelid wound 

67938 ....... Remove eyelid foreign body 

68020 ....... Incise/drain eyelid lining 

68040 ....... Treatment of eyelid lesions 

ADDENDUM CC.—PROPOSED LIST

OF PROCEDURES FOR CY 2008 

SUBJECT TO PAYMENT LIMITATION

AT THE MPFS NONFACILITY

AMOUNT—Continued 

HCPCS Short Description 

68100 ....... Biopsy of eyelid lining 

68110 ....... Remove eyelid lining lesion 

68135 ....... Remove eyelid lining lesion 

68200 ....... Treat eyelid by injection 

68400 ....... Incise/drain tear gland 

68420 ....... Incise/drain tear sac 

68440 ....... Incise tear duct opening 

68530 ....... Clearance of tear duct 

68705 ....... Revise tear duct opening 

68760 ....... Close tear duct opening 

68761 ....... Close tear duct opening 

68801 ....... Dilate tear duct opening 

68840 ....... Explore/irrigate tear ducts 

69000 ....... Drain external ear lesion 

69005 ....... Drain external ear lesion 

69020 ....... Drain outer ear canal lesion 

69100 ....... Biopsy of external ear 

69105 ....... Biopsy of external ear canal 

69200 ....... Clear outer ear canal 

69210 ....... Remove impacted ear wax 

69220 ....... Clean out mastoid cavity 

69222 ....... Clean out mastoid cavity 

69399 ....... Outer ear surgery procedure 

69400 ....... Inflate middle ear canal 

69401 ....... Inflate middle ear canal 

69405 ....... Catheterize middle ear canal 

69410 ....... Inset middle ear (baffle) 

69420 ....... Incision of eardrum 

69424 ....... Remove ventilating tube 

69433 ....... Create eardrum opening 

69540 ....... Remove ear lesion 

69610 ....... Repair of eardrum 

ADDENDUM D1.—PROPOSED PAYMENT STATUS INDICATORS

Indicator Item/code/service OPPS payment status 

A ................ Services furnished to a hospital outpatient that are paid under a 

fee schedule or payment system other than OPPS, for example: 

• Ambulance Services 

• Clinical Diagnostic Laboratory Services 

• Non-Implantable Prosthetic and Orthotic Devices 

Not paid under OPPS. Paid by fiscal intermediaries under a fee 

schedule or payment system other than OPPS. 

• EPO for ESRD Patients 

• Physical, Occupational, and Speech Therapy 

• Routine Dialysis Services for ESRD Patients Provided in a 

Certified Dialysis Unit of a Hospital 

• Diagnostic Mammography 

• Screening Mammography 

B ................ Codes that are not recognized by OPPS when submitted on an 

outpatient hospital Part B bill type (12x and 13x).

Not paid under OPPS. 

• May be paid by intermediaries when submitted on a different 

bill type, for example, 75x (CORF), but not paid under OPPS. 

• An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x) 

may be available. 

C ................ Inpatient Procedures ..................................................................... Not paid under OPPS. Admit patient. Bill as inpatient. 

D ................ Discontinued Codes ...................................................................... Not paid under OPPS or any other Medicare payment system. 

E ................ Items, Codes, and Services: 

• That are not covered by Medicare based on statutory exclusion 

• That are not covered by Medicare for reasons other than statutory exclusion 

Not paid under OPPS or any other Medicare payment system. 

• That are not recognized by Medicare but for which an alternate code for the same item or service may be available 

• For which separate payment is not provided by Medicare. 


sroberts on PROD1PC70 with PROPOSALS
49952 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM D1.—PROPOSED PAYMENT STATUS INDICATORS—Continued 

Indicator Item/code/service OPPS payment status 

F ................ Corneal Tissue Acquisition; Certain CRNA Services; and Hepatitis B Vaccines.Not paid under OPPS. Paid at reasonable cost. 

G ............... Pass-Through Drugs and Biologicals ........................................... Paid under OPPS; Separate APC payment includes passthrough amount. 

H ................ Pass-Through Device Categories ................................................. Separate cost-based pass-through payment; Not subject to coinsurance. 

K ................ (1) Non-Pass-Through Drugs and Biologicals, and Radiopharmaceutical Agents.(1) Paid under OPPS; Separate APC payment. 

(2) Brachytherapy Sources ........................................................... (2) Paid under OPPS; Separate APC payment. 

(3) Blood and Blood Products ...................................................... (3) Paid under OPPS; Separate APC payment. 

L ................ Influenza Vaccine; Pneumococcal Pneumonia Vaccine .............. Not paid under OPPS. Paid at reasonable cost; Not subject to 

deductible or coinsurance. 

M ............... Items and Services Not Billable to the Fiscal Intermediary ......... Not paid under OPPS. 

N ................ Items and Services Packaged into APC Rates ............................ Paid under OPPS; Payment is packaged into payment for other 

services, including outliers. Therefore, there is no separate 

APC payment. 

P ................ Partial Hospitalization ................................................................... Paid under OPPS; Per diem APC payment. 

Q ............... Packaged Services Subject to Separate Payment Under OPPS 

Payment Criteria.

Paid under OPPS; Addendum B displays APC assignments 

when services are separately payable. 

(1) Separate APC payment based on OPPS payment criteria. 

(2) If criteria are not met, payment is packaged into payment for 

other services, including outliers. Therefore, there is no separate APC payment. 

S ................ Significant Procedure, Not Discounted when Multiple ................. Paid under OPPS; Separate APC payment. 

T ................ Significant Procedure, Multiple Reduction Applies ....................... Paid under OPPS; Separate APC payment.

V ................ Clinic or Emergency Department Visit ......................................... Paid under OPPS; Separate APC payment. 

Y ................ Non-Implantable Durable Medical Equipment .............................. Not paid under OPPS. All institutional providers other than 

home health agencies bill to DMERC. 

X ................ Ancillary Services ......................................................................... Paid under OPPS; Separate APC payment. 

ADDENDUM D2.—PROPOSED COMMENT INDICATORS

Comment 

indicator Descriptor 

NF ............ New code, final APC assignment; Comments were accepted on a proposed APC assignment in the Proposed Rule; APC assignment is no longer open to comment. 

NI ............. New code, interim APC assignment; Comments will be accepted on the interim APC assignment for the new code. 

CH ........... Active HCPCS codes in current year and next calendar year; status indicator and/or APC assignment have changed. 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

00176 .......................................................... Anesth, pharyngeal surgery ............................................................................................. C 

00192 .......................................................... Anesth, facial bone surgery ............................................................................................. C 

00214 .......................................................... Anesth, skull drainage ..................................................................................................... C 

00215 .......................................................... Anesth, skull repair/fract .................................................................................................. C 

00404 .......................................................... Anesth, surgery of breast ................................................................................................ C 

00406 .......................................................... Anesth, surgery of breast ................................................................................................ C 

00452 .......................................................... Anesth, surgery of shoulder ............................................................................................ C 

00474 .......................................................... Anesth, surgery of rib(s) .................................................................................................. C 

00524 .......................................................... Anesth, chest drainage .................................................................................................... C 

00540 .......................................................... Anesth, chest surgery ...................................................................................................... C 

00542 .......................................................... Anesth, release of lung .................................................................................................... C 

00546 .......................................................... Anesth, lung, chest wall surg .......................................................................................... C 

00560 .......................................................... Anesth, heart surg w/o pump .......................................................................................... C 

00561 .......................................................... Anesth, heart surgry < age 1 ........................................................................................... C 

00562 .......................................................... Anesth, heart surg w/pump ............................................................................................. C 

00580 .......................................................... Anesth, heart/lung transplnt ............................................................................................. C 

00604 .......................................................... Anesth, sitting procedure ................................................................................................. C 

00622 .......................................................... Anesth, removal of nerves ............................................................................................... C 

00632 .......................................................... Anesth, removal of nerves ............................................................................................... C 

00670 .......................................................... Anesth, spine, cord surgery ............................................................................................. C 

00792 .......................................................... Anesth, hemorr/excise liver ............................................................................................. C 

00794 .......................................................... Anesth, pancreas removal ............................................................................................... C 

00796 .......................................................... Anesth, for liver transplant ............................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49953 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

00802 .......................................................... Anesth, fat layer removal ................................................................................................. C 

00844 .......................................................... Anesth, pelvis surgery ..................................................................................................... C 

00846 .......................................................... Anesth, hysterectomy ...................................................................................................... C 

00848 .......................................................... Anesth, pelvic organ surg ................................................................................................ C 

00864 .......................................................... Anesth, removal of bladder ............................................................................................. C 

00865 .......................................................... Anesth, removal of prostate ............................................................................................ C 

00866 .......................................................... Anesth, removal of adrenal ............................................................................................. C 

00868 .......................................................... Anesth, kidney transplant ................................................................................................ C 

00882 .......................................................... Anesth, major vein ligation .............................................................................................. C 

00904 .......................................................... Anesth, perineal surgery .................................................................................................. C 

00908 .......................................................... Anesth, removal of prostate ............................................................................................ C 

00932 .......................................................... Anesth, amputation of penis ............................................................................................ C 

00934 .......................................................... Anesth, penis, nodes removal ......................................................................................... C 

00936 .......................................................... Anesth, penis, nodes removal ......................................................................................... C 

00944 .......................................................... Anesth, vaginal hysterectomy .......................................................................................... C 

01140 .......................................................... Anesth, amputation at pelvis ........................................................................................... C 

01150 .......................................................... Anesth, pelvic tumor surgery ........................................................................................... C 

01212 .......................................................... Anesth, hip disarticulation ................................................................................................ C 

01214 .......................................................... Anesth, hip arthroplasty ................................................................................................... C 

01232 .......................................................... Anesth, amputation of femur ........................................................................................... C 

01234 .......................................................... Anesth, radical femur surg .............................................................................................. C 

01272 .......................................................... Anesth, femoral artery surg ............................................................................................. C 

01274 .......................................................... Anesth, femoral embolectomy ......................................................................................... C 

01402 .......................................................... Anesth, knee arthroplasty ................................................................................................ C 

01404 .......................................................... Anesth, amputation at knee ............................................................................................. C 

01442 .......................................................... Anesth, knee artery surg ................................................................................................. C 

01444 .......................................................... Anesth, knee artery repair ............................................................................................... C 

01486 .......................................................... Anesth, ankle replacement .............................................................................................. C 

01502 .......................................................... Anesth, lwr leg embolectomy .......................................................................................... C 

01632 .......................................................... Anesth, surgery of shoulder ............................................................................................ C 

01634 .......................................................... Anesth, shoulder joint amput ........................................................................................... C 

01636 .......................................................... Anesth, forequarter amput ............................................................................................... C 

01638 .......................................................... Anesth, shoulder replacement ......................................................................................... C 

01652 .......................................................... Anesth, shoulder vessel surg .......................................................................................... C 

01654 .......................................................... Anesth, shoulder vessel surg .......................................................................................... C 

01656 .......................................................... Anesth, arm-leg vessel surg ............................................................................................ C 

01756 .......................................................... Anesth, radical humerus surg .......................................................................................... C 

01990 .......................................................... Support for organ donor .................................................................................................. C 

11004 .......................................................... Debride genitalia & perineum .......................................................................................... C 

11005 .......................................................... Debride abdom wall ......................................................................................................... C 

11006 .......................................................... Debride genit/per/abdom wall .......................................................................................... C 

11008 .......................................................... Remove mesh from abd wall ........................................................................................... C 

15756 .......................................................... Free myo/skin flap microvasc .......................................................................................... C 

15757 .......................................................... Free skin flap, microvasc ................................................................................................. C 

15758 .......................................................... Free fascial flap, microvasc ............................................................................................. C 

16036 .......................................................... Escharotomy; add’l incision ............................................................................................. C 

19200 .......................................................... Removal of breast ........................................................................................................... C 

19220 .......................................................... Removal of breast ........................................................................................................... C 

19271 .......................................................... Revision of chest wall ...................................................................................................... C 

19272 .......................................................... Extensive chest wall surgery ........................................................................................... C 

19361 .......................................................... Breast reconstruction ....................................................................................................... C 

19364 .......................................................... Breast reconstruction ....................................................................................................... C 

19367 .......................................................... Breast reconstruction ....................................................................................................... C 

19368 .......................................................... Breast reconstruction ....................................................................................................... C 

19369 .......................................................... Breast reconstruction ....................................................................................................... C 

20660 .......................................................... Apply, rem fixation device ............................................................................................... C 

20661 .......................................................... Application of head brace ................................................................................................ C 

20664 .......................................................... Halo brace application ..................................................................................................... C 

20802 .......................................................... Replantation, arm, complete ............................................................................................ C 

20805 .......................................................... Replant forearm, complete .............................................................................................. C 

20808 .......................................................... Replantation hand, complete ........................................................................................... C 

20816 .......................................................... Replantation digit, complete ............................................................................................ C 

20824 .......................................................... Replantation thumb, complete ......................................................................................... C 

20827 .......................................................... Replantation thumb, complete ......................................................................................... C 

20838 .......................................................... Replantation foot, complete ............................................................................................. C 

20930 .......................................................... Spinal bone allograft ........................................................................................................ C 

20931 .......................................................... Spinal bone allograft ........................................................................................................ C 

20936 .......................................................... Spinal bone autograft ...................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49954 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

20937 .......................................................... Spinal bone autograft ...................................................................................................... C 

20938 .......................................................... Spinal bone autograft ...................................................................................................... C 

20955 .......................................................... Fibula bone graft, microvasc ........................................................................................... C 

20956 .......................................................... Iliac bone graft, microvasc ............................................................................................... C 

20957 .......................................................... Mt bone graft, microvasc ................................................................................................. C 

20962 .......................................................... Other bone graft, microvasc ............................................................................................ C 

20969 .......................................................... Bone/skin graft, microvasc .............................................................................................. C 

20970 .......................................................... Bone/skin graft, iliac crest ............................................................................................... C 

21045 .......................................................... Extensive jaw surgery ...................................................................................................... C 

21141 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21142 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21143 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21145 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21146 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21147 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21151 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21154 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21155 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21159 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21160 .......................................................... Reconstruct midface, lefort .............................................................................................. C 

21172 .......................................................... Reconstruct orbit/forehead .............................................................................................. C 

21179 .......................................................... Reconstruct entire forehead ............................................................................................ C 

21180 .......................................................... Reconstruct entire forehead ............................................................................................ C 

21182 .......................................................... Reconstruct cranial bone ................................................................................................. C 

21183 .......................................................... Reconstruct cranial bone ................................................................................................. C 

21184 .......................................................... Reconstruct cranial bone ................................................................................................. C 

21188 .......................................................... Reconstruction of midface ............................................................................................... C 

21193 .......................................................... Reconst lwr jaw w/o graft ................................................................................................ C 

21194 .......................................................... Reconst lwr jaw w/graft ................................................................................................... C 

21196 .......................................................... Reconst lwr jaw w/fixation ............................................................................................... C 

21247 .......................................................... Reconstruct lower jaw bone ............................................................................................ C 

21255 .......................................................... Reconstruct lower jaw bone ............................................................................................ C 

21256 .......................................................... Reconstruction of orbit ..................................................................................................... C 

21268 .......................................................... Revise eye sockets .......................................................................................................... C 

21343 .......................................................... Treatment of sinus fracture ............................................................................................. C 

21344 .......................................................... Treatment of sinus fracture ............................................................................................. C 

21346 .......................................................... Treat nose/jaw fracture .................................................................................................... C 

21347 .......................................................... Treat nose/jaw fracture .................................................................................................... C 

21348 .......................................................... Treat nose/jaw fracture .................................................................................................... C 

21360 .......................................................... Treat cheek bone fracture ............................................................................................... C 

21365 .......................................................... Treat cheek bone fracture ............................................................................................... C 

21366 .......................................................... Treat cheek bone fracture ............................................................................................... C 

21385 .......................................................... Treat eye socket fracture ................................................................................................. C 

21386 .......................................................... Treat eye socket fracture ................................................................................................. C 

21387 .......................................................... Treat eye socket fracture ................................................................................................. C 

21395 .......................................................... Treat eye socket fracture ................................................................................................. C 

21422 .......................................................... Treat mouth roof fracture ................................................................................................. C 

21423 .......................................................... Treat mouth roof fracture ................................................................................................. C 

21431 .......................................................... Treat craniofacial fracture ................................................................................................ C 

21432 .......................................................... Treat craniofacial fracture ................................................................................................ C 

21433 .......................................................... Treat craniofacial fracture ................................................................................................ C 

21435 .......................................................... Treat craniofacial fracture ................................................................................................ C 

21436 .......................................................... Treat craniofacial fracture ................................................................................................ C 

21510 .......................................................... Drainage of bone lesion .................................................................................................. C 

21615 .......................................................... Removal of rib ................................................................................................................. C 

21616 .......................................................... Removal of rib and nerves .............................................................................................. C 

21620 .......................................................... Partial removal of sternum .............................................................................................. C 

21627 .......................................................... Sternal debridement ........................................................................................................ C 

21630 .......................................................... Extensive sternum surgery .............................................................................................. C 

21632 .......................................................... Extensive sternum surgery .............................................................................................. C 

21705 .......................................................... Revision of neck muscle/rib ............................................................................................. C 

21740 .......................................................... Reconstruction of sternum ............................................................................................... C 

21750 .......................................................... Repair of sternum separation .......................................................................................... C 

21810 .......................................................... Treatment of rib fracture(s) .............................................................................................. C 

21825 .......................................................... Treat sternum fracture ..................................................................................................... C 

22010 .......................................................... I&d, p-spine, c/t/cerv-thor ................................................................................................ C 

22015 .......................................................... I&d, p-spine, l/s/ls ............................................................................................................ C 

22110 .......................................................... Remove part of neck vertebra ......................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49955 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

22112 .......................................................... Remove part, thorax vertebra .......................................................................................... C 

22114 .......................................................... Remove part, lumbar vertebra ......................................................................................... C 

22116 .......................................................... Remove extra spine segment .......................................................................................... C 

22210 .......................................................... Revision of neck spine .................................................................................................... C 

22212 .......................................................... Revision of thorax spine .................................................................................................. C 

22214 .......................................................... Revision of lumbar spine ................................................................................................. C 

22216 .......................................................... Revise, extra spine segment ........................................................................................... C 

22220 .......................................................... Revision of neck spine .................................................................................................... C 

22224 .......................................................... Revision of lumbar spine ................................................................................................. C 

22226 .......................................................... Revise, extra spine segment ........................................................................................... C 

22318 .......................................................... Treat odontoid fx w/o graft .............................................................................................. C 

22319 .......................................................... Treat odontoid fx w/graft .................................................................................................. C 

22325 .......................................................... Treat spine fracture ......................................................................................................... C 

22326 .......................................................... Treat neck spine fracture ................................................................................................. C 

22327 .......................................................... Treat thorax spine fracture .............................................................................................. C 

22328 .......................................................... Treat each add spine fx ................................................................................................... C 

22532 .......................................................... Lat thorax spine fusion .................................................................................................... C 

22533 .......................................................... Lat lumbar spine fusion ................................................................................................... C 

22534 .......................................................... Lat thor/lumb, add’l seg ................................................................................................... C 

22548 .......................................................... Neck spine fusion ............................................................................................................ C 

22554 .......................................................... Neck spine fusion ............................................................................................................ C 

22556 .......................................................... Thorax spine fusion ......................................................................................................... C 

22558 .......................................................... Lumbar spine fusion ........................................................................................................ C 

22585 .......................................................... Additional spinal fusion .................................................................................................... C 

22590 .......................................................... Spine & skull spinal fusion .............................................................................................. C 

22595 .......................................................... Neck spinal fusion ........................................................................................................... C 

22600 .......................................................... Neck spine fusion ............................................................................................................ C 

22610 .......................................................... Thorax spine fusion ......................................................................................................... C 

22630 .......................................................... Lumbar spine fusion ........................................................................................................ C 

22632 .......................................................... Spine fusion, extra segment ............................................................................................ C 

22800 .......................................................... Fusion of spine ................................................................................................................ C 

22802 .......................................................... Fusion of spine ................................................................................................................ C 

22804 .......................................................... Fusion of spine ................................................................................................................ C 

22808 .......................................................... Fusion of spine ................................................................................................................ C 

22810 .......................................................... Fusion of spine ................................................................................................................ C 

22812 .......................................................... Fusion of spine ................................................................................................................ C 

22818 .......................................................... Kyphectomy, 1-2 segments ............................................................................................. C 

22819 .......................................................... Kyphectomy, 3 or more ................................................................................................... C 

22830 .......................................................... Exploration of spinal fusion ............................................................................................. C 

22840 .......................................................... Insert spine fixation device .............................................................................................. C 

22841 .......................................................... Insert spine fixation device .............................................................................................. C 

22842 .......................................................... Insert spine fixation device .............................................................................................. C 

22843 .......................................................... Insert spine fixation device .............................................................................................. C 

22844 .......................................................... Insert spine fixation device .............................................................................................. C 

22845 .......................................................... Insert spine fixation device .............................................................................................. C 

22846 .......................................................... Insert spine fixation device .............................................................................................. C 

22847 .......................................................... Insert spine fixation device .............................................................................................. C 

22848 .......................................................... Insert pelv fixation device ................................................................................................ C 

22849 .......................................................... Reinsert spinal fixation .................................................................................................... C 

22850 .......................................................... Remove spine fixation device .......................................................................................... C 

22851 .......................................................... Apply spine prosth device ............................................................................................... C 

22852 .......................................................... Remove spine fixation device .......................................................................................... C 

22855 .......................................................... Remove spine fixation device .......................................................................................... C 

23200 .......................................................... Removal of collar bone .................................................................................................... C 

23210 .......................................................... Removal of shoulder blade .............................................................................................. C 

23220 .......................................................... Partial removal of humerus ............................................................................................. C 

23221 .......................................................... Partial removal of humerus ............................................................................................. C 

23222 .......................................................... Partial removal of humerus ............................................................................................. C 

23332 .......................................................... Remove shoulder foreign body ....................................................................................... C 

23472 .......................................................... Reconstruct shoulder joint ............................................................................................... C 

23900 .......................................................... Amputation of arm & girdle .............................................................................................. C 

23920 .......................................................... Amputation at shoulder joint ............................................................................................ C 

24900 .......................................................... Amputation of upper arm ................................................................................................. C 

24920 .......................................................... Amputation of upper arm ................................................................................................. C 

24930 .......................................................... Amputation follow-up surgery .......................................................................................... C 

24931 .......................................................... Amputate upper arm & implant ....................................................................................... C 

24940 .......................................................... Revision of upper arm ..................................................................................................... C 

25900 .......................................................... Amputation of forearm ..................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49956 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

25905 .......................................................... Amputation of forearm ..................................................................................................... C 

25909 .......................................................... Amputation follow-up surgery .......................................................................................... C 

25915 .......................................................... Amputation of forearm ..................................................................................................... C 

25920 .......................................................... Amputate hand at wrist .................................................................................................... C 

25924 .......................................................... Amputation follow-up surgery .......................................................................................... C 

25927 .......................................................... Amputation of hand ......................................................................................................... C 

25931 .......................................................... Amputation follow-up surgery .......................................................................................... C 

26551 .......................................................... Great toe-hand transfer ................................................................................................... C 

26553 .......................................................... Single transfer, toe-hand ................................................................................................. C 

26554 .......................................................... Double transfer, toe-hand ................................................................................................ C 

26556 .......................................................... Toe joint transfer .............................................................................................................. C 

26992 .......................................................... Drainage of bone lesion .................................................................................................. C 

27005 .......................................................... Incision of hip tendon ...................................................................................................... C 

27006 .......................................................... Incision of hip tendons ..................................................................................................... C 

27025 .......................................................... Incision of hip/thigh fascia ............................................................................................... C 

27030 .......................................................... Drainage of hip joint ........................................................................................................ C 

27036 .......................................................... Excision of hip joint/muscle ............................................................................................. C 

27054 .......................................................... Removal of hip joint lining ............................................................................................... C 

27070 .......................................................... Partial removal of hip bone ............................................................................................. C 

27071 .......................................................... Partial removal of hip bone ............................................................................................. C 

27075 .......................................................... Extensive hip surgery ...................................................................................................... C 

27076 .......................................................... Extensive hip surgery ...................................................................................................... C 

27077 .......................................................... Extensive hip surgery ...................................................................................................... C 

27078 .......................................................... Extensive hip surgery ...................................................................................................... C 

27079 .......................................................... Extensive hip surgery ...................................................................................................... C 

27090 .......................................................... Removal of hip prosthesis ............................................................................................... C 

27091 .......................................................... Removal of hip prosthesis ............................................................................................... C 

27120 .......................................................... Reconstruction of hip socket ........................................................................................... C 

27122 .......................................................... Reconstruction of hip socket ........................................................................................... C 

27125 .......................................................... Partial hip replacement .................................................................................................... C 

27130 .......................................................... Total hip arthroplasty ....................................................................................................... C 

27132 .......................................................... Total hip arthroplasty ....................................................................................................... C 

27134 .......................................................... Revise hip joint replacement ........................................................................................... C 

27137 .......................................................... Revise hip joint replacement ........................................................................................... C 

27138 .......................................................... Revise hip joint replacement ........................................................................................... C 

27140 .......................................................... Transplant femur ridge .................................................................................................... C 

27146 .......................................................... Incision of hip bone ......................................................................................................... C 

27147 .......................................................... Revision of hip bone ........................................................................................................ C 

27151 .......................................................... Incision of hip bones ........................................................................................................ C 

27156 .......................................................... Revision of hip bones ...................................................................................................... C 

27158 .......................................................... Revision of pelvis ............................................................................................................. C 

27161 .......................................................... Incision of neck of femur ................................................................................................. C 

27165 .......................................................... Incision/fixation of femur .................................................................................................. C 

27170 .......................................................... Repair/graft femur head/neck .......................................................................................... C 

27175 .......................................................... Treat slipped epiphysis .................................................................................................... C 

27176 .......................................................... Treat slipped epiphysis .................................................................................................... C 

27177 .......................................................... Treat slipped epiphysis .................................................................................................... C 

27178 .......................................................... Treat slipped epiphysis .................................................................................................... C 

27179 .......................................................... Revise head/neck of femur .............................................................................................. C 

27181 .......................................................... Treat slipped epiphysis .................................................................................................... C 

27185 .......................................................... Revision of femur epiphysis ............................................................................................ C 

27187 .......................................................... Reinforce hip bones ......................................................................................................... C 

27215 .......................................................... Treat pelvic fracture(s) ..................................................................................................... C 

27217 .......................................................... Treat pelvic ring fracture .................................................................................................. C 

27218 .......................................................... Treat pelvic ring fracture .................................................................................................. C 

27222 .......................................................... Treat hip socket fracture .................................................................................................. C 

27226 .......................................................... Treat hip wall fracture ...................................................................................................... C 

27227 .......................................................... Treat hip fracture(s) ......................................................................................................... C 

27228 .......................................................... Treat hip fracture(s) ......................................................................................................... C 

27232 .......................................................... Treat thigh fracture .......................................................................................................... C 

27236 .......................................................... Treat thigh fracture .......................................................................................................... C 

27240 .......................................................... Treat thigh fracture .......................................................................................................... C 

27244 .......................................................... Treat thigh fracture .......................................................................................................... C 

27245 .......................................................... Treat thigh fracture .......................................................................................................... C 

27248 .......................................................... Treat thigh fracture .......................................................................................................... C 

27253 .......................................................... Treat hip dislocation ........................................................................................................ C 

27254 .......................................................... Treat hip dislocation ........................................................................................................ C 

27258 .......................................................... Treat hip dislocation ........................................................................................................ C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49957 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

27259 .......................................................... Treat hip dislocation ........................................................................................................ C 

27280 .......................................................... Fusion of sacroiliac joint .................................................................................................. C 

27282 .......................................................... Fusion of pubic bones ..................................................................................................... C 

27284 .......................................................... Fusion of hip joint ............................................................................................................ C 

27286 .......................................................... Fusion of hip joint ............................................................................................................ C 

27290 .......................................................... Amputation of leg at hip .................................................................................................. C 

27295 .......................................................... Amputation of leg at hip .................................................................................................. C 

27303 .......................................................... Drainage of bone lesion .................................................................................................. C 

27365 .......................................................... Extensive leg surgery ...................................................................................................... C 

27445 .......................................................... Revision of knee joint ...................................................................................................... C 

27447 .......................................................... Total knee arthroplasty .................................................................................................... C 

27448 .......................................................... Incision of thigh ................................................................................................................ C 

27450 .......................................................... Incision of thigh ................................................................................................................ C 

27454 .......................................................... Realignment of thigh bone .............................................................................................. C 

27455 .......................................................... Realignment of knee ........................................................................................................ C 

27457 .......................................................... Realignment of knee ........................................................................................................ C 

27465 .......................................................... Shortening of thigh bone ................................................................................................. C 

27466 .......................................................... Lengthening of thigh bone ............................................................................................... C 

27468 .......................................................... Shorten/lengthen thighs ................................................................................................... C 

27470 .......................................................... Repair of thigh ................................................................................................................. C 

27472 .......................................................... Repair/graft of thigh ......................................................................................................... C 

27477 .......................................................... Surgery to stop leg growth .............................................................................................. C 

27479 .......................................................... Surgery to stop leg growth .............................................................................................. C 

27485 .......................................................... Surgery to stop leg growth .............................................................................................. C 

27486 .......................................................... Revise/replace knee joint ................................................................................................ C 

27487 .......................................................... Revise/replace knee joint ................................................................................................ C 

27488 .......................................................... Removal of knee prosthesis ............................................................................................ C 

27495 .......................................................... Reinforce thigh ................................................................................................................. C 

27506 .......................................................... Treatment of thigh fracture .............................................................................................. C 

27507 .......................................................... Treatment of thigh fracture .............................................................................................. C 

27511 .......................................................... Treatment of thigh fracture .............................................................................................. C 

27513 .......................................................... Treatment of thigh fracture .............................................................................................. C 

27514 .......................................................... Treatment of thigh fracture .............................................................................................. C 

27519 .......................................................... Treat thigh fx growth plate ............................................................................................... C 

27535 .......................................................... Treat knee fracture .......................................................................................................... C 

27536 .......................................................... Treat knee fracture .......................................................................................................... C 

27540 .......................................................... Treat knee fracture .......................................................................................................... C 

27556 .......................................................... Treat knee dislocation ..................................................................................................... C 

27557 .......................................................... Treat knee dislocation ..................................................................................................... C 

27558 .......................................................... Treat knee dislocation ..................................................................................................... C 

27580 .......................................................... Fusion of knee ................................................................................................................. C 

27590 .......................................................... Amputate leg at thigh ...................................................................................................... C 

27591 .......................................................... Amputate leg at thigh ...................................................................................................... C 

27592 .......................................................... Amputate leg at thigh ...................................................................................................... C 

27596 .......................................................... Amputation follow-up surgery .......................................................................................... C 

27598 .......................................................... Amputate lower leg at knee ............................................................................................. C 

27645 .......................................................... Extensive lower leg surgery ............................................................................................ C 

27646 .......................................................... Extensive lower leg surgery ............................................................................................ C 

27702 .......................................................... Reconstruct ankle joint .................................................................................................... C 

27703 .......................................................... Reconstruction, ankle joint .............................................................................................. C 

27712 .......................................................... Realignment of lower leg ................................................................................................. C 

27715 .......................................................... Revision of lower leg ....................................................................................................... C 

27720 .......................................................... Repair of tibia .................................................................................................................. C 

27722 .......................................................... Repair/graft of tibia .......................................................................................................... C 

27724 .......................................................... Repair/graft of tibia .......................................................................................................... C 

27725 .......................................................... Repair of lower leg .......................................................................................................... C 

27727 .......................................................... Repair of lower leg .......................................................................................................... C 

27880 .......................................................... Amputation of lower leg ................................................................................................... C 

27881 .......................................................... Amputation of lower leg ................................................................................................... C 

27882 .......................................................... Amputation of lower leg ................................................................................................... C 

27886 .......................................................... Amputation follow-up surgery .......................................................................................... C 

27888 .......................................................... Amputation of foot at ankle ............................................................................................. C 

28800 .......................................................... Amputation of midfoot ...................................................................................................... C 

28805 .......................................................... Amputation thru metatarsal ............................................................................................. C 

31225 .......................................................... Removal of upper jaw ...................................................................................................... C 

31230 .......................................................... Removal of upper jaw ...................................................................................................... C 

31290 .......................................................... Nasal/sinus endoscopy, surg ........................................................................................... C 

31291 .......................................................... Nasal/sinus endoscopy, surg ........................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49958 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

31360 .......................................................... Removal of larynx ............................................................................................................ C 

31365 .......................................................... Removal of larynx ............................................................................................................ C 

31367 .......................................................... Partial removal of larynx .................................................................................................. C 

31368 .......................................................... Partial removal of larynx .................................................................................................. C 

31370 .......................................................... Partial removal of larynx .................................................................................................. C 

31375 .......................................................... Partial removal of larynx .................................................................................................. C 

31380 .......................................................... Partial removal of larynx .................................................................................................. C 

31382 .......................................................... Partial removal of larynx .................................................................................................. C 

31390 .......................................................... Removal of larynx & pharynx .......................................................................................... C 

31395 .......................................................... Reconstruct larynx & pharynx ......................................................................................... C 

31584 .......................................................... Treat larynx fracture ........................................................................................................ C 

31587 .......................................................... Revision of larynx ............................................................................................................ C 

31725 .......................................................... Clearance of airways ....................................................................................................... C 

31760 .......................................................... Repair of windpipe ........................................................................................................... C 

31766 .......................................................... Reconstruction of windpipe ............................................................................................. C 

31770 .......................................................... Repair/graft of bronchus .................................................................................................. C 

31775 .......................................................... Reconstruct bronchus ...................................................................................................... C 

31780 .......................................................... Reconstruct windpipe ...................................................................................................... C 

31781 .......................................................... Reconstruct windpipe ...................................................................................................... C 

31786 .......................................................... Remove windpipe lesion .................................................................................................. C 

31800 .......................................................... Repair of windpipe injury ................................................................................................. C 

31805 .......................................................... Repair of windpipe injury ................................................................................................. C 

32035 .......................................................... Exploration of chest ......................................................................................................... C 

32036 .......................................................... Exploration of chest ......................................................................................................... C 

32095 .......................................................... Biopsy through chest wall ................................................................................................ C 

32100 .......................................................... Exploration/biopsy of chest .............................................................................................. C 

32110 .......................................................... Explore/repair chest ......................................................................................................... C 

32120 .......................................................... Re-exploration of chest .................................................................................................... C 

32124 .......................................................... Explore chest free adhesions .......................................................................................... C 

32140 .......................................................... Removal of lung lesion(s) ................................................................................................ C 

32141 .......................................................... Remove/treat lung lesions ............................................................................................... C 

32150 .......................................................... Removal of lung lesion(s) ................................................................................................ C 

32151 .......................................................... Remove lung foreign body .............................................................................................. C 

32160 .......................................................... Open chest heart massage ............................................................................................. C 

32200 .......................................................... Drain, open, lung lesion ................................................................................................... C 

32215 .......................................................... Treat chest lining ............................................................................................................. C 

32220 .......................................................... Release of lung ................................................................................................................ C 

32225 .......................................................... Partial release of lung ...................................................................................................... C 

32310 .......................................................... Removal of chest lining ................................................................................................... C 

32320 .......................................................... Free/remove chest lining ................................................................................................. C 

32402 .......................................................... Open biopsy chest lining ................................................................................................. C 

32440 .......................................................... Removal of lung ............................................................................................................... C 

32442 .......................................................... Sleeve pneumonectomy .................................................................................................. C 

32445 .......................................................... Removal of lung ............................................................................................................... C 

32480 .......................................................... Partial removal of lung ..................................................................................................... C 

32482 .......................................................... Bilobectomy ..................................................................................................................... C 

32484 .......................................................... Segmentectomy ............................................................................................................... C 

32486 .......................................................... Sleeve lobectomy ............................................................................................................ C 

32488 .......................................................... Completion pneumonectomy ........................................................................................... C 

32491 .......................................................... Lung volume reduction .................................................................................................... C 

32500 .......................................................... Partial removal of lung ..................................................................................................... C 

32501 .......................................................... Repair bronchus add-on .................................................................................................. C 

32503 .......................................................... Resect apical lung tumor ................................................................................................. C 

32504 .......................................................... Resect apical lung tum/chest .......................................................................................... C 

32540 .......................................................... Removal of lung lesion .................................................................................................... C 

32650 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32651 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32652 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32653 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32654 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32655 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32656 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32657 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32658 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32659 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32660 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32661 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32662 .......................................................... Thoracoscopy, surgical .................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49959 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

32663 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32664 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32665 .......................................................... Thoracoscopy, surgical .................................................................................................... C 

32800 .......................................................... Repair lung hernia ........................................................................................................... C 

32810 .......................................................... Close chest after drainage .............................................................................................. C 

32815 .......................................................... Close bronchial fistula ..................................................................................................... C 

32820 .......................................................... Reconstruct injured chest ................................................................................................ C 

32850 .......................................................... Donor pneumonectomy ................................................................................................... C 

32851 .......................................................... Lung transplant, single .................................................................................................... C 

32852 .......................................................... Lung transplant with bypass ............................................................................................ C 

32853 .......................................................... Lung transplant, double ................................................................................................... C 

32854 .......................................................... Lung transplant with bypass ............................................................................................ C 

32855 .......................................................... Prepare donor lung, single .............................................................................................. C 

32856 .......................................................... Prepare donor lung, double ............................................................................................. C 

32900 .......................................................... Removal of rib(s) ............................................................................................................. C 

32905 .......................................................... Revise & repair chest wall ............................................................................................... C 

32906 .......................................................... Revise & repair chest wall ............................................................................................... C 

32940 .......................................................... Revision of lung ............................................................................................................... C 

32997 .......................................................... Total lung lavage ............................................................................................................. C 

33015 .......................................................... Incision of heart sac ........................................................................................................ C 

33020 .......................................................... Incision of heart sac ........................................................................................................ C 

33025 .......................................................... Incision of heart sac ........................................................................................................ C 

33030 .......................................................... Partial removal of heart sac ............................................................................................ C 

33031 .......................................................... Partial removal of heart sac ............................................................................................ C 

33050 .......................................................... Removal of heart sac lesion ............................................................................................ C 

33120 .......................................................... Removal of heart lesion ................................................................................................... C 

33130 .......................................................... Removal of heart lesion ................................................................................................... C 

33140 .......................................................... Heart revascularize (tmr) ................................................................................................. C 

33141 .......................................................... Heart tmr w/other procedure ........................................................................................... C 

33200 .......................................................... Insertion of heart pacemaker ........................................................................................... C 

33201 .......................................................... Insertion of heart pacemaker ........................................................................................... C 

33236 .......................................................... Remove electrode/thoracotomy ....................................................................................... C 

33237 .......................................................... Remove electrode/thoracotomy ....................................................................................... C 

33238 .......................................................... Remove electrode/thoracotomy ....................................................................................... C 

33243 .......................................................... Remove eltrd/thoracotomy ............................................................................................... C 

33245 .......................................................... Insert epic eltrd pace-defib .............................................................................................. C 

33246 .......................................................... Insert epic eltrd/generator ................................................................................................ C 

33250 .......................................................... Ablate heart dysrhythm focus .......................................................................................... C 

33251 .......................................................... Ablate heart dysrhythm focus .......................................................................................... C 

33253 .......................................................... Reconstruct atria .............................................................................................................. C 

33261 .......................................................... Ablate heart dysrhythm focus .......................................................................................... C 

33300 .......................................................... Repair of heart wound ..................................................................................................... C 

33305 .......................................................... Repair of heart wound ..................................................................................................... C 

33310 .......................................................... Exploratory heart surgery ................................................................................................ C 

33315 .......................................................... Exploratory heart surgery ................................................................................................ C 

33320 .......................................................... Repair major blood vessel(s) ........................................................................................... C 

33321 .......................................................... Repair major vessel ......................................................................................................... C 

33322 .......................................................... Repair major blood vessel(s) ........................................................................................... C 

33330 .......................................................... Insert major vessel graft .................................................................................................. C 

33332 .......................................................... Insert major vessel graft .................................................................................................. C 

33335 .......................................................... Insert major vessel graft .................................................................................................. C 

33400 .......................................................... Repair of aortic valve ....................................................................................................... C 

33401 .......................................................... Valvuloplasty, open .......................................................................................................... C 

33403 .......................................................... Valvuloplasty, w/cp bypass .............................................................................................. C 

33404 .......................................................... Prepare heart-aorta conduit ............................................................................................. C 

33405 .......................................................... Replacement of aortic valve ............................................................................................ C 

33406 .......................................................... Replacement of aortic valve ............................................................................................ C 

33410 .......................................................... Replacement of aortic valve ............................................................................................ C 

33411 .......................................................... Replacement of aortic valve ............................................................................................ C 

33412 .......................................................... Replacement of aortic valve ............................................................................................ C 

33413 .......................................................... Replacement of aortic valve ............................................................................................ C 

33414 .......................................................... Repair of aortic valve ....................................................................................................... C 

33415 .......................................................... Revision, subvalvular tissue ............................................................................................ C 

33416 .......................................................... Revise ventricle muscle ................................................................................................... C 

33417 .......................................................... Repair of aortic valve ....................................................................................................... C 

33420 .......................................................... Revision of mitral valve ................................................................................................... C 

33422 .......................................................... Revision of mitral valve ................................................................................................... C 

33425 .......................................................... Repair of mitral valve ....................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49960 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

33426 .......................................................... Repair of mitral valve ....................................................................................................... C 

33427 .......................................................... Repair of mitral valve ....................................................................................................... C 

33430 .......................................................... Replacement of mitral valve ............................................................................................ C 

33460 .......................................................... Revision of tricuspid valve ............................................................................................... C 

33463 .......................................................... Valvuloplasty, tricuspid .................................................................................................... C 

33464 .......................................................... Valvuloplasty, tricuspid .................................................................................................... C 

33465 .......................................................... Replace tricuspid valve .................................................................................................... C 

33468 .......................................................... Revision of tricuspid valve ............................................................................................... C 

33470 .......................................................... Revision of pulmonary valve ........................................................................................... C 

33471 .......................................................... Valvotomy, pulmonary valve ............................................................................................ C 

33472 .......................................................... Revision of pulmonary valve ........................................................................................... C 

33474 .......................................................... Revision of pulmonary valve ........................................................................................... C 

33475 .......................................................... Replacement, pulmonary valve ....................................................................................... C 

33476 .......................................................... Revision of heart chamber .............................................................................................. C 

33478 .......................................................... Revision of heart chamber .............................................................................................. C 

33496 .......................................................... Repair, prosth valve clot .................................................................................................. C 

33500 .......................................................... Repair heart vessel fistula ............................................................................................... C 

33501 .......................................................... Repair heart vessel fistula ............................................................................................... C 

33502 .......................................................... Coronary artery correction ............................................................................................... C 

33503 .......................................................... Coronary artery graft ....................................................................................................... C 

33504 .......................................................... Coronary artery graft ....................................................................................................... C 

33505 .......................................................... Repair artery w/tunnel ..................................................................................................... C 

33506 .......................................................... Repair artery, translocation ............................................................................................. C 

33507 .......................................................... Repair art, intramural ....................................................................................................... C 

33510 .......................................................... CABG, vein, single .......................................................................................................... C 

33511 .......................................................... CABG, vein, two .............................................................................................................. C 

33512 .......................................................... CABG, vein, three ............................................................................................................ C 

33513 .......................................................... CABG, vein, four .............................................................................................................. C 

33514 .......................................................... CABG, vein, five .............................................................................................................. C 

33516 .......................................................... Cabg, vein, six or more ................................................................................................... C 

33517 .......................................................... CABG, artery-vein, single ................................................................................................ C 

33518 .......................................................... CABG, artery-vein, two .................................................................................................... C 

33519 .......................................................... CABG, artery-vein, three ................................................................................................. C 

33521 .......................................................... CABG, artery-vein, four ................................................................................................... C 

33522 .......................................................... CABG, artery-vein, five .................................................................................................... C 

33523 .......................................................... Cabg, art-vein, six or more .............................................................................................. C 

33530 .......................................................... Coronary artery, bypass/reop .......................................................................................... C 

33533 .......................................................... CABG, arterial, single ...................................................................................................... C 

33534 .......................................................... CABG, arterial, two .......................................................................................................... C 

33535 .......................................................... CABG, arterial, three ....................................................................................................... C 

33536 .......................................................... Cabg, arterial, four or more ............................................................................................. C 

33542 .......................................................... Removal of heart lesion ................................................................................................... C 

33545 .......................................................... Repair of heart damage ................................................................................................... C 

33548 .......................................................... Restore/remodel, ventricle ............................................................................................... C 

33572 .......................................................... Open coronary endarterectomy ....................................................................................... C 

33600 .......................................................... Closure of valve ............................................................................................................... C 

33602 .......................................................... Closure of valve ............................................................................................................... C 

33606 .......................................................... Anastomosis/artery-aorta ................................................................................................. C 

33608 .......................................................... Repair anomaly w/conduit ............................................................................................... C 

33610 .......................................................... Repair by enlargement .................................................................................................... C 

33611 .......................................................... Repair double ventricle .................................................................................................... C 

33612 .......................................................... Repair double ventricle .................................................................................................... C 

33615 .......................................................... Repair, modified fontan ................................................................................................... C 

33617 .......................................................... Repair single ventricle ..................................................................................................... C 

33619 .......................................................... Repair single ventricle ..................................................................................................... C 

33641 .......................................................... Repair heart septum defect ............................................................................................. C 

33645 .......................................................... Revision of heart veins .................................................................................................... C 

33647 .......................................................... Repair heart septum defects ........................................................................................... C 

33660 .......................................................... Repair of heart defects .................................................................................................... C 

33665 .......................................................... Repair of heart defects .................................................................................................... C 

33670 .......................................................... Repair of heart chambers ................................................................................................ C 

33681 .......................................................... Repair heart septum defect ............................................................................................. C 

33684 .......................................................... Repair heart septum defect ............................................................................................. C 

33688 .......................................................... Repair heart septum defect ............................................................................................. C 

33690 .......................................................... Reinforce pulmonary artery ............................................................................................. C 

33692 .......................................................... Repair of heart defects .................................................................................................... C 

33694 .......................................................... Repair of heart defects .................................................................................................... C 

33697 .......................................................... Repair of heart defects .................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49961 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

33702 .......................................................... Repair of heart defects .................................................................................................... C 

33710 .......................................................... Repair of heart defects .................................................................................................... C 

33720 .......................................................... Repair of heart defect ...................................................................................................... C 

33722 .......................................................... Repair of heart defect ...................................................................................................... C 

33730 .......................................................... Repair heart-vein defect(s) .............................................................................................. C 

33732 .......................................................... Repair heart-vein defect .................................................................................................. C 

33735 .......................................................... Revision of heart chamber .............................................................................................. C 

33736 .......................................................... Revision of heart chamber .............................................................................................. C 

33737 .......................................................... Revision of heart chamber .............................................................................................. C 

33750 .......................................................... Major vessel shunt ........................................................................................................... C 

33755 .......................................................... Major vessel shunt ........................................................................................................... C 

33762 .......................................................... Major vessel shunt ........................................................................................................... C 

33764 .......................................................... Major vessel shunt & graft ............................................................................................... C 

33766 .......................................................... Major vessel shunt ........................................................................................................... C 

33767 .......................................................... Major vessel shunt ........................................................................................................... C 

33768 .......................................................... Cavopulmonary shunting ................................................................................................. C 

33770 .......................................................... Repair great vessels defect ............................................................................................. C 

33771 .......................................................... Repair great vessels defect ............................................................................................. C 

33774 .......................................................... Repair great vessels defect ............................................................................................. C 

33775 .......................................................... Repair great vessels defect ............................................................................................. C 

33776 .......................................................... Repair great vessels defect ............................................................................................. C 

33777 .......................................................... Repair great vessels defect ............................................................................................. C 

33778 .......................................................... Repair great vessels defect ............................................................................................. C 

33779 .......................................................... Repair great vessels defect ............................................................................................. C 

33780 .......................................................... Repair great vessels defect ............................................................................................. C 

33781 .......................................................... Repair great vessels defect ............................................................................................. C 

33786 .......................................................... Repair arterial trunk ......................................................................................................... C 

33788 .......................................................... Revision of pulmonary artery ........................................................................................... C 

33800 .......................................................... Aortic suspension ............................................................................................................ C 

33802 .......................................................... Repair vessel defect ........................................................................................................ C 

33803 .......................................................... Repair vessel defect ........................................................................................................ C 

33813 .......................................................... Repair septal defect ......................................................................................................... C 

33814 .......................................................... Repair septal defect ......................................................................................................... C 

33820 .......................................................... Revise major vessel ........................................................................................................ C 

33822 .......................................................... Revise major vessel ........................................................................................................ C 

33824 .......................................................... Revise major vessel ........................................................................................................ C 

33840 .......................................................... Remove aorta constriction ............................................................................................... C 

33845 .......................................................... Remove aorta constriction ............................................................................................... C 

33851 .......................................................... Remove aorta constriction ............................................................................................... C 

33852 .......................................................... Repair septal defect ......................................................................................................... C 

33853 .......................................................... Repair septal defect ......................................................................................................... C 

33860 .......................................................... Ascending aortic graft ...................................................................................................... C 

33861 .......................................................... Ascending aortic graft ...................................................................................................... C 

33863 .......................................................... Ascending aortic graft ...................................................................................................... C 

33870 .......................................................... Transverse aortic arch graft ............................................................................................ C 

33875 .......................................................... Thoracic aortic graft ......................................................................................................... C 

33877 .......................................................... Thoracoabdominal graft ................................................................................................... C 

33880 .......................................................... Endovasc taa repr incl subcl ........................................................................................... C 

33881 .......................................................... Endovasc taa repr w/o subcl ........................................................................................... C 

33883 .......................................................... Insert endovasc prosth, taa ............................................................................................. C 

33884 .......................................................... Endovasc prosth, taa, add-on ......................................................................................... C 

33886 .......................................................... Endovasc prosth, delayed ............................................................................................... C 

33889 .......................................................... Artery transpose/endovas taa .......................................................................................... C 

33891 .......................................................... Car-car bp grft/endovas taa ............................................................................................. C 

33910 .......................................................... Remove lung artery emboli ............................................................................................. C 

33915 .......................................................... Remove lung artery emboli ............................................................................................. C 

33916 .......................................................... Surgery of great vessel ................................................................................................... C 

33917 .......................................................... Repair pulmonary artery .................................................................................................. C 

33920 .......................................................... Repair pulmonary atresia ................................................................................................ C 

33922 .......................................................... Transect pulmonary artery ............................................................................................... C 

33924 .......................................................... Remove pulmonary shunt ................................................................................................ C 

33925 .......................................................... Rpr pul art unifocal w/o cpb ............................................................................................ C 

33926 .......................................................... Repr pul art, unifocal w/cpb ............................................................................................. C 

33930 .......................................................... Removal of donor heart/lung ........................................................................................... C 

33933 .......................................................... Prepare donor heart/lung ................................................................................................. C 

33935 .......................................................... Transplantation, heart/lung .............................................................................................. C 

33940 .......................................................... Removal of donor heart ................................................................................................... C 

33944 .......................................................... Prepare donor heart ........................................................................................................ C 


sroberts on PROD1PC70 with PROPOSALS
49962 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

33945 .......................................................... Transplantation of heart ................................................................................................... C 

33960 .......................................................... External circulation assist ................................................................................................ C 

33961 .......................................................... External circulation assist ................................................................................................ C 

33967 .......................................................... Insert ia percut device ..................................................................................................... C 

33968 .......................................................... Remove aortic assist device ............................................................................................ C 

33970 .......................................................... Aortic circulation assist .................................................................................................... C 

33971 .......................................................... Aortic circulation assist .................................................................................................... C 

33973 .......................................................... Insert balloon device ........................................................................................................ C 

33974 .......................................................... Remove intra-aortic balloon ............................................................................................. C 

33975 .......................................................... Implant ventricular device ................................................................................................ C 

33976 .......................................................... Implant ventricular device ................................................................................................ C 

33977 .......................................................... Remove ventricular device .............................................................................................. C 

33978 .......................................................... Remove ventricular device .............................................................................................. C 

33979 .......................................................... Insert intracorporeal device ............................................................................................. C 

33980 .......................................................... Remove intracorporeal device ......................................................................................... C 

34001 .......................................................... Removal of artery clot ..................................................................................................... C 

34051 .......................................................... Removal of artery clot ..................................................................................................... C 

34151 .......................................................... Removal of artery clot ..................................................................................................... C 

34401 .......................................................... Removal of vein clot ........................................................................................................ C 

34451 .......................................................... Removal of vein clot ........................................................................................................ C 

34502 .......................................................... Reconstruct vena cava .................................................................................................... C 

34800 .......................................................... Endovas aaa repr w/sm tube .......................................................................................... C 

34802 .......................................................... Endovas aaa repr w/2-p part ........................................................................................... C 

34803 .......................................................... Endovas aaa repr w/3-p part ........................................................................................... C 

34804 .......................................................... Endovas aaa repr w/1-p part ........................................................................................... C 

34805 .......................................................... Endovas aaa repr w/long tube ........................................................................................ C 

34808 .......................................................... Endovas iliac a device addon .......................................................................................... C 

34812 .......................................................... Xpose for endoprosth, femorl .......................................................................................... C 

34813 .......................................................... Femoral endovas graft add-on ........................................................................................ C 

34820 .......................................................... Xpose for endoprosth, iliac .............................................................................................. C 

34825 .......................................................... Endovasc extend prosth, init ........................................................................................... C 

34826 .......................................................... Endovasc exten prosth, add’l .......................................................................................... C 

34830 .......................................................... Open aortic tube prosth repr ........................................................................................... C 

34831 .......................................................... Open aortoiliac prosth repr .............................................................................................. C 

34832 .......................................................... Open aortofemor prosth repr ........................................................................................... C 

34833 .......................................................... Xpose for endoprosth, iliac .............................................................................................. C 

34834 .......................................................... Xpose, endoprosth, brachial ............................................................................................ C 

34900 .......................................................... Endovasc iliac repr w/graft .............................................................................................. C 

35001 .......................................................... Repair defect of artery ..................................................................................................... C 

35002 .......................................................... Repair artery rupture, neck .............................................................................................. C 

35005 .......................................................... Repair defect of artery ..................................................................................................... C 

35013 .......................................................... Repair artery rupture, arm ............................................................................................... C 

35021 .......................................................... Repair defect of artery ..................................................................................................... C 

35022 .......................................................... Repair artery rupture, chest ............................................................................................. C 

35045 .......................................................... Repair defect of arm artery ............................................................................................. C 

35081 .......................................................... Repair defect of artery ..................................................................................................... C 

35082 .......................................................... Repair artery rupture, aorta ............................................................................................. C 

35091 .......................................................... Repair defect of artery ..................................................................................................... C 

35092 .......................................................... Repair artery rupture, aorta ............................................................................................. C 

35102 .......................................................... Repair defect of artery ..................................................................................................... C 

35103 .......................................................... Repair artery rupture, groin ............................................................................................. C 

35111 .......................................................... Repair defect of artery ..................................................................................................... C 

35112 .......................................................... Repair artery rupture,spleen ............................................................................................ C 

35121 .......................................................... Repair defect of artery ..................................................................................................... C 

35122 .......................................................... Repair artery rupture, belly .............................................................................................. C 

35131 .......................................................... Repair defect of artery ..................................................................................................... C 

35132 .......................................................... Repair artery rupture, groin ............................................................................................. C 

35141 .......................................................... Repair defect of artery ..................................................................................................... C 

35142 .......................................................... Repair artery rupture, thigh ............................................................................................. C 

35151 .......................................................... Repair defect of artery ..................................................................................................... C 

35152 .......................................................... Repair artery rupture, knee ............................................................................................. C 

35182 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35189 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35211 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35216 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35221 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35241 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35246 .......................................................... Repair blood vessel lesion .............................................................................................. C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49963 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

35251 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35271 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35276 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35281 .......................................................... Repair blood vessel lesion .............................................................................................. C 

35301 .......................................................... Rechanneling of artery .................................................................................................... C 

35311 .......................................................... Rechanneling of artery .................................................................................................... C 

35331 .......................................................... Rechanneling of artery .................................................................................................... C 

35341 .......................................................... Rechanneling of artery .................................................................................................... C 

35351 .......................................................... Rechanneling of artery .................................................................................................... C 

35355 .......................................................... Rechanneling of artery .................................................................................................... C 

35361 .......................................................... Rechanneling of artery .................................................................................................... C 

35363 .......................................................... Rechanneling of artery .................................................................................................... C 

35371 .......................................................... Rechanneling of artery .................................................................................................... C 

35372 .......................................................... Rechanneling of artery .................................................................................................... C 

35381 .......................................................... Rechanneling of artery .................................................................................................... C 

35390 .......................................................... Reoperation, carotid add-on ............................................................................................ C 

35400 .......................................................... Angioscopy ...................................................................................................................... C 

35450 .......................................................... Repair arterial blockage ................................................................................................... C 

35452 .......................................................... Repair arterial blockage ................................................................................................... C 

35454 .......................................................... Repair arterial blockage ................................................................................................... C 

35456 .......................................................... Repair arterial blockage ................................................................................................... C 

35480 .......................................................... Atherectomy, open ........................................................................................................... C 

35481 .......................................................... Atherectomy, open ........................................................................................................... C 

35482 .......................................................... Atherectomy, open ........................................................................................................... C 

35483 .......................................................... Atherectomy, open ........................................................................................................... C 

35501 .......................................................... Artery bypass graft .......................................................................................................... C 

35506 .......................................................... Artery bypass graft .......................................................................................................... C 

35507 .......................................................... Artery bypass graft .......................................................................................................... C 

35508 .......................................................... Artery bypass graft .......................................................................................................... C 

35509 .......................................................... Artery bypass graft .......................................................................................................... C 

35510 .......................................................... Artery bypass graft .......................................................................................................... C 

35511 .......................................................... Artery bypass graft .......................................................................................................... C 

35512 .......................................................... Artery bypass graft .......................................................................................................... C 

35515 .......................................................... Artery bypass graft .......................................................................................................... C 

35516 .......................................................... Artery bypass graft .......................................................................................................... C 

35518 .......................................................... Artery bypass graft .......................................................................................................... C 

35521 .......................................................... Artery bypass graft .......................................................................................................... C 

35522 .......................................................... Artery bypass graft .......................................................................................................... C 

35525 .......................................................... Artery bypass graft .......................................................................................................... C 

35526 .......................................................... Artery bypass graft .......................................................................................................... C 

35531 .......................................................... Artery bypass graft .......................................................................................................... C 

35533 .......................................................... Artery bypass graft .......................................................................................................... C 

35536 .......................................................... Artery bypass graft .......................................................................................................... C 

35541 .......................................................... Artery bypass graft .......................................................................................................... C 

35546 .......................................................... Artery bypass graft .......................................................................................................... C 

35548 .......................................................... Artery bypass graft .......................................................................................................... C 

35549 .......................................................... Artery bypass graft .......................................................................................................... C 

35551 .......................................................... Artery bypass graft .......................................................................................................... C 

35556 .......................................................... Artery bypass graft .......................................................................................................... C 

35558 .......................................................... Artery bypass graft .......................................................................................................... C 

35560 .......................................................... Artery bypass graft .......................................................................................................... C 

35563 .......................................................... Artery bypass graft .......................................................................................................... C 

35565 .......................................................... Artery bypass graft .......................................................................................................... C 

35566 .......................................................... Artery bypass graft .......................................................................................................... C 

35571 .......................................................... Artery bypass graft .......................................................................................................... C 

35583 .......................................................... Vein bypass graft ............................................................................................................. C 

35585 .......................................................... Vein bypass graft ............................................................................................................. C 

35587 .......................................................... Vein bypass graft ............................................................................................................. C 

35600 .......................................................... Harvest artery for cabg .................................................................................................... C 

35601 .......................................................... Artery bypass graft .......................................................................................................... C 

35606 .......................................................... Artery bypass graft .......................................................................................................... C 

35612 .......................................................... Artery bypass graft .......................................................................................................... C 

35616 .......................................................... Artery bypass graft .......................................................................................................... C 

35621 .......................................................... Artery bypass graft .......................................................................................................... C 

35623 .......................................................... Bypass graft, not vein ...................................................................................................... C 

35626 .......................................................... Artery bypass graft .......................................................................................................... C 

35631 .......................................................... Artery bypass graft .......................................................................................................... C 

35636 .......................................................... Artery bypass graft .......................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49964 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

35641 .......................................................... Artery bypass graft .......................................................................................................... C 

35642 .......................................................... Artery bypass graft .......................................................................................................... C 

35645 .......................................................... Artery bypass graft .......................................................................................................... C 

35646 .......................................................... Artery bypass graft .......................................................................................................... C 

35647 .......................................................... Artery bypass graft .......................................................................................................... C 

35650 .......................................................... Artery bypass graft .......................................................................................................... C 

35651 .......................................................... Artery bypass graft .......................................................................................................... C 

35654 .......................................................... Artery bypass graft .......................................................................................................... C 

35656 .......................................................... Artery bypass graft .......................................................................................................... C 

35661 .......................................................... Artery bypass graft .......................................................................................................... C 

35663 .......................................................... Artery bypass graft .......................................................................................................... C 

35665 .......................................................... Artery bypass graft .......................................................................................................... C 

35666 .......................................................... Artery bypass graft .......................................................................................................... C 

35671 .......................................................... Artery bypass graft .......................................................................................................... C 

35681 .......................................................... Composite bypass graft ................................................................................................... C 

35682 .......................................................... Composite bypass graft ................................................................................................... C 

35683 .......................................................... Composite bypass graft ................................................................................................... C 

35691 .......................................................... Arterial transposition ........................................................................................................ C 

35693 .......................................................... Arterial transposition ........................................................................................................ C 

35694 .......................................................... Arterial transposition ........................................................................................................ C 

35695 .......................................................... Arterial transposition ........................................................................................................ C 

35697 .......................................................... Reimplant artery each ..................................................................................................... C 

35700 .......................................................... Reoperation, bypass graft ............................................................................................... C 

35701 .......................................................... Exploration, carotid artery ................................................................................................ C 

35721 .......................................................... Exploration, femoral artery .............................................................................................. C 

35741 .......................................................... Exploration popliteal artery .............................................................................................. C 

35800 .......................................................... Explore neck vessels ....................................................................................................... C 

35820 .......................................................... Explore chest vessels ...................................................................................................... C 

35840 .......................................................... Explore abdominal vessels .............................................................................................. C 

35870 .......................................................... Repair vessel graft defect ................................................................................................ C 

35901 .......................................................... Excision, graft, neck ........................................................................................................ C 

35905 .......................................................... Excision, graft, thorax ...................................................................................................... C 

35907 .......................................................... Excision, graft, abdomen ................................................................................................. C 

36660 .......................................................... Insertion catheter, artery .................................................................................................. C 

36822 .......................................................... Insertion of cannula(s) ..................................................................................................... C 

36823 .......................................................... Insertion of cannula(s) ..................................................................................................... C 

37140 .......................................................... Revision of circulation ...................................................................................................... C 

37145 .......................................................... Revision of circulation ...................................................................................................... C 

37160 .......................................................... Revision of circulation ...................................................................................................... C 

37180 .......................................................... Revision of circulation ...................................................................................................... C 

37181 .......................................................... Splice spleen/kidney veins .............................................................................................. C 

37182 .......................................................... Insert hepatic shunt (tips) ................................................................................................ C 

37215 .......................................................... Transcath stent, cca w/eps .............................................................................................. C 

37216 .......................................................... Transcath stent, cca w/o eps .......................................................................................... C 

37616 .......................................................... Ligation of chest artery .................................................................................................... C 

37617 .......................................................... Ligation of abdomen artery .............................................................................................. C 

37618 .......................................................... Ligation of extremity artery .............................................................................................. C 

37660 .......................................................... Revision of major vein ..................................................................................................... C 

37788 .......................................................... Revascularization, penis .................................................................................................. C 

38100 .......................................................... Removal of spleen, total .................................................................................................. C 

38101 .......................................................... Removal of spleen, partial ............................................................................................... C 

38102 .......................................................... Removal of spleen, total .................................................................................................. C 

38115 .......................................................... Repair of ruptured spleen ................................................................................................ C 

38380 .......................................................... Thoracic duct procedure .................................................................................................. C 

38381 .......................................................... Thoracic duct procedure .................................................................................................. C 

38382 .......................................................... Thoracic duct procedure .................................................................................................. C 

38562 .......................................................... Removal, pelvic lymph nodes .......................................................................................... C 

38564 .......................................................... Removal, abdomen lymph nodes .................................................................................... C 

38724 .......................................................... Removal of lymph nodes, neck ....................................................................................... C 

38746 .......................................................... Remove thoracic lymph nodes ........................................................................................ C 

38747 .......................................................... Remove abdominal lymph nodes .................................................................................... C 

38765 .......................................................... Remove groin lymph nodes ............................................................................................. C 

38770 .......................................................... Remove pelvis lymph nodes ........................................................................................... C 

38780 .......................................................... Remove abdomen lymph nodes ...................................................................................... C 

39000 .......................................................... Exploration of chest ......................................................................................................... C 

39010 .......................................................... Exploration of chest ......................................................................................................... C 

39200 .......................................................... Removal chest lesion ...................................................................................................... C 

39220 .......................................................... Removal chest lesion ...................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49965 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

39499 .......................................................... Chest procedure .............................................................................................................. C 

39501 .......................................................... Repair diaphragm laceration ........................................................................................... C 

39502 .......................................................... Repair paraesophageal hernia ........................................................................................ C 

39503 .......................................................... Repair of diaphragm hernia ............................................................................................. C 

39520 .......................................................... Repair of diaphragm hernia ............................................................................................. C 

39530 .......................................................... Repair of diaphragm hernia ............................................................................................. C 

39531 .......................................................... Repair of diaphragm hernia ............................................................................................. C 

39540 .......................................................... Repair of diaphragm hernia ............................................................................................. C 

39541 .......................................................... Repair of diaphragm hernia ............................................................................................. C 

39545 .......................................................... Revision of diaphragm ..................................................................................................... C 

39560 .......................................................... Resect diaphragm, simple ............................................................................................... C 

39561 .......................................................... Resect diaphragm, complex ............................................................................................ C 

39599 .......................................................... Diaphragm surgery procedure ......................................................................................... C 

41130 .......................................................... Partial removal of tongue ................................................................................................ C 

41135 .......................................................... Tongue and neck surgery ................................................................................................ C 

41140 .......................................................... Removal of tongue .......................................................................................................... C 

41145 .......................................................... Tongue removal, neck surgery ........................................................................................ C 

41150 .......................................................... Tongue, mouth, jaw surgery ............................................................................................ C 

41153 .......................................................... Tongue, mouth, neck surgery .......................................................................................... C 

41155 .......................................................... Tongue, jaw, & neck surgery ........................................................................................... C 

42426 .......................................................... Excise parotid gland/lesion .............................................................................................. C 

42845 .......................................................... Extensive surgery of throat .............................................................................................. C 

42894 .......................................................... Revision of pharyngeal walls ........................................................................................... C 

42953 .......................................................... Repair throat, esophagus ................................................................................................ C 

42961 .......................................................... Control throat bleeding .................................................................................................... C 

42971 .......................................................... Control nose/throat bleeding ........................................................................................... C 

43045 .......................................................... Incision of esophagus ...................................................................................................... C 

43100 .......................................................... Excision of esophagus lesion .......................................................................................... C 

43101 .......................................................... Excision of esophagus lesion .......................................................................................... C 

43107 .......................................................... Removal of esophagus .................................................................................................... C 

43108 .......................................................... Removal of esophagus .................................................................................................... C 

43112 .......................................................... Removal of esophagus .................................................................................................... C 

43113 .......................................................... Removal of esophagus .................................................................................................... C 

43116 .......................................................... Partial removal of esophagus .......................................................................................... C 

43117 .......................................................... Partial removal of esophagus .......................................................................................... C 

43118 .......................................................... Partial removal of esophagus .......................................................................................... C 

43121 .......................................................... Partial removal of esophagus .......................................................................................... C 

43122 .......................................................... Partial removal of esophagus .......................................................................................... C 

43123 .......................................................... Partial removal of esophagus .......................................................................................... C 

43124 .......................................................... Removal of esophagus .................................................................................................... C 

43135 .......................................................... Removal of esophagus pouch ......................................................................................... C 

43300 .......................................................... Repair of esophagus ....................................................................................................... C 

43305 .......................................................... Repair esophagus and fistula .......................................................................................... C 

43310 .......................................................... Repair of esophagus ....................................................................................................... C 

43312 .......................................................... Repair esophagus and fistula .......................................................................................... C 

43313 .......................................................... Esophagoplasty congenital .............................................................................................. C 

43314 .......................................................... Tracheo-esophagoplasty cong ........................................................................................ C 

43320 .......................................................... Fuse esophagus & stomach ............................................................................................ C 

43324 .......................................................... Revise esophagus & stomach ......................................................................................... C 

43325 .......................................................... Revise esophagus & stomach ......................................................................................... C 

43326 .......................................................... Revise esophagus & stomach ......................................................................................... C 

43330 .......................................................... Repair of esophagus ....................................................................................................... C 

43331 .......................................................... Repair of esophagus ....................................................................................................... C 

43340 .......................................................... Fuse esophagus & intestine ............................................................................................ C 

43341 .......................................................... Fuse esophagus & intestine ............................................................................................ C 

43350 .......................................................... Surgical opening, esophagus .......................................................................................... C 

43351 .......................................................... Surgical opening, esophagus .......................................................................................... C 

43352 .......................................................... Surgical opening, esophagus .......................................................................................... C 

43360 .......................................................... Gastrointestinal repair ...................................................................................................... C 

43361 .......................................................... Gastrointestinal repair ...................................................................................................... C 

43400 .......................................................... Ligate esophagus veins ................................................................................................... C 

43401 .......................................................... Esophagus surgery for veins ........................................................................................... C 

43405 .......................................................... Ligate/staple esophagus .................................................................................................. C 

43410 .......................................................... Repair esophagus wound ................................................................................................ C 

43415 .......................................................... Repair esophagus wound ................................................................................................ C 

43420 .......................................................... Repair esophagus opening .............................................................................................. C 

43425 .......................................................... Repair esophagus opening .............................................................................................. C 

43460 .......................................................... Pressure treatment esophagus ....................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49966 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

43496 .......................................................... Free jejunum flap, microvasc .......................................................................................... C 

43500 .......................................................... Surgical opening of stomach ........................................................................................... C 

43501 .......................................................... Surgical repair of stomach ............................................................................................... C 

43502 .......................................................... Surgical repair of stomach ............................................................................................... C 

43520 .......................................................... Incision of pyloric muscle ................................................................................................ C 

43605 .......................................................... Biopsy of stomach ........................................................................................................... C 

43610 .......................................................... Excision of stomach lesion .............................................................................................. C 

43611 .......................................................... Excision of stomach lesion .............................................................................................. C 

43620 .......................................................... Removal of stomach ........................................................................................................ C 

43621 .......................................................... Removal of stomach ........................................................................................................ C 

43622 .......................................................... Removal of stomach ........................................................................................................ C 

43631 .......................................................... Removal of stomach, partial ............................................................................................ C 

43632 .......................................................... Removal of stomach, partial ............................................................................................ C 

43633 .......................................................... Removal of stomach, partial ............................................................................................ C 

43634 .......................................................... Removal of stomach, partial ............................................................................................ C 

43635 .......................................................... Removal of stomach, partial ............................................................................................ C 

43640 .......................................................... Vagotomy & pylorus repair .............................................................................................. C 

43641 .......................................................... Vagotomy & pylorus repair .............................................................................................. C 

43644 .......................................................... Lap gastric bypass/roux-en-y .......................................................................................... C 

43645 .......................................................... Lap gastr bypass incl smll i ............................................................................................. C 

43770 .......................................................... Lap, place gastr adjust band ........................................................................................... C 

43771 .......................................................... Lap, revise adjust gast band ........................................................................................... C 

43772 .......................................................... Lap, remove adjust gast band ......................................................................................... C 

43773 .......................................................... Lap, change adjust gast band ......................................................................................... C 

43774 .......................................................... Lap remov adj gast band/port ......................................................................................... C 

43800 .......................................................... Reconstruction of pylorus ................................................................................................ C 

43810 .......................................................... Fusion of stomach and bowel ......................................................................................... C 

43820 .......................................................... Fusion of stomach and bowel ......................................................................................... C 

43825 .......................................................... Fusion of stomach and bowel ......................................................................................... C 

43832 .......................................................... Place gastrostomy tube ................................................................................................... C 

43840 .......................................................... Repair of stomach lesion ................................................................................................. C 

43842 .......................................................... V-band gastroplasty ......................................................................................................... C 

43843 .......................................................... Gastroplasty w/o v-band .................................................................................................. C 

43845 .......................................................... Gastroplasty duodenal switch .......................................................................................... C 

43846 .......................................................... Gastric bypass for obesity ............................................................................................... C 

43847 .......................................................... Gastric bypass incl small i ............................................................................................... C 

43848 .......................................................... Revision gastroplasty ....................................................................................................... C 

43850 .......................................................... Revise stomach-bowel fusion .......................................................................................... C 

43855 .......................................................... Revise stomach-bowel fusion .......................................................................................... C 

43860 .......................................................... Revise stomach-bowel fusion .......................................................................................... C 

43865 .......................................................... Revise stomach-bowel fusion .......................................................................................... C 

43880 .......................................................... Repair stomach-bowel fistula .......................................................................................... C 

44005 .......................................................... Freeing of bowel adhesion .............................................................................................. C 

44010 .......................................................... Incision of small bowel .................................................................................................... C 

44015 .......................................................... Insert needle cath bowel ................................................................................................. C 

44020 .......................................................... Explore small intestine ..................................................................................................... C 

44021 .......................................................... Decompress small bowel ................................................................................................. C 

44025 .......................................................... Incision of large bowel ..................................................................................................... C 

44050 .......................................................... Reduce bowel obstruction ............................................................................................... C 

44055 .......................................................... Correct malrotation of bowel ........................................................................................... C 

44110 .......................................................... Excise intestine lesion(s) ................................................................................................. C 

44111 .......................................................... Excision of bowel lesion(s) .............................................................................................. C 

44120 .......................................................... Removal of small intestine .............................................................................................. C 

44121 .......................................................... Removal of small intestine .............................................................................................. C 

44125 .......................................................... Removal of small intestine .............................................................................................. C 

44126 .......................................................... Enterectomy w/o taper, cong ........................................................................................... C 

44127 .......................................................... Enterectomy w/taper, cong .............................................................................................. C 

44128 .......................................................... Enterectomy cong, add-on .............................................................................................. C 

44130 .......................................................... Bowel to bowel fusion ...................................................................................................... C 

44132 .......................................................... Enterectomy, cadaver donor ........................................................................................... C 

44133 .......................................................... Enterectomy, live donor ................................................................................................... C 

44135 .......................................................... Intestine transplnt, cadaver ............................................................................................. C 

44136 .......................................................... Intestine transplant, live ................................................................................................... C 

44137 .......................................................... Remove intestinal allograft .............................................................................................. C 

44139 .......................................................... Mobilization of colon ........................................................................................................ C 

44140 .......................................................... Partial removal of colon ................................................................................................... C 

44141 .......................................................... Partial removal of colon ................................................................................................... C 

44143 .......................................................... Partial removal of colon ................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49967 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

44144 .......................................................... Partial removal of colon ................................................................................................... C 

44145 .......................................................... Partial removal of colon ................................................................................................... C 

44146 .......................................................... Partial removal of colon ................................................................................................... C 

44147 .......................................................... Partial removal of colon ................................................................................................... C 

44150 .......................................................... Removal of colon ............................................................................................................. C 

44151 .......................................................... Removal of colon/ileostomy ............................................................................................. C 

44152 .......................................................... Removal of colon/ileostomy ............................................................................................. C 

44153 .......................................................... Removal of colon/ileostomy ............................................................................................. C 

44155 .......................................................... Removal of colon/ileostomy ............................................................................................. C 

44156 .......................................................... Removal of colon/ileostomy ............................................................................................. C 

44160 .......................................................... Removal of colon ............................................................................................................. C 

44187 .......................................................... Lap, ileo/jejuno-stomy ...................................................................................................... C 

44188 .......................................................... Lap, colostomy ................................................................................................................. C 

44202 .......................................................... Lap, enterectomy ............................................................................................................. C 

44203 .......................................................... Lap resect s/intestine, addl .............................................................................................. C 

44204 .......................................................... Laparo partial colectomy ................................................................................................. C 

44205 .......................................................... Lap colectomy part w/ileum ............................................................................................. C 

44210 .......................................................... Laparo total proctocolectomy .......................................................................................... C 

44211 .......................................................... Laparo total proctocolectomy .......................................................................................... C 

44212 .......................................................... Laparo total proctocolectomy .......................................................................................... C 

44227 .......................................................... Lap, close enterostomy ................................................................................................... C 

44300 .......................................................... Open bowel to skin .......................................................................................................... C 

44310 .......................................................... Ileostomy/jejunostomy ..................................................................................................... C 

44314 .......................................................... Revision of ileostomy ....................................................................................................... C 

44316 .......................................................... Devise bowel pouch ........................................................................................................ C 

44320 .......................................................... Colostomy ........................................................................................................................ C 

44322 .......................................................... Colostomy with biopsies .................................................................................................. C 

44345 .......................................................... Revision of colostomy ...................................................................................................... C 

44346 .......................................................... Revision of colostomy ...................................................................................................... C 

44602 .......................................................... Suture, small intestine ..................................................................................................... C 

44603 .......................................................... Suture, small intestine ..................................................................................................... C 

44604 .......................................................... Suture, large intestine ...................................................................................................... C 

44605 .......................................................... Repair of bowel lesion ..................................................................................................... C 

44615 .......................................................... Intestinal stricturoplasty ................................................................................................... C 

44620 .......................................................... Repair bowel opening ...................................................................................................... C 

44625 .......................................................... Repair bowel opening ...................................................................................................... C 

44626 .......................................................... Repair bowel opening ...................................................................................................... C 

44640 .......................................................... Repair bowel-skin fistula .................................................................................................. C 

44650 .......................................................... Repair bowel fistula ......................................................................................................... C 

44660 .......................................................... Repair bowel-bladder fistula ............................................................................................ C 

44661 .......................................................... Repair bowel-bladder fistula ............................................................................................ C 

44680 .......................................................... Surgical revision, intestine ............................................................................................... C 

44700 .......................................................... Suspend bowel w/prosthesis ........................................................................................... C 

44715 .......................................................... Prepare donor intestine ................................................................................................... C 

44720 .......................................................... Prep donor intestine/venous ............................................................................................ C 

44721 .......................................................... Prep donor intestine/artery .............................................................................................. C 

44800 .......................................................... Excision of bowel pouch .................................................................................................. C 

44820 .......................................................... Excision of mesentery lesion ........................................................................................... C 

44850 .......................................................... Repair of mesentery ........................................................................................................ C 

44899 .......................................................... Bowel surgery procedure ................................................................................................. C 

44900 .......................................................... Drain app abscess, open ................................................................................................. C 

44950 .......................................................... Appendectomy ................................................................................................................. C 

44955 .......................................................... Appendectomy add-on ..................................................................................................... C 

44960 .......................................................... Appendectomy ................................................................................................................. C 

45110 .......................................................... Removal of rectum .......................................................................................................... C 

45111 .......................................................... Partial removal of rectum ................................................................................................ C 

45112 .......................................................... Removal of rectum .......................................................................................................... C 

45113 .......................................................... Partial proctectomy .......................................................................................................... C 

45114 .......................................................... Partial removal of rectum ................................................................................................ C 

45116 .......................................................... Partial removal of rectum ................................................................................................ C 

45119 .......................................................... Remove rectum w/reservoir ............................................................................................. C 

45120 .......................................................... Removal of rectum .......................................................................................................... C 

45121 .......................................................... Removal of rectum and colon ......................................................................................... C 

45123 .......................................................... Partial proctectomy .......................................................................................................... C 

45126 .......................................................... Pelvic exenteration .......................................................................................................... C 

45130 .......................................................... Excision of rectal prolapse .............................................................................................. C 

45135 .......................................................... Excision of rectal prolapse .............................................................................................. C 

45136 .......................................................... Excise ileoanal reservior .................................................................................................. C 


sroberts on PROD1PC70 with PROPOSALS
49968 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

45395 .......................................................... Lap, removal of rectum .................................................................................................... C 

45397 .......................................................... Lap, remove rectum w/pouch .......................................................................................... C 

45400 .......................................................... Laparoscopic proctopexy ................................................................................................. C 

45402 .......................................................... Lap proctopexy w/sig resect ............................................................................................ C 

45540 .......................................................... Correct rectal prolapse .................................................................................................... C 

45550 .......................................................... Repair rectum/remove sigmoid ........................................................................................ C 

45562 .......................................................... Exploration/repair of rectum ............................................................................................ C 

45563 .......................................................... Exploration/repair of rectum ............................................................................................ C 

45800 .......................................................... Repair rect/bladder fistula ................................................................................................ C 

45805 .......................................................... Repair fistula w/colostomy ............................................................................................... C 

45820 .......................................................... Repair rectourethral fistula .............................................................................................. C 

45825 .......................................................... Repair fistula w/colostomy ............................................................................................... C 

46705 .......................................................... Repair of anal stricture .................................................................................................... C 

46710 .......................................................... Repr per/vag pouch sngl proc ......................................................................................... C 

46712 .......................................................... Repr per/vag pouch dbl proc ........................................................................................... C 

46715 .......................................................... Rep perf anoper fistu ....................................................................................................... C 

46716 .......................................................... Rep perf anoper/vestib fistu ............................................................................................ C 

46730 .......................................................... Construction of absent anus ............................................................................................ C 

46735 .......................................................... Construction of absent anus ............................................................................................ C 

46740 .......................................................... Construction of absent anus ............................................................................................ C 

46742 .......................................................... Repair of imperforated anus ............................................................................................ C 

46744 .......................................................... Repair of cloacal anomaly ............................................................................................... C 

46746 .......................................................... Repair of cloacal anomaly ............................................................................................... C 

46748 .......................................................... Repair of cloacal anomaly ............................................................................................... C 

46751 .......................................................... Repair of anal sphincter .................................................................................................. C 

47010 .......................................................... Open drainage, liver lesion .............................................................................................. C 

47015 .......................................................... Inject/aspirate liver cyst ................................................................................................... C 

47100 .......................................................... Wedge biopsy of liver ...................................................................................................... C 

47120 .......................................................... Partial removal of liver ..................................................................................................... C 

47122 .......................................................... Extensive removal of liver ............................................................................................... C 

47125 .......................................................... Partial removal of liver ..................................................................................................... C 

47130 .......................................................... Partial removal of liver ..................................................................................................... C 

47133 .......................................................... Removal of donor liver .................................................................................................... C 

47135 .......................................................... Transplantation of liver .................................................................................................... C 

47136 .......................................................... Transplantation of liver .................................................................................................... C 

47140 .......................................................... Partial removal, donor liver .............................................................................................. C 

47141 .......................................................... Partial removal, donor liver .............................................................................................. C 

47142 .......................................................... Partial removal, donor liver .............................................................................................. C 

47143 .......................................................... Prep donor liver, whole .................................................................................................... C 

47144 .......................................................... Prep donor liver, 3-segment ............................................................................................ C 

47145 .......................................................... Prep donor liver, lobe split ............................................................................................... C 

47146 .......................................................... Prep donor liver/venous ................................................................................................... C 

47147 .......................................................... Prep donor liver/arterial ................................................................................................... C 

47300 .......................................................... Surgery for liver lesion ..................................................................................................... C 

47350 .......................................................... Repair liver wound ........................................................................................................... C 

47360 .......................................................... Repair liver wound ........................................................................................................... C 

47361 .......................................................... Repair liver wound ........................................................................................................... C 

47362 .......................................................... Repair liver wound ........................................................................................................... C 

47380 .......................................................... Open ablate liver tumor rf ................................................................................................ C 

47381 .......................................................... Open ablate liver tumor cryo ........................................................................................... C 

47400 .......................................................... Incision of liver duct ......................................................................................................... C 

47420 .......................................................... Incision of bile duct .......................................................................................................... C 

47425 .......................................................... Incision of bile duct .......................................................................................................... C 

47460 .......................................................... Incise bile duct sphincter ................................................................................................. C 

47480 .......................................................... Incision of gallbladder ...................................................................................................... C 

47550 .......................................................... Bile duct endoscopy add-on ............................................................................................ C 

47570 .......................................................... Laparo cholecystoenterostomy ........................................................................................ C 

47600 .......................................................... Removal of gallbladder .................................................................................................... C 

47605 .......................................................... Removal of gallbladder .................................................................................................... C 

47610 .......................................................... Removal of gallbladder .................................................................................................... C 

47612 .......................................................... Removal of gallbladder .................................................................................................... C 

47620 .......................................................... Removal of gallbladder .................................................................................................... C 

47700 .......................................................... Exploration of bile ducts .................................................................................................. C 

47701 .......................................................... Bile duct revision ............................................................................................................. C 

47711 .......................................................... Excision of bile duct tumor .............................................................................................. C 

47712 .......................................................... Excision of bile duct tumor .............................................................................................. C 

47715 .......................................................... Excision of bile duct cyst ................................................................................................. C 

47716 .......................................................... Fusion of bile duct cyst .................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49969 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

47720 .......................................................... Fuse gallbladder & bowel ................................................................................................ C 

47721 .......................................................... Fuse upper gi structures .................................................................................................. C 

47740 .......................................................... Fuse gallbladder & bowel ................................................................................................ C 

47741 .......................................................... Fuse gallbladder & bowel ................................................................................................ C 

47760 .......................................................... Fuse bile ducts and bowel ............................................................................................... C 

47765 .......................................................... Fuse liver ducts & bowel ................................................................................................. C 

47780 .......................................................... Fuse bile ducts and bowel ............................................................................................... C 

47785 .......................................................... Fuse bile ducts and bowel ............................................................................................... C 

47800 .......................................................... Reconstruction of bile ducts ............................................................................................ C 

47801 .......................................................... Placement, bile duct support ........................................................................................... C 

47802 .......................................................... Fuse liver duct & intestine ............................................................................................... C 

47900 .......................................................... Suture bile duct injury ...................................................................................................... C 

48000 .......................................................... Drainage of abdomen ...................................................................................................... C 

48001 .......................................................... Placement of drain, pancreas .......................................................................................... C 

48005 .......................................................... Resect/debride pancreas ................................................................................................. C 

48020 .......................................................... Removal of pancreatic stone ........................................................................................... C 

48100 .......................................................... Biopsy of pancreas, open ................................................................................................ C 

48120 .......................................................... Removal of pancreas lesion ............................................................................................ C 

48140 .......................................................... Partial removal of pancreas ............................................................................................. C 

48145 .......................................................... Partial removal of pancreas ............................................................................................. C 

48146 .......................................................... Pancreatectomy ............................................................................................................... C 

48148 .......................................................... Removal of pancreatic duct ............................................................................................. C 

48150 .......................................................... Partial removal of pancreas ............................................................................................. C 

48152 .......................................................... Pancreatectomy ............................................................................................................... C 

48153 .......................................................... Pancreatectomy ............................................................................................................... C 

48154 .......................................................... Pancreatectomy ............................................................................................................... C 

48155 .......................................................... Removal of pancreas ....................................................................................................... C 

48180 .......................................................... Fuse pancreas and bowel ............................................................................................... C 

48400 .......................................................... Injection, intraop add-on .................................................................................................. C 

48500 .......................................................... Surgery of pancreatic cyst ............................................................................................... C 

48510 .......................................................... Drain pancreatic pseudocyst ........................................................................................... C 

48520 .......................................................... Fuse pancreas cyst and bowel ........................................................................................ C 

48540 .......................................................... Fuse pancreas cyst and bowel ........................................................................................ C 

48545 .......................................................... Pancreatorrhaphy ............................................................................................................ C 

48547 .......................................................... Duodenal exclusion ......................................................................................................... C 

48551 .......................................................... Prep donor pancreas ....................................................................................................... C 

48552 .......................................................... Prep donor pancreas/venous .......................................................................................... C 

48554 .......................................................... Transpl allograft pancreas ............................................................................................... C 

48556 .......................................................... Removal, allograft pancreas ............................................................................................ C 

49000 .......................................................... Exploration of abdomen ................................................................................................... C 

49002 .......................................................... Reopening of abdomen ................................................................................................... C 

49010 .......................................................... Exploration behind abdomen ........................................................................................... C 

49020 .......................................................... Drain abdominal abscess ................................................................................................ C 

49040 .......................................................... Drain, open, abdom abscess ........................................................................................... C 

49060 .......................................................... Drain, open, retrop abscess ............................................................................................ C 

49062 .......................................................... Drain to peritoneal cavity ................................................................................................. C 

49201 .......................................................... Remove abdom lesion, complex ..................................................................................... C 

49215 .......................................................... Excise sacral spine tumor ............................................................................................... C 

49220 .......................................................... Multiple surgery, abdomen .............................................................................................. C 

49255 .......................................................... Removal of omentum ...................................................................................................... C 

49425 .......................................................... Insert abdomen-venous drain .......................................................................................... C 

49428 .......................................................... Ligation of shunt .............................................................................................................. C 

49605 .......................................................... Repair umbilical lesion ..................................................................................................... C 

49606 .......................................................... Repair umbilical lesion ..................................................................................................... C 

49610 .......................................................... Repair umbilical lesion ..................................................................................................... C 

49611 .......................................................... Repair umbilical lesion ..................................................................................................... C 

49900 .......................................................... Repair of abdominal wall ................................................................................................. C 

49904 .......................................................... Omental flap, extra-abdom .............................................................................................. C 

49905 .......................................................... Omental flap, intra-abdom ............................................................................................... C 

49906 .......................................................... Free omental flap, microvasc .......................................................................................... C 

50010 .......................................................... Exploration of kidney ....................................................................................................... C 

50040 .......................................................... Drainage of kidney ........................................................................................................... C 

50045 .......................................................... Exploration of kidney ....................................................................................................... C 

50060 .......................................................... Removal of kidney stone ................................................................................................. C 

50065 .......................................................... Incision of kidney ............................................................................................................. C 

50070 .......................................................... Incision of kidney ............................................................................................................. C 

50075 .......................................................... Removal of kidney stone ................................................................................................. C 

50100 .......................................................... Revise kidney blood vessels ........................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49970 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

50120 .......................................................... Exploration of kidney ....................................................................................................... C 

50125 .......................................................... Explore and drain kidney ................................................................................................. C 

50130 .......................................................... Removal of kidney stone ................................................................................................. C 

50135 .......................................................... Exploration of kidney ....................................................................................................... C 

50205 .......................................................... Biopsy of kidney .............................................................................................................. C 

50220 .......................................................... Remove kidney, open ...................................................................................................... C 

50225 .......................................................... Removal kidney open, complex ...................................................................................... C 

50230 .......................................................... Removal kidney open, radical ......................................................................................... C 

50234 .......................................................... Removal of kidney & ureter ............................................................................................. C 

50236 .......................................................... Removal of kidney & ureter ............................................................................................. C 

50240 .......................................................... Partial removal of kidney ................................................................................................. C 

50250 .......................................................... Cryoablate renal mass open ........................................................................................... C 

50280 .......................................................... Removal of kidney lesion ................................................................................................ C 

50290 .......................................................... Removal of kidney lesion ................................................................................................ C 

50300 .......................................................... Remove cadaver donor kidney ........................................................................................ C 

50320 .......................................................... Remove kidney, living donor ........................................................................................... C 

50323 .......................................................... Prep cadaver renal allograft ............................................................................................ C 

50325 .......................................................... Prep donor renal graft ..................................................................................................... C 

50327 .......................................................... Prep renal graft/venous ................................................................................................... C 

50328 .......................................................... Prep renal graft/arterial .................................................................................................... C 

50329 .......................................................... Prep renal graft/ureteral ................................................................................................... C 

50340 .......................................................... Removal of kidney ........................................................................................................... C 

50360 .......................................................... Transplantation of kidney ................................................................................................ C 

50365 .......................................................... Transplantation of kidney ................................................................................................ C 

50370 .......................................................... Remove transplanted kidney ........................................................................................... C 

50380 .......................................................... Reimplantation of kidney ................................................................................................. C 

50400 .......................................................... Revision of kidney/ureter ................................................................................................. C 

50405 .......................................................... Revision of kidney/ureter ................................................................................................. C 

50500 .......................................................... Repair of kidney wound ................................................................................................... C 

50520 .......................................................... Close kidney-skin fistula .................................................................................................. C 

50525 .......................................................... Repair renal-abdomen fistula .......................................................................................... C 

50526 .......................................................... Repair renal-abdomen fistula .......................................................................................... C 

50540 .......................................................... Revision of horseshoe kidney ......................................................................................... C 

50545 .......................................................... Laparo radical nephrectomy ............................................................................................ C 

50546 .......................................................... Laparoscopic nephrectomy .............................................................................................. C 

50547 .......................................................... Laparo removal donor kidney .......................................................................................... C 

50548 .......................................................... Laparo remove w/ureter .................................................................................................. C 

50580 .......................................................... Kidney endoscopy & treatment ....................................................................................... C 

50600 .......................................................... Exploration of ureter ........................................................................................................ C 

50605 .......................................................... Insert ureteral support ..................................................................................................... C 

50610 .......................................................... Removal of ureter stone .................................................................................................. C 

50620 .......................................................... Removal of ureter stone .................................................................................................. C 

50630 .......................................................... Removal of ureter stone .................................................................................................. C 

50650 .......................................................... Removal of ureter ............................................................................................................ C 

50660 .......................................................... Removal of ureter ............................................................................................................ C 

50700 .......................................................... Revision of ureter ............................................................................................................ C 

50715 .......................................................... Release of ureter ............................................................................................................. C 

50722 .......................................................... Release of ureter ............................................................................................................. C 

50725 .......................................................... Release/revise ureter ....................................................................................................... C 

50727 .......................................................... Revise ureter ................................................................................................................... C 

50728 .......................................................... Revise ureter ................................................................................................................... C 

50740 .......................................................... Fusion of ureter & kidney ................................................................................................ C 

50750 .......................................................... Fusion of ureter & kidney ................................................................................................ C 

50760 .......................................................... Fusion of ureters .............................................................................................................. C 

50770 .......................................................... Splicing of ureters ............................................................................................................ C 

50780 .......................................................... Reimplant ureter in bladder ............................................................................................. C 

50782 .......................................................... Reimplant ureter in bladder ............................................................................................. C 

50783 .......................................................... Reimplant ureter in bladder ............................................................................................. C 

50785 .......................................................... Reimplant ureter in bladder ............................................................................................. C 

50800 .......................................................... Implant ureter in bowel .................................................................................................... C 

50810 .......................................................... Fusion of ureter & bowel ................................................................................................. C 

50815 .......................................................... Urine shunt to intestine .................................................................................................... C 

50820 .......................................................... Construct bowel bladder .................................................................................................. C 

50825 .......................................................... Construct bowel bladder .................................................................................................. C 

50830 .......................................................... Revise urine flow ............................................................................................................. C 

50840 .......................................................... Replace ureter by bowel .................................................................................................. C 

50845 .......................................................... Appendico-vesicostomy ................................................................................................... C 

50860 .......................................................... Transplant ureter to skin .................................................................................................. C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49971 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

50900 .......................................................... Repair of ureter ................................................................................................................ C 

50920 .......................................................... Closure ureter/skin fistula ................................................................................................ C 

50930 .......................................................... Closure ureter/bowel fistula ............................................................................................. C 

50940 .......................................................... Release of ureter ............................................................................................................. C 

51060 .......................................................... Removal of ureter stone .................................................................................................. C 

51525 .......................................................... Removal of bladder lesion ............................................................................................... C 

51530 .......................................................... Removal of bladder lesion ............................................................................................... C 

51535 .......................................................... Repair of ureter lesion ..................................................................................................... C 

51550 .......................................................... Partial removal of bladder ............................................................................................... C 

51555 .......................................................... Partial removal of bladder ............................................................................................... C 

51565 .......................................................... Revise bladder & ureter(s) .............................................................................................. C 

51570 .......................................................... Removal of bladder ......................................................................................................... C 

51575 .......................................................... Removal of bladder & nodes ........................................................................................... C 

51580 .......................................................... Remove bladder/revise tract ............................................................................................ C 

51585 .......................................................... Removal of bladder & nodes ........................................................................................... C 

51590 .......................................................... Remove bladder/revise tract ............................................................................................ C 

51595 .......................................................... Remove bladder/revise tract ............................................................................................ C 

51596 .......................................................... Remove bladder/create pouch ........................................................................................ C 

51597 .......................................................... Removal of pelvic structures ........................................................................................... C 

51800 .......................................................... Revision of bladder/urethra ............................................................................................. C 

51820 .......................................................... Revision of urinary tract ................................................................................................... C 

51840 .......................................................... Attach bladder/urethra ..................................................................................................... C 

51841 .......................................................... Attach bladder/urethra ..................................................................................................... C 

51845 .......................................................... Repair bladder neck ........................................................................................................ C 

51860 .......................................................... Repair of bladder wound ................................................................................................. C 

51865 .......................................................... Repair of bladder wound ................................................................................................. C 

51900 .......................................................... Repair bladder/vagina lesion ........................................................................................... C 

51920 .......................................................... Close bladder-uterus fistula ............................................................................................. C 

51925 .......................................................... Hysterectomy/bladder repair ............................................................................................ C 

51940 .......................................................... Correction of bladder defect ............................................................................................ C 

51960 .......................................................... Revision of bladder & bowel ............................................................................................ C 

51980 .......................................................... Construct bladder opening .............................................................................................. C 

53415 .......................................................... Reconstruction of urethra ................................................................................................ C 

53448 .......................................................... Remov/replc ur sphinctr comp ......................................................................................... C 

54125 .......................................................... Removal of penis ............................................................................................................. C 

54130 .......................................................... Remove penis & nodes ................................................................................................... C 

54135 .......................................................... Remove penis & nodes ................................................................................................... C 

54332 .......................................................... Revise penis/urethra ........................................................................................................ C 

54336 .......................................................... Revise penis/urethra ........................................................................................................ C 

54390 .......................................................... Repair penis and bladder ................................................................................................ C 

54411 .......................................................... Remov/replc penis pros, comp ........................................................................................ C 

54417 .......................................................... Remv/replc penis pros, compl ......................................................................................... C 

54430 .......................................................... Revision of penis ............................................................................................................. C 

54535 .......................................................... Extensive testis surgery ................................................................................................... C 

54650 .......................................................... Orchiopexy (Fowler-Stephens) ........................................................................................ C 

55605 .......................................................... Incise sperm duct pouch ................................................................................................. C 

55650 .......................................................... Remove sperm duct pouch ............................................................................................. C 

55801 .......................................................... Removal of prostate ........................................................................................................ C 

55810 .......................................................... Extensive prostate surgery .............................................................................................. C 

55812 .......................................................... Extensive prostate surgery .............................................................................................. C 

55815 .......................................................... Extensive prostate surgery .............................................................................................. C 

55821 .......................................................... Removal of prostate ........................................................................................................ C 

55831 .......................................................... Removal of prostate ........................................................................................................ C 

55840 .......................................................... Extensive prostate surgery .............................................................................................. C 

55842 .......................................................... Extensive prostate surgery .............................................................................................. C 

55845 .......................................................... Extensive prostate surgery .............................................................................................. C 

55862 .......................................................... Extensive prostate surgery .............................................................................................. C 

55865 .......................................................... Extensive prostate surgery .............................................................................................. C 

55866 .......................................................... Laparo radical prostatectomy .......................................................................................... C 

56630 .......................................................... Extensive vulva surgery ................................................................................................... C 

56631 .......................................................... Extensive vulva surgery ................................................................................................... C 

56632 .......................................................... Extensive vulva surgery ................................................................................................... C 

56633 .......................................................... Extensive vulva surgery ................................................................................................... C 

56634 .......................................................... Extensive vulva surgery ................................................................................................... C 

56637 .......................................................... Extensive vulva surgery ................................................................................................... C 

56640 .......................................................... Extensive vulva surgery ................................................................................................... C 

57110 .......................................................... Remove vagina wall, complete ........................................................................................ C 

57111 .......................................................... Remove vagina tissue, compl ......................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49972 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

57112 .......................................................... Vaginectomy w/nodes, compl .......................................................................................... C 

57270 .......................................................... Repair of bowel pouch ..................................................................................................... C 

57280 .......................................................... Suspension of vagina ...................................................................................................... C 

57282 .......................................................... Colpopexy, extraperitoneal .............................................................................................. C 

57283 .......................................................... Colpopexy, intraperitoneal ............................................................................................... C 

57305 .......................................................... Repair rectum-vagina fistula ............................................................................................ C 

57307 .......................................................... Fistula repair & colostomy ............................................................................................... C 

57308 .......................................................... Fistula repair, transperine ................................................................................................ C 

57311 .......................................................... Repair urethrovaginal lesion ............................................................................................ C 

57531 .......................................................... Removal of cervix, radical ............................................................................................... C 

57540 .......................................................... Removal of residual cervix .............................................................................................. C 

57545 .......................................................... Remove cervix/repair pelvis ............................................................................................ C 

58140 .......................................................... Myomectomy abdom method .......................................................................................... C 

58146 .......................................................... Myomectomy abdom complex ......................................................................................... C 

58150 .......................................................... Total hysterectomy .......................................................................................................... C 

58152 .......................................................... Total hysterectomy .......................................................................................................... C 

58180 .......................................................... Partial hysterectomy ........................................................................................................ C 

58200 .......................................................... Extensive hysterectomy ................................................................................................... C 

58210 .......................................................... Extensive hysterectomy ................................................................................................... C 

58240 .......................................................... Removal of pelvis contents ............................................................................................. C 

58260 .......................................................... Vaginal hysterectomy ...................................................................................................... C 

58262 .......................................................... Vag hyst including t/o ...................................................................................................... C 

58263 .......................................................... Vag hyst w/t/o & vag repair ............................................................................................. C 

58267 .......................................................... Vag hyst w/urinary repair ................................................................................................. C 

58270 .......................................................... Vag hyst w/enterocele repair ........................................................................................... C 

58275 .......................................................... Hysterectomy/revise vagina ............................................................................................. C 

58280 .......................................................... Hysterectomy/revise vagina ............................................................................................. C 

58285 .......................................................... Extensive hysterectomy ................................................................................................... C 

58290 .......................................................... Vag hyst complex ............................................................................................................ C 

58291 .......................................................... Vag hyst incl t/o, complex ............................................................................................... C 

58292 .......................................................... Vag hyst t/o & repair, compl ............................................................................................ C 

58293 .......................................................... Vag hyst w/uro repair, compl ........................................................................................... C 

58294 .......................................................... Vag hyst w/enterocele, compl ......................................................................................... C 

58400 .......................................................... Suspension of uterus ....................................................................................................... C 

58410 .......................................................... Suspension of uterus ....................................................................................................... C 

58520 .......................................................... Repair of ruptured uterus ................................................................................................ C 

58540 .......................................................... Revision of uterus ............................................................................................................ C 

58605 .......................................................... Division of fallopian tube ................................................................................................. C 

58611 .......................................................... Ligate oviduct(s) add-on .................................................................................................. C 

58700 .......................................................... Removal of fallopian tube ................................................................................................ C 

58720 .......................................................... Removal of ovary/tube(s) ................................................................................................ C 

58740 .......................................................... Revise fallopian tube(s) ................................................................................................... C 

58750 .......................................................... Repair oviduct .................................................................................................................. C 

58752 .......................................................... Revise ovarian tube(s) ..................................................................................................... C 

58760 .......................................................... Remove tubal obstruction ................................................................................................ C 

58805 .......................................................... Drainage of ovarian cyst(s) ............................................................................................. C 

58822 .......................................................... Drain ovary abscess, percut ............................................................................................ C 

58825 .......................................................... Transposition, ovary(s) .................................................................................................... C 

58940 .......................................................... Removal of ovary(s) ........................................................................................................ C 

58943 .......................................................... Removal of ovary(s) ........................................................................................................ C 

58950 .......................................................... Resect ovarian malignancy ............................................................................................. C 

58951 .......................................................... Resect ovarian malignancy ............................................................................................. C 

58952 .......................................................... Resect ovarian malignancy ............................................................................................. C 

58953 .......................................................... Tah, rad dissect for debulk .............................................................................................. C 

58954 .......................................................... Tah rad debulk/lymph remove ......................................................................................... C 

58956 .......................................................... Bso, omentectomy w/tah ................................................................................................. C 

58960 .......................................................... Exploration of abdomen ................................................................................................... C 

59120 .......................................................... Treat ectopic pregnancy .................................................................................................. C 

59121 .......................................................... Treat ectopic pregnancy .................................................................................................. C 

59130 .......................................................... Treat ectopic pregnancy .................................................................................................. C 

59135 .......................................................... Treat ectopic pregnancy .................................................................................................. C 

59136 .......................................................... Treat ectopic pregnancy .................................................................................................. C 

59140 .......................................................... Treat ectopic pregnancy .................................................................................................. C 

59325 .......................................................... Revision of cervix ............................................................................................................ C 

59350 .......................................................... Repair of uterus ............................................................................................................... C 

59514 .......................................................... Cesarean delivery only .................................................................................................... C 

59525 .......................................................... Remove uterus after cesarean ........................................................................................ C 

59620 .......................................................... Attempted vbac delivery only .......................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49973 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

59830 .......................................................... Treat uterus infection ....................................................................................................... C 

59850 .......................................................... Abortion ............................................................................................................................ C 

59851 .......................................................... Abortion ............................................................................................................................ C 

59852 .......................................................... Abortion ............................................................................................................................ C 

59855 .......................................................... Abortion ............................................................................................................................ C 

59856 .......................................................... Abortion ............................................................................................................................ C 

59857 .......................................................... Abortion ............................................................................................................................ C 

60254 .......................................................... Extensive thyroid surgery ................................................................................................ C 

60270 .......................................................... Removal of thyroid ........................................................................................................... C 

60271 .......................................................... Removal of thyroid ........................................................................................................... C 

60502 .......................................................... Re-explore parathyroids .................................................................................................. C 

60505 .......................................................... Explore parathyroid glands .............................................................................................. C 

60520 .......................................................... Removal of thymus gland ................................................................................................ C 

60521 .......................................................... Removal of thymus gland ................................................................................................ C 

60522 .......................................................... Removal of thymus gland ................................................................................................ C 

60540 .......................................................... Explore adrenal gland ...................................................................................................... C 

60545 .......................................................... Explore adrenal gland ...................................................................................................... C 

60600 .......................................................... Remove carotid body lesion ............................................................................................ C 

60605 .......................................................... Remove carotid body lesion ............................................................................................ C 

60650 .......................................................... Laparoscopy adrenalectomy ............................................................................................ C 

61105 .......................................................... Twist drill hole .................................................................................................................. C 

61107 .......................................................... Drill skull for implantation ................................................................................................ C 

61108 .......................................................... Drill skull for drainage ...................................................................................................... C 

61120 .......................................................... Burr hole for puncture ...................................................................................................... C 

61140 .......................................................... Pierce skull for biopsy ..................................................................................................... C 

61150 .......................................................... Pierce skull for drainage .................................................................................................. C 

61151 .......................................................... Pierce skull for drainage .................................................................................................. C 

61154 .......................................................... Pierce skull & remove clot ............................................................................................... C 

61156 .......................................................... Pierce skull for drainage .................................................................................................. C 

61210 .......................................................... Pierce skull, implant device ............................................................................................. C 

61250 .......................................................... Pierce skull & explore ...................................................................................................... C 

61253 .......................................................... Pierce skull & explore ...................................................................................................... C 

61304 .......................................................... Open skull for exploration ................................................................................................ C 

61305 .......................................................... Open skull for exploration ................................................................................................ C 

61312 .......................................................... Open skull for drainage ................................................................................................... C 

61313 .......................................................... Open skull for drainage ................................................................................................... C 

61314 .......................................................... Open skull for drainage ................................................................................................... C 

61315 .......................................................... Open skull for drainage ................................................................................................... C 

61316 .......................................................... Implt cran bone flap to abdo ........................................................................................... C 

61320 .......................................................... Open skull for drainage ................................................................................................... C 

61321 .......................................................... Open skull for drainage ................................................................................................... C 

61322 .......................................................... Decompressive craniotomy ............................................................................................. C 

61323 .......................................................... Decompressive lobectomy ............................................................................................... C 

61332 .......................................................... Explore/biopsy eye socket ............................................................................................... C 

61333 .......................................................... Explore orbit/remove lesion ............................................................................................. C 

61340 .......................................................... Subtemporal decompression ........................................................................................... C 

61343 .......................................................... Incise skull (press relief) .................................................................................................. C 

61345 .......................................................... Relieve cranial pressure .................................................................................................. C 

61440 .......................................................... Incise skull for surgery ..................................................................................................... C 

61450 .......................................................... Incise skull for surgery ..................................................................................................... C 

61458 .......................................................... Incise skull for brain wound ............................................................................................. C 

61460 .......................................................... Incise skull for surgery ..................................................................................................... C 

61470 .......................................................... Incise skull for surgery ..................................................................................................... C 

61480 .......................................................... Incise skull for surgery ..................................................................................................... C 

61490 .......................................................... Incise skull for surgery ..................................................................................................... C 

61500 .......................................................... Removal of skull lesion .................................................................................................... C 

61501 .......................................................... Remove infected skull bone ............................................................................................ C 

61510 .......................................................... Removal of brain lesion ................................................................................................... C 

61512 .......................................................... Remove brain lining lesion .............................................................................................. C 

61514 .......................................................... Removal of brain abscess ............................................................................................... C 

61516 .......................................................... Removal of brain lesion ................................................................................................... C 

61517 .......................................................... Implt brain chemotx add-on ............................................................................................. C 

61518 .......................................................... Removal of brain lesion ................................................................................................... C 

61519 .......................................................... Remove brain lining lesion .............................................................................................. C 

61520 .......................................................... Removal of brain lesion ................................................................................................... C 

61521 .......................................................... Removal of brain lesion ................................................................................................... C 

61522 .......................................................... Removal of brain abscess ............................................................................................... C 

61524 .......................................................... Removal of brain lesion ................................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
49974 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

61526 .......................................................... Removal of brain lesion ................................................................................................... C 

61530 .......................................................... Removal of brain lesion ................................................................................................... C 

61531 .......................................................... Implant brain electrodes .................................................................................................. C 

61533 .......................................................... Implant brain electrodes .................................................................................................. C 

61534 .......................................................... Removal of brain lesion ................................................................................................... C 

61535 .......................................................... Remove brain electrodes ................................................................................................. C 

61536 .......................................................... Removal of brain lesion ................................................................................................... C 

61537 .......................................................... Removal of brain tissue ................................................................................................... C 

61538 .......................................................... Removal of brain tissue ................................................................................................... C 

61539 .......................................................... Removal of brain tissue ................................................................................................... C 

61540 .......................................................... Removal of brain tissue ................................................................................................... C 

61541 .......................................................... Incision of brain tissue ..................................................................................................... C 

61542 .......................................................... Removal of brain tissue ................................................................................................... C 

61543 .......................................................... Removal of brain tissue ................................................................................................... C 

61544 .......................................................... Remove & treat brain lesion ............................................................................................ C 

61545 .......................................................... Excision of brain tumor .................................................................................................... C 

61546 .......................................................... Removal of pituitary gland ............................................................................................... C 

61548 .......................................................... Removal of pituitary gland ............................................................................................... C 

61550 .......................................................... Release of skull seams ................................................................................................... C 

61552 .......................................................... Release of skull seams ................................................................................................... C 

61556 .......................................................... Incise skull/sutures .......................................................................................................... C 

61557 .......................................................... Incise skull/sutures .......................................................................................................... C 

61558 .......................................................... Excision of skull/sutures .................................................................................................. C 

61559 .......................................................... Excision of skull/sutures .................................................................................................. C 

61563 .......................................................... Excision of skull tumor ..................................................................................................... C 

61564 .......................................................... Excision of skull tumor ..................................................................................................... C 

61566 .......................................................... Removal of brain tissue ................................................................................................... C 

61567 .......................................................... Incision of brain tissue ..................................................................................................... C 

61570 .......................................................... Remove foreign body, brain ............................................................................................ C 

61571 .......................................................... Incise skull for brain wound ............................................................................................. C 

61575 .......................................................... Skull base/brainstem surgery .......................................................................................... C 

61576 .......................................................... Skull base/brainstem surgery .......................................................................................... C 

61580 .......................................................... Craniofacial approach, skull ............................................................................................ C 

61581 .......................................................... Craniofacial approach, skull ............................................................................................ C 

61582 .......................................................... Craniofacial approach, skull ............................................................................................ C 

61583 .......................................................... Craniofacial approach, skull ............................................................................................ C 

61584 .......................................................... Orbitocranial approach/skull ............................................................................................ C 

61585 .......................................................... Orbitocranial approach/skull ............................................................................................ C 

61586 .......................................................... Resect nasopharynx, skull ............................................................................................... C 

61590 .......................................................... Infratemporal approach/skull ........................................................................................... C 

61591 .......................................................... Infratemporal approach/skull ........................................................................................... C 

61592 .......................................................... Orbitocranial approach/skull ............................................................................................ C 

61595 .......................................................... Transtemporal approach/skull ......................................................................................... C 

61596 .......................................................... Transcochlear approach/skull .......................................................................................... C 

61597 .......................................................... Transcondylar approach/skull .......................................................................................... C 

61598 .......................................................... Transpetrosal approach/skull ........................................................................................... C 

61600 .......................................................... Resect/excise cranial lesion ............................................................................................ C 

61601 .......................................................... Resect/excise cranial lesion ............................................................................................ C 

61605 .......................................................... Resect/excise cranial lesion ............................................................................................ C 

61606 .......................................................... Resect/excise cranial lesion ............................................................................................ C 

61607 .......................................................... Resect/excise cranial lesion ............................................................................................ C 

61608 .......................................................... Resect/excise cranial lesion ............................................................................................ C 

61609 .......................................................... Transect artery, sinus ...................................................................................................... C 

61610 .......................................................... Transect artery, sinus ...................................................................................................... C 

61611 .......................................................... Transect artery, sinus ...................................................................................................... C 

61612 .......................................................... Transect artery, sinus ...................................................................................................... C 

61613 .......................................................... Remove aneurysm, sinus ................................................................................................ C 

61615 .......................................................... Resect/excise lesion, skull ............................................................................................... C 

61616 .......................................................... Resect/excise lesion, skull ............................................................................................... C 

61618 .......................................................... Repair dura ...................................................................................................................... C 

61619 .......................................................... Repair dura ...................................................................................................................... C 

61624 .......................................................... Transcath occlusion, cns ................................................................................................. C 

61680 .......................................................... Intracranial vessel surgery ............................................................................................... C 

61682 .......................................................... Intracranial vessel surgery ............................................................................................... C 

61684 .......................................................... Intracranial vessel surgery ............................................................................................... C 

61686 .......................................................... Intracranial vessel surgery ............................................................................................... C 

61690 .......................................................... Intracranial vessel surgery ............................................................................................... C 

61692 .......................................................... Intracranial vessel surgery ............................................................................................... C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49975 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

61697 .......................................................... Brain aneurysm repr, complx .......................................................................................... C 

61698 .......................................................... Brain aneurysm repr, complx .......................................................................................... C 

61700 .......................................................... Brain aneurysm repr, simple ........................................................................................... C 

61702 .......................................................... Inner skull vessel surgery ................................................................................................ C 

61703 .......................................................... Clamp neck artery ........................................................................................................... C 

61705 .......................................................... Revise circulation to head ............................................................................................... C 

61708 .......................................................... Revise circulation to head ............................................................................................... C 

61710 .......................................................... Revise circulation to head ............................................................................................... C 

61711 .......................................................... Fusion of skull arteries .................................................................................................... C 

61735 .......................................................... Incise skull/brain surgery ................................................................................................. C 

61750 .......................................................... Incise skull/brain biopsy ................................................................................................... C 

61751 .......................................................... Brain biopsy w/ct/mr guide .............................................................................................. C 

61760 .......................................................... Implant brain electrodes .................................................................................................. C 

61770 .......................................................... Incise skull for treatment ................................................................................................. C 

61850 .......................................................... Implant neuroelectrodes .................................................................................................. C 

61860 .......................................................... Implant neuroelectrodes .................................................................................................. C 

61863 .......................................................... Implant neuroelectrode .................................................................................................... C 

61864 .......................................................... Implant neuroelectrde, addl ............................................................................................. C 

61867 .......................................................... Implant neuroelectrode .................................................................................................... C 

61868 .......................................................... Implant neuroelectrde, add’l ............................................................................................ C 

61870 .......................................................... Implant neuroelectrodes .................................................................................................. C 

61875 .......................................................... Implant neuroelectrodes .................................................................................................. C 

62005 .......................................................... Treat skull fracture ........................................................................................................... C 

62010 .......................................................... Treatment of head injury ................................................................................................. C 

62100 .......................................................... Repair brain fluid leakage ................................................................................................ C 

62115 .......................................................... Reduction of skull defect ................................................................................................. C 

62116 .......................................................... Reduction of skull defect ................................................................................................. C 

62117 .......................................................... Reduction of skull defect ................................................................................................. C 

62120 .......................................................... Repair skull cavity lesion ................................................................................................. C 

62121 .......................................................... Incise skull repair ............................................................................................................. C 

62140 .......................................................... Repair of skull defect ....................................................................................................... C 

62141 .......................................................... Repair of skull defect ....................................................................................................... C 

62142 .......................................................... Remove skull plate/flap ................................................................................................... C 

62143 .......................................................... Replace skull plate/flap .................................................................................................... C 

62145 .......................................................... Repair of skull & brain ..................................................................................................... C 

62146 .......................................................... Repair of skull with graft .................................................................................................. C 

62147 .......................................................... Repair of skull with graft .................................................................................................. C 

62148 .......................................................... Retr bone flap to fix skull ................................................................................................. C 

62161 .......................................................... Dissect brain w/scope ...................................................................................................... C 

62162 .......................................................... Remove colloid cyst w/scope .......................................................................................... C 

62163 .......................................................... Neuroendoscopy w/fb removal ........................................................................................ C 

62164 .......................................................... Remove brain tumor w/scope .......................................................................................... C 

62165 .......................................................... Remove pituit tumor w/scope .......................................................................................... C 

62180 .......................................................... Establish brain cavity shunt ............................................................................................. C 

62190 .......................................................... Establish brain cavity shunt ............................................................................................. C 

62192 .......................................................... Establish brain cavity shunt ............................................................................................. C 

62200 .......................................................... Establish brain cavity shunt ............................................................................................. C 

62201 .......................................................... Brain cavity shunt w/scope .............................................................................................. C 

62220 .......................................................... Establish brain cavity shunt ............................................................................................. C 

62223 .......................................................... Establish brain cavity shunt ............................................................................................. C 

62256 .......................................................... Remove brain cavity shunt .............................................................................................. C 

62258 .......................................................... Replace brain cavity shunt .............................................................................................. C 

63043 .......................................................... Laminotomy, add’l cervical .............................................................................................. C 

63044 .......................................................... Laminotomy, add’l lumbar ............................................................................................... C 

63050 .......................................................... Cervical laminoplasty ....................................................................................................... C 

63051 .......................................................... C-laminoplasty w/graft/plate ............................................................................................ C 

63076 .......................................................... Neck spine disk surgery .................................................................................................. C 

63077 .......................................................... Spine disk surgery, thorax ............................................................................................... C 

63078 .......................................................... Spine disk surgery, thorax ............................................................................................... C 

63081 .......................................................... Removal of vertebral body .............................................................................................. C 

63082 .......................................................... Remove vertebral body add-on ....................................................................................... C 

63085 .......................................................... Removal of vertebral body .............................................................................................. C 

63086 .......................................................... Remove vertebral body add-on ....................................................................................... C 

63087 .......................................................... Removal of vertebral body .............................................................................................. C 

63088 .......................................................... Remove vertebral body add-on ....................................................................................... C 

63090 .......................................................... Removal of vertebral body .............................................................................................. C 

63091 .......................................................... Remove vertebral body add-on ....................................................................................... C 

63101 .......................................................... Removal of vertebral body .............................................................................................. C 


sroberts on PROD1PC70 with PROPOSALS
49976 Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

63102 .......................................................... Removal of vertebral body .............................................................................................. C 

63103 .......................................................... Remove vertebral body add-on ....................................................................................... C 

63170 .......................................................... Incise spinal cord tract(s) ................................................................................................ C 

63172 .......................................................... Drainage of spinal cyst .................................................................................................... C 

63173 .......................................................... Drainage of spinal cyst .................................................................................................... C 

63180 .......................................................... Revise spinal cord ligaments ........................................................................................... C 

63182 .......................................................... Revise spinal cord ligaments ........................................................................................... C 

63185 .......................................................... Incise spinal column/nerves ............................................................................................ C 

63190 .......................................................... Incise spinal column/nerves ............................................................................................ C 

63191 .......................................................... Incise spinal column/nerves ............................................................................................ C 

63194 .......................................................... Incise spinal column & cord ............................................................................................ C 

63195 .......................................................... Incise spinal column & cord ............................................................................................ C 

63196 .......................................................... Incise spinal column & cord ............................................................................................ C 

63197 .......................................................... Incise spinal column & cord ............................................................................................ C 

63198 .......................................................... Incise spinal column & cord ............................................................................................ C 

63199 .......................................................... Incise spinal column & cord ............................................................................................ C 

63200 .......................................................... Release of spinal cord ..................................................................................................... C 

63250 .......................................................... Revise spinal cord vessels .............................................................................................. C 

63251 .......................................................... Revise spinal cord vessels .............................................................................................. C 

63252 .......................................................... Revise spinal cord vessels .............................................................................................. C 

63265 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63266 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63267 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63268 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63270 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63271 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63272 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63273 .......................................................... Excise intraspinal lesion .................................................................................................. C 

63275 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63276 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63277 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63278 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63280 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63281 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63282 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63283 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63285 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63286 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63287 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63290 .......................................................... Biopsy/excise spinal tumor .............................................................................................. C 

63295 .......................................................... Repair of laminectomy defect .......................................................................................... C 

63300 .......................................................... Removal of vertebral body .............................................................................................. C 

63301 .......................................................... Removal of vertebral body .............................................................................................. C 

63302 .......................................................... Removal of vertebral body .............................................................................................. C 

63303 .......................................................... Removal of vertebral body .............................................................................................. C 

63304 .......................................................... Removal of vertebral body .............................................................................................. C 

63305 .......................................................... Removal of vertebral body .............................................................................................. C 

63306 .......................................................... Removal of vertebral body .............................................................................................. C 

63307 .......................................................... Removal of vertebral body .............................................................................................. C 

63308 .......................................................... Remove vertebral body add-on ....................................................................................... C 

63700 .......................................................... Repair of spinal herniation ............................................................................................... C 

63702 .......................................................... Repair of spinal herniation ............................................................................................... C 

63704 .......................................................... Repair of spinal herniation ............................................................................................... C 

63706 .......................................................... Repair of spinal herniation ............................................................................................... C 

63707 .......................................................... Repair spinal fluid leakage .............................................................................................. C 

63709 .......................................................... Repair spinal fluid leakage .............................................................................................. C 

63710 .......................................................... Graft repair of spine defect .............................................................................................. C 

63740 .......................................................... Install spinal shunt ........................................................................................................... C 

64752 .......................................................... Incision of vagus nerve .................................................................................................... C 

64755 .......................................................... Incision of stomach nerves .............................................................................................. C 

64760 .......................................................... Incision of vagus nerve .................................................................................................... C 

64809 .......................................................... Remove sympathetic nerves ........................................................................................... C 

64818 .......................................................... Remove sympathetic nerves ........................................................................................... C 

64866 .......................................................... Fusion of facial/other nerve ............................................................................................. C 

64868 .......................................................... Fusion of facial/other nerve ............................................................................................. C 

65273 .......................................................... Repair of eye wound ....................................................................................................... C 

69155 .......................................................... Extensive ear/neck surgery ............................................................................................. C 

69535 .......................................................... Remove part of temporal bone ........................................................................................ C 


sroberts on PROD1PC70 with PROPOSALS
Federal Register / Vol. 71, No. 163 / Wednesday, August 23, 2006 / Proposed Rules 49977 

ADDENDUM E.—CPT CODES THAT ARE PAID ONLY AS INPATIENT PROCEDURES—Continued 

CPT/HCPCS Description 

CY 2007 

Proposed 

Rule 

Status 

Indicator 

69554 .......................................................... Remove ear lesion ........................................................................................................... C 

69950 .......................................................... Incise inner ear nerve ...................................................................................................... C 

69970 .......................................................... Remove inner ear lesion ................................................................................................. C 

75900 .......................................................... Intravascular cath exchange ............................................................................................ C 

75952 .......................................................... Endovasc repair abdom aorta ......................................................................................... C 

75953 .......................................................... Abdom aneurysm endovas rpr ........................................................................................ C 

75954 .......................................................... Iliac aneurysm endovas rpr ............................................................................................. C 

75956 .......................................................... Xray, endovasc thor ao repr ............................................................................................ C 

75957 .......................................................... Xray, endovasc thor ao repr ............................................................................................ C 

75958 .......................................................... Xray, place prox ext thor ao ............................................................................................ C 

75959 .......................................................... Xray, place dist ext thor ao ............................................................................................. C 

92970 .......................................................... Cardioassist, internal ....................................................................................................... C 

92971 .......................................................... Cardioassist, external ...................................................................................................... C 

92975 .......................................................... Dissolve clot, heart vessel ............................................................................................... C 

92992 .......................................................... Revision of heart chamber .............................................................................................. C 

92993 .......................................................... Revision of heart chamber .............................................................................................. C 

99190 .......................................................... Special pump services ..................................................................................................... C 

99191 .......................................................... Special pump services ..................................................................................................... C 

99192 .......................................................... Special pump services ..................................................................................................... C 

99251 .......................................................... Initial inpatient consult ..................................................................................................... C 

99252 .......................................................... Initial inpatient consult ..................................................................................................... C 

99253 .......................................................... Initial inpatient consult ..................................................................................................... C 

99254 .......................................................... Initial inpatient consult ..................................................................................................... C 

99255 .......................................................... Initial inpatient consult ..................................................................................................... C 

99293 .......................................................... Ped critical care, initial ..................................................................................................... C 

99294 .......................................................... Ped critical care, subseq ................................................................................................. C 

99295 .......................................................... Neonate crit care, initial ................................................................................................... C 

99296 .......................................................... Neonate critical care subseq ........................................................................................... C 

99298 .......................................................... Ic for lbw infant < 1500 gm .............................................................................................. C 

99299 .......................................................... Ic, lbw infant 1500-2500 gm ............................................................................................ C 

99356 .......................................................... Prolonged service, inpatient ............................................................................................ C 

99357 .......................................................... Prolonged service, inpatient ............................................................................................ C 

99433 .......................................................... Normal newborn care/hospital ......................................................................................... C 

0021T .......................................................... Fetal oximetry, trnsvag/cerv ............................................................................................ C 

0024T .......................................................... Transcath cardiac reduction ............................................................................................ C 

0048T .......................................................... Implant ventricular device ................................................................................................ C 

0049T .......................................................... External circulation assist ................................................................................................ C 

0050T .......................................................... Removal circulation assist ............................................................................................... C 

0051T .......................................................... Implant total heart system ............................................................................................... C 

0052T .......................................................... Replace component heart syst ........................................................................................ C 

0053T .......................................................... Replace component heart syst ........................................................................................ C 

0075T .......................................................... Perq stent/chest vert art .................................................................................................. C 

0076T .......................................................... S&i stent/chest vert art .................................................................................................... C 

0077T .......................................................... Cereb therm perfusion probe .......................................................................................... C 

0078T .......................................................... Endovasc aort repr w/device ........................................................................................... C 

0079T .......................................................... Endovasc visc extnsn repr .............................................................................................. C 

0080T .......................................................... Endovasc aort repr rad s&i .............................................................................................. C 

0081T .......................................................... Endovasc visc extnsn s&i ................................................................................................ C 

0090T .......................................................... Cervical artific disc ........................................................................................................... C 

0091T .......................................................... Lumbar artific disc ........................................................................................................... C 

0092T .......................................................... Artific disc addl ................................................................................................................ C 

0093T .......................................................... Cervical artific diskectomy ............................................................................................... C 

0094T .......................................................... Lumbar artific diskectomy ................................................................................................ C 

0095T .......................................................... Artific diskectomy addl ..................................................................................................... C 

0096T .......................................................... Rev cervical artific disc .................................................................................................... C 

0097T .......................................................... Rev lumbar artific disc ..................................................................................................... C 

0098T .......................................................... Rev artific disc addl ......................................................................................................... C 

0153T .......................................................... Implant aneur sensor add-on .......................................................................................... C 

G0341 .......................................................... Percutaneous islet celltrans ............................................................................................. C 

G0342 .......................................................... Laparoscopy islet cell trans ............................................................................................. C 

G0343 .......................................................... Laparotomy islet cell transp ............................................................................................. C 

[FR Doc. 06–6846 Filed 8–8–06; 4:15 pm] 

BILLING CODE 4120–01–P 


sroberts on PROD1PC70 with PROPOSALS